Antimicrobial management of Tropheryma whipplei endocarditis: the Spanish Collaboration on Endocarditis (GAMES) experience.

OBJECTIVES: Tropheryma whipplei has been detected in 3.5% of the blood culture-negative cases of endocarditis in Spain. Experience in the management of T. whipplei endocarditis is limited. Here we report the long-term outcome of the treatment of previously reported patients who were diagnosed with infective endocarditis (IE) caused by T. whipplei from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España (GAMES) and discuss potential options for antimicrobial therapy for IE caused by T. whipplei. PATIENTS AND METHODS: Seventeen patients with T. whipplei endocarditis were recruited between 2008 and 2014 in 25 Spanish hospitals. Patients were classified according to the therapeutic regimen: ceftriaxone and trimethoprim/sulfamethoxazole, doxycycline + hydroxychloroquine and other treatment options. RESULTS: Follow-up data were obtained from 14 patients. The median follow-up was 46.5 months. All patients completed the antibiotic treatment prescribed, with a median duration of 13 months. Six patients were treated with ceftriaxone and trimethoprim/sulfamethoxazole (median duration 13 months), four with doxycycline + hydroxychloroquine (median duration 13.8 months) and four with other treatment options (median duration 22.3 months). The follow-up after the end of the treatments was between 5 and 84 months (median 24 months). CONCLUSIONS: All treatment lines were effective and well tolerated. Therapeutic failures were not detected during the treatment. None of the patients died or experienced a relapse during the follow-up. Only six patients received antibiotic treatment in accordance with guidelines. These data suggest that shorter antimicrobial treatments could be effective.

Systematic review of the use of fibrin sealant in abdominal-wall repair surgery.

PURPOSE: Our objective was to analyze the advantages and inconveniences associated with the use of fibrin sealant compared with mechanical means for mesh fixation following abdominal-wall surgery. METHODS: Literature search was conducted in MedLine, EMBASE, and Cochrane Library Plus databases. Articles were randomized clinical trials, nonrandomized comparative studies, and case series containing at least ten patients. RESULTS: The fibrin sealant was shown to be biocompatible with the surrounding tissue. In patients treated with fibrin sealant, lower prevalence of acute and chronic postoperative pain was observed, and less hemorrhagic complications occurred. There are no data on the influence of fibrin sealant on seroma decrease. Efficiency in experimental models was similar to that observed for mechanical methods of fixation. Also, adhesions with fibrin sealant were less than that for mechanical methods. CONCLUSIONS: Compared with mechanical methods, fibrin sealant is an efficacious alternative for mesh fixation postsurgery of the abdominal wall.

Sportsmen hernia: what do we know?

Athletes and other physically active people often suffer prolonged inguinal pain, which can become a serious debilitating condition and may place an athlete's career at risk. A sportsmen hernia is a controversial cause of this chronic groin pain, as it is difficult to be defined. From an anatomical point of view, the definition and the name of this entity should be reviewed. In the majority of athletic manoeuvres, a tremendous amount of torque or twisting occurs in the mid-portion of the body and the front, or anterior portion, of the pelvis accounts for the majority of the force. The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. These opposing forces cause a disruption of the muscle/tendon at their insertion site on the pubis, so the problem could be related to the fact that the forces are excessive and imbalanced, and a weak area at the groin could be increased due to the forces produced by the muscles. The forces produced by these muscles may be imbalanced and could produce a disruption of the muscle/tendon at their insertion site on the pubis or/and a weak area may be increased due to the forces produced by the muscles, and just this last possibility could be defined as "sportsmen hernia." In conclusion, this global entity could be considered to be an imbalance of the muscles (abductor and abdominal) at the pubis, that leads to an increase of the weakness of the posterior wall of the groin and produces a tendon enthesitis, once a true origin is not detected, that may lead to a degenerative arthropathy of the pubic symphysis in the advanced stages. Based on this, this entity could be re-named as "syndrome of muscle imbalance of the groin" and the sportsmen hernia could be considered as an entity included in this syndrome. It is recommended that a multidisciplinary approach is given to this entity, since the present literature does not supply the proper diagnostic studies and the correct treatment which should be performed in these patients.

[Peritoneal tuberculosis as a complication in a case of unclassifiable myelodysplastic/myeloproliferative disease]. / Tuberculosis peritoneal como complicación en un caso de síndrome mielodisplásico/mieloproliferativo inclasificable.

We report the case of a 68-year-old male with a diagnosis of unclassifiable myelodysplatic/myeloproliferative disease (WHO classification), under prolonged steroid treatment and unsuccesful chemotherapy response, who developed progressive asthenia, thoracic pain, minimal efforts dyspnea, and abdominal distension, that initially was suspicious of splenic rupture. Exploratory laparotomy showed multiple peritoneal implants, and a diagnosis of peritoneal tuberculosis was obtained from local biopsy. Definitive diagnosis included a positive result to culture and PCR urine test, together with a possible pleural and splenic tuberculous affectation. Response to tuberculostatic treatment was successful. To the best of our knowledge, this is the first reported case with such characteristics.

[Role of malnutrition in intestinal anastomosis collagenization: an analysis of procollagen (PINP) and carboxyterminal telopeptide (ICTP) by radioimmunoassay]. / Efectos de la desnutrición sobre la colagenización de anastomosisintestinales: análisis de procolágeno y telopéptido carboxiterminalmediante radioinmunoanálisis.

INTRODUCTION: some clinical, anatomo-pathological, and technical factors influence the correct healing of intestinal suture following an intestinal resection. One of the most influential factors is patient nutritional status. OBJECTIVES: to evaluate the influence of malnutrition on the viability of primary intestinal anastomosis by the analysis of collagen I deposition. METHODS: 40 Wistar rats, radioimmunoassay material. We used 2 groups of rats, 20 animals in each group: a control group (A) and a "malnutrition" group (B). RESULTS: there was a decrease in PINP (procollagen) deposition in the colon of group B rats as compared to the colon of group A (0.3620 and 0.4340 mg/g respectively) (p = 0.032). There is an increase in ICTP (carboxyterminal telopeptide) in the colon of group B (0.9545 as against 0.8460 mg/g in group A) (p = 0.875). In anastomoses of group B there was a decrease in PINP synthesis as compared to group A (0.376 and 0.468 mg/g respectively, p = 0.002). As regards ICTP, there was an increase in group B (p = 0.330). In relation to the control group no differences were observed in ICTP increases in group B (p = 1). CONCLUSIONS: colonic anastomosis increases the levels of PINP and ICTP in healed tissue (p = 0.000); malnutrition reduces collagenization in anastomoses (p = 0.000).

Efectos de la desnutrición sobre la colagenización de anastomosis intestinales: análisis de procolágeno y telopéptido carboxiterminal mediante radioinmunoanálisis / Role of malnutrition in intestinal anastomosis collagenization: an analysis of procollagen (PINP) andcarboxyterminal telopeptide (ICTP) by radioimmunoassay

Introducción: diversos factores influyen en la cicatrización correcta de las suturas intestinales tras la práctica de una resección intestinal. Uno de los factores más implicados es el estado nutricional del paciente. Objetivos: evaluar la influencia de la desnutrición inducida sobre la viabilidad de una anastomosis intestinal primaria mediante el análisis del procolágeno (PINP) como marcador de la síntesis de colágeno I, y del telopéptido carboxiterminal del colágeno I (ICTP) como marcador de la destrucción del mismo. Métodos: 40 ratas Wistar y material de radioinmunoensayo. Métodos: diseñamos 2 grupos de ratas, 20 animales por cada grupo: grupo control (A) y grupo “desnutrición” (B). Se analiza PINP e ICTP mediante RIA sobre tejido colónico homogeneizado, preanastomótico y anastomótico. Resultados: existen unos niveles menores de PINP en el colon de las ratas del grupo B comparado con el colon del grupo A (0,3620 y 0,4340 μg/g respectivamente) (p = 0,032). Hay un mayor nivel de ICTP analizado en el colon del grupo B (0,9545 en contraposición a 0,8460 μg/g en el grupo A) (p = 0,875). En las anastomosis del grupo B existe una menor síntesis de PINP en comparación con el grupo A (0,376 y 0,468 μg/g respectivamente, p = 0,002). Conclusiones: la anastomosis colónica incrementa los niveles de PINP e ICTP en el tejido cicatricial (p = 0,000); la malnutrición reduce la colagenización de las anastomosis (p = 0,000)

Introduction: some clinical, anatomo-pathological, and technical factors influence the correct healing of intestinal suture following an intestinal resection. One of the most influential factors is patient nutritional status. Objectives: to evaluate the influence of malnutrition on the viability of primary intestinal anastomosis by the analysis of collagen I deposition. Methods: 40 Wistar rats, radioimmunoassay material. We used 2 groups of rats, 20 animals in each group: a control group (A) and a “malnutrition” group (B). Results: there was a decrease in PINP (procollagen) deposition in the colon of group B rats as compared to the colon of group A (0.3620 and 0.4340 μg/g respectively) (p = 0.032). There is an increase in ICTP (carboxyterminal telopeptide) in the colon of group B (0.9545 as against 0.8460 μg/g in group A) (p = 0.875). In anastomoses of group B there was a decrease in PINP synthesis as compared to group A (0.376 and 0.468 mg/g respectively, p = 0.002). As regards ICTP, there was an increase in group B (p = 0.330). In relation to the control group no differences were observed in ICTP increases in group B (p = 1). Conclusions: colonic anastomosis increases the levels of PINP and ICTP in healed tissue (p = 0.000); malnutrition reduces collagenization in anastomoses (p = 0.000)

Sepsis de repetición en un paciente con gammapatía monoclonal de significado incierto / Several episodes of bacterial infections in a patient with monoclonal gammapathy of undetermined significance

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[Diarrhoea in the traveller]. / Diarrea del viajero.

Diarrhoeic diseases caused by water and food contaminated by enteropathogens continue to be an important cause of morbidity in countries with a low level of development. Some 50,000 cases of diarrhoea in travellers are estimated in the world every day, and this is the main cause of consultation by travellers who return from undeveloped zones. The principal determinant of risk is the place of destination; there are significant differences between different regions with respect to risk and to the aetiology of the diarrhoea. The most frequent cause of diarrhoeas is of bacterial origin, which represents between 60 and 85% of the cases, while parasites represent 10% and some 5% are produced by viruses. Although it normally follows a benign course, complications can arise, with mortality being only exceptionally associated to this disease. Prevention is essentially based on strictly following elemental hygienic measures and avoiding the ingestion of foodstuffs and drinks with a risk of contamination. Prophylaxis with antibiotics is only advisable in journeys of short duration, in which the risk and/or seriousness of diarrhoeas, above all in immunosuppressed patients, are higher than the possible collateral effects. The treatment of diarrhoea in the traveller is based on adequate hydration, and the use of microbians is reserved for moderate and serious situations, with quinolones being the drug of choice. Rifaximine is a new drug approved for the treatment of diarrhoeas in the traveller, above all in areas with enteropathogens that are resistant to quinolones.

[Internet use to obtain health information among patients attending a digestive diseases office]. / Uso médico de Internet entre los pacientes de una consulta general de enfermedades del aparato digestivo.

INTRODUCTION: The use of the Internet to gain health information has increased in Spain. This is changing the way patients access medical information and, in turn, the physician-patient relationship. OBJECTIVES: To analyze the use of the Internet for medical purposes by patients attending a digestive diseases office and to determine the profile of patients seeking this information. MATERIAL AND METHODS: A questionnaire was administered to consecutive patients attending a general digestive diseases office for the first time. RESULTS: Four hundred twenty-three patients completed the questionnaire (56% women, 44% men, mean age 42.63 [15.994] years). A total of 2.4% had only not completed basic education, 14% had completed basic education, 32.8% had completed high school, 50.6% had university degrees, and 0.2% did not answer. More than three-quarters (76.4%) had a computer at home and 72% had internet access. Forty-two percent looked for health information on the internet. Seventeen percent had searched for specific information on their illnesses before consulting and 66% believed the internet is a good resource for obtaining medical information. Seventy percent would be interested in a specific web page on digestive disease topics and 75% would use e-mail to consult with their physicians. The group that most frequently looked for medical information consisted of patients aged 45 years or younger with secondary school or university education. CONCLUSIONS: In our environment, patients with digestive diseases routinely use the Internet to search for medical information. These patients have a high degree of confidence in the information obtained and would be interested in a specific website devoted to diseases of the digestive system. The patients that most frequently searched for health information were aged less than 45 years old and had secondary school education or university degrees.

Uso médico de Internet entre los pacientes de una consulta general de enfermedades del aparato digestivo / Internet use to obtain health information among patients attending a digestive diseases office

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Diarrea del viajero / Diarrhoea in the traveller

Las enfermedades diarreicas causadas por la contaminación de agua y alimentos por enteropatógenos continúan siendo causa de importante morbilidad en los países con escaso nivel de desarrollo. Se estima alrededor de unos 50.000 casos diarios de diarreas del viajero en el mundo, siendo el principal motivo de consulta de los viajeros que regresan de zonas no desarrolladas. El principal determinante de riesgo es el lugar de destino, existiendo diferencias importantes entre las distintas regiones en cuanto al riesgo y la etiología de la diarrea. La causa más frecuente de diarreas es la bacteriana, que representa del 60 al 85% de los casos, los parásitos representan el 10% y un 5% están producidas por virus. Aunque habitualmente cursa de forma benigna, pueden aparecer complicaciones, siendo excepcional la mortalidad asociada esta enfermedad. La prevención se basa fundamentalmente en seguir estrictamente las medidas higiénicas elementales y evitar la ingesta de alimentos y bebidas con riesgo de contaminación. La profilaxis con antibióticos sólo se aconseja en viajes de corta duración, en los que el riesgo y/o gravedad de las diarreas, sobre todo en pacientes inmunosuprimidos, sean superiores a los posibles efectos colaterales. El tratamiento de la diarrea del viajero se basa en una adecuada hidratación y se reserva el uso de antimicrobianos para situaciones clínicas moderadas y graves, siendo las quinolonas el fármaco de elección. La rifaximina es un nuevo fármaco aprobado para el tratamiento de las diarreas del viajero, sobre todo en áreas con enteropatógenos resistentes a las quinolonas

Diarrhoeic diseases caused by water and food contaminated by enteropathogens continue to be an important cause of morbidity in countries with a low level of development. Some 50,000 cases of diarrhoea in travellers are estimated in the world every day, and this is the main cause of consultation by travellers who return from undeveloped zones. The principal determinant of risk is the place of destination; there are significant differences between different regions with respect to risk and to the aetiology of the diarrhoea. The most frequent cause of diarrhoeas is of bacterial origin, which represents between 60 and 85% of the cases, while parasites represent 10% and some 5% are produced by viruses. Although it normally follows a benign course, complications can arise, with mortality being only exceptionally associated to this disease. Prevention is essentially based on strictly following elemental hygienic measures and avoiding the ingestion of foodstuffs and drinks with a risk of contamination. Prophylaxis with antibiotics is only advisable in journeys of short duration, in which the risk and/or seriousness of diarrhoeas, above all in immunosuppressed patients, are higher than the possible collateral effects. The treatment of diarrhoea in the traveller is based on adequate hydration, and the use of microbians is reserved for moderate and serious situations, with quinolones being the drug of choice. Rifaximine is a new drug approved for the treatment of diarrhoeas in the traveller, above all in areas with enteropathogens that are resistant to quinolones

Mycotic pseudoaneurysms after liver transplantation.

The most frequent etiology of visceral artery aneurysms is arteriosclerosis, but vascular manipulation during hepatic transplantation may also cause a mycotic pseudoaneurysm. Treatment with embolization, stents or percutaneous thrombin injection have been recommended but surgical revascularization is indicated when interventional techniques fail. A 43-year-old man with hepatitis C virus cirrhosis who underwent orthotopic liver transplantation from a cadaveric donor was treated with cyclosporine, mycophenolate, and steroids and was discharged from hospital at 35 days. Two months later he was readmitted with a febrile syndrome. Abdominal computed tomography showed necrosis of hepatic segments IV, V, and VI. Magnetic resonance imaging and angiography revealed partial thrombosis of the hepatic artery and stenosis of the portal anastomosis secondary to an aneurysm of the hepatic artery. A few hours after the radiological diagnosis, the patient suffered a bout of upper gastrointestinal bleeding and shock. Emergency surgery revealed a mycotic pseudoaneurysm of the common hepatic artery, which had ruptured into the bile tract with hemobilia. The liver graft was removed because of severe necrosis of the right liver. The patient died awaiting a new liver transplantation.

Hemorragia digestiva alta asociada a diverticulosis yeyunal masiva y sobredosificación de Sintrom® / Severe gastrointestinal bleeding associated to massive jejunal diverticulosis and Sintrom® treatment

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