Long-Term Incidence of Advanced Colorectal Neoplasia in Patients with Serrated Polyposis Syndrome: Experience in a Single Academic Centre.

Serrated polyposis syndrome (SPS) implies a slightly elevated risk of colorectal cancer (CRC) during endoscopic follow-up, but its natural course is still not well known. The main objective of this study was to describe the long-term risk of developing advanced neoplasia (AN) in these patients. Until October 2020, individuals who fulfilled 2010 WHO criteria I and/or III for SPS were retrospectively recruited. We selected those under endoscopic surveillance after resection of all lesions >3 mm in a high-quality colonoscopy. We excluded patients with total colectomy at diagnosis and those with any interval between colonoscopies >3.5 years. We defined AN as advanced serrated polyp (≥10 mm and/or with dysplasia), advanced adenoma, or CRC. In 109 patients, 342 colonoscopies were performed (median = 3, median interval = 1.8 years) during a median follow-up after colonic clearance of 5.0 years. Five-year cumulative incidences of AN were 21.6% globally, and 5.6%, 10.8%, and 50.8% in patients who fulfilled criterion I, III, and both, respectively (p < 0.001). No CRC was diagnosed and only 1 (0.9%) patient underwent surgery. In conclusion, cumulative incidences of AN could be lower than previously described, at least in patients who fulfil the 2010 WHO criterion III alone. Therefore, low-risk individuals might benefit from less stringent surveillance.

Degeneración combinada subaguda en un paciente sin anemia y con hipertensión severa / Subacute combined degeneration in a patient without anemia but with severe hypertension

RESUMEN La degeneración combinada subaguda, es una patología de tipo neuropsiquiatrica asociada al déficit de vitamina B12. Se manifiesta clínicamente por ataxia sensorial, neuropatía periférica, disfunción cognitiva y neuropatía óptica; estas manifestaciones generalmente son atribuidas a la síntesis anormal de mielina. Puede tener una presentación clínica inespecífica, pero la medición de los niveles de vitamina B12, algunos metabolitos séricos, y el uso de métodos de neuroimagen, ayudan a confirmar el diagnóstico ante su sospecha. A continuación se describe el caso de un paciente con un cuadro de degeneración combinada subaguda, quien consultó por síntomas neurológicos e hipertensión severa, quien luego del tratamiento presentó mejoría de su sintomatologia neurológica y vascular.

SUMMARY Sub-acute combined degeneration is a neuropsychiatrical pathology associated with vitamin B12 deficiency It is clinically manifested through sensorial ataxia, peripheral neuropathy, cognitive dysfunction and optical neuropathy; these manifestations are generally attributed to the abnormal synthesis of myelin. It can have a nonspecific clinical presentation but the measurement of the levels of vitamin B12, some serum metabolites, and the use of neuroimaging methods help to confirm the diagnose when suspected. The case of a patient with sub-acute combined degeneration is described below. The patient was attended because of neurological symptoms and severe hypertension, and after the treatment, the patient's neurological and vascular symptomatology improved.

Uso de inmunoglobulinas intravenosas en una paciente obstétrica con choque séptico: reporte de caso y revisión de la literatura / Use of intravenous immunoglobulins in an obstetric patient with septic shock: Case report and review of the literature

Objetivo: Reportar el caso de una paciente obstétrica que desarrolló un shock séptico secundario a una infección gastrointestinal y el uso de inmunoglobulina endovenosa (IVIG) como terapia coadyuvante y hacer una revisión de la literatura publicada del uso de inmunoglobulinas en shock séptico con énfasis en su uso en el embarazo. Materiales y métodos: Se presenta el caso de una paciente con embarazo de 36 semanas, quien presentó un choque séptico secundario a una infección gastrointestinal y progresó con falla orgánica multisistémica. En vista de la pobre respuesta al tratamiento instaurado se inició terapia coadyuvante con inmunoglobulina enriquecida en IgM con una buena respuesta. Se realizó una búsqueda de la literatura en la bases de datos de Medline vía PubMed, Direct Sciencie, Biblioteca Cochrane y SciELO utilizando las palabras clave de los Descriptores en Ciencias de la Salud (DeCS) como inmunoglobulina endovenosa y sepsis en embarazo. Resultados: Se encontraron 6 artículos relacionados directamente con el uso de IVIG en sepsis en el embarazo, 1 revisión de tema, 2 reportes de caso y 3 guías diagnósticas y de manejo. Las inmunoglobulinas intravenosas se han utilizado con mayor frecuencia en pacientes no obstétricas en shock séptico como terapia coadyuvante especialmente en infección por estreptococos y estafilococos. Conclusión: Las inmunoglobulinas intravenosas podrían ser una alternativa como coadyuvante en manejo de shock séptico en gestantes con pobre respuesta al tratamiento convencional. Se necesitan estudios analíticos que incluyan gestantes para confirmar estos hallazgos.

Objective: To report the case of an obstetric patient who developed septic shock secondary to a gastrointestinal infection, and the use of intravenous immunoglobulin (IVIG) as an adjunct, and to conduct a review of the published literature on the use of immunoglobulins in septic shock with emphasis on its use during pregnancy. Materials and methods: Case report of a patient with 36 weeks of gestation who presented with septic shock secondary to a gastrointestinal infection resulting in multiple organ failure. In view of poor response to treatment, adjunctive therapy with IgM-enriched immunoglobulin therapy was initiated, achieving good response. A search of the literature was conducted in the Medline, Direct Science, Cochrane Library and SciELO databases using Health Science Descriptors (DeCS) such as intravenous immunoglobulin and sepsis in pregnancy. Results: Six articles directly related to the use of IVIG in sepsis during pregnancy were found, including 1 review, 2 case reports and 3 diagnosis and management guidelines. Intravenous immunoglobulins have been used with greater frequency in non-obstetric patients in septic shock as an adjunct especially in streptococcal and staphylococcal in fections. Conclusion: Intravenous immunoglobulins could be an alternative as adjunct therapy in the management of septic shock in pregnant women who respond poorly to conventional treatment. Analytical studies including pregnant women are needed in order to confirm these findings.

Proctitis as the clinical presentation of lymphogranuloma venereum, a re-emerging disease in developed countries.

Lymphogranuloma venereum (LGV) is a sexually transmitted infectious disease caused by serovars L1, L2 and L3 of Chlamydia trachomatis. The initial presentation is usually a painless ulcerated papule on the genitalia or distal proctitis. The progression of the infection can lead to major complications: rectal strictures, intestinal obstruction or perforation. We present five cases of LGV proctitis as the initial presentation of the disease. All patients were male, mean age 44.6 years, with positive serology to human immunodeficiency virus (HIV) and promiscuous men who have sex with men (MSM).The initial diagnosis was made by rectosigmoidoscopy indicated for pain and anal discharge. All cases were confirmed by polymerase chain reaction technique in rectal tissue. Endoscopic images obtained showed a great variety of rectal lesions, from mild erythema of the mucosa and ulcers to deep ulcers with elevated borders and purulent exudate. All cases were resolved after treatment with doxycycline for 3 weeks. It emphasizes the importance of suspecting this re-emerging disease in patients with risk factors (HIV and MSM), with the aim of early treatment and to avoid major complications.

Proctitis como forma de presentación del linfogranuloma venéreo, una entidad emergente en los países desarrollados / Proctitis as the clinical presentation of lymphogranuloma venereum, a re-emerging disease in developed countries

El linfogranuloma venéreo (LGV) es una enfermedad infecciosa de transmisión sexual causada por los serotipos L1, L2 y L3 de Chlamydia trachomatis. Se manifiesta inicialmente como una pápula ulcerada e indolora en los genitales o como una proctitis distal. La progresión de la infección puede dar lugar a complicaciones mayores: estenosis rectal, obstrucción o perforación intestinal. Se presentan cinco casos de LGV con proctitis como signo inicial de la enfermedad. Todos los pacientes eran varones, de edad media 44,6 años, con serología positiva al virus de inmunodeficiencia humana (VIH) y homosexuales promiscuos. El diagnóstico se realizó mediante rectoscopia indicada por dolor y supuración anal. Todos los casos fueron confirmados mediante técnica de reacción en cadena de la polimerasa en tejido rectal. Las imágenes endoscópicas obtenidas muestran la gran diversidad de lesiones rectales posibles, desde leve eritema de la mucosa con aftas hasta úlceras profundas con bordes sobreelevados y abundante fibrina. Tras tratamiento con doxiciclina, durante 3 semanas, todos los casos se resolvieron de forma satisfactoria. Se enfatiza la importancia de sospechar esta patología emergente en pacientes con factores de riesgo (VIH y homosexuales), con el fin de instaurar un tratamiento precoz y evitar las complicaciones mayores (AU)

Lymphogranuloma venereum (LGV) is a sexually transmitted infectious disease caused by serovars L1, L2 and L3 of Chlamydia trachomatis. The initial presentation is usually a painless ulcerated papule on the genitalia or distal proctitis. The progression of the infection can lead to major complications: rectal strictures, intestinal obstruction or perforation. We present five cases of LGV proctitis as the initial presentation of the disease. All patients were male, mean age 44.6 years, with positive serology to human immunodeficiency virus (HIV) and promiscuous men who have sex with men (MSM). The initial diagnosis was made by rectosigmoidoscopy indicated for pain and anal discharge. All cases were confirmed by polymerase chain reaction technique in rectal tissue. Endoscopic images obtained showed a great variety of rectal lesions, from mild erythema of the mucosa and ulcers to deep ulcers with elevated borders and purulent exudate. All cases were resolved after treatment with doxycycline for 3 weeks. It emphasizes the importance of suspecting this re-emerging disease in patients with risk factors (HIV and MSM), with the aim of early treatment and to avoid major complications (AU)

Avances en hígado graso no alcohólico / Advances innonalcoholic fatty liver disease

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[Medical management of primary nonalcoholic fatty liver disease]. / Tratamiento médico de la hepatopatía grasa no alcohólica primaria.

The need for an effective and safe medical treatment of nonalcoholic fatty liver disease is urgent due to its high prevalence and progressive character. At the moment, therapeutic strategies are largely empirical and based on the control of associated clinical conditions (especially obesity, type 2 diabetes mellitus, and hypertriglyceridemia) and the use of some specific drugs (insulin sensitizing agents, cytoprotectives, antioxidants, and anticytokines) as an attempt to counteract known elements of the pathogenesis. None of these specifics measures have been found to display enough evidence to recommend their clinical use. It is indispensable to join efforts in coordinated networks to define, as soon as possible, the best treatment and the best time to start it.

Tratamiento médico de la hepatopatía grasa no alcohólica primaria / Medical management of primary nonalcoholic fatty liver disease

La necesidad de un tratamiento eficaz y seguro de la hepatopatía grasa no alcohólica primaria es clara y urgente, en función de su alta prevalencia y potencial evolutivo. Las estrategias terapéuticas utilizadas hoy en día son, en su mayor parte, empíricas y se basan en el control de los procesos clínicos asociados (en especial, la obesidad, la diabetes mellitus tipo 2 y la hipertrigliceridemia) y en la utilización de ciertos fármacos específicos (sensibilizantes a la acción de la insulina, citoprotectores, antioxidantes y anticitocinas) que intentan contrarrestar elementos conocidos de la patogenia. Ninguna de estas medidas específicas goza de la suficiente evidencia científica para recomendar su uso en la práctica clínica diaria. Es imprescindible que unamos nuestros esfuerzos en redes de investigación coordinadas para definir con precisión, y lo antes posible, el mejor tratamiento y el momento idóneo para su inicio

The need for an effective and safe medical treatment of nonalcoholic fatty liver disease is urgent due to its high prevalence and progressive character. At the moment, therapeutic strategies are largely empirical and based on the control of associated clinical conditions (especially obesity, type 2 diabetes mellitus, and hypertriglyceridemia) and the use of some specific drugs (insulin sensitizing agents, cytoprotectives, antioxidants, and anticytokines) as an attempt to counteract known elements of the pathogenesis. None of these specifics measures have been found to display enough evidence to recommend their clinical use. It is indispensable to join efforts in coordinated networks to define, as soon as possible, the best treatment and the best time to start it

[Pathogenesis of primary nonalcoholic fatty liver disease]. / Patogenia de la hepatopatía grasa no alcohólica primaria.

The challenges of growing prevalence and evident trend to progressive damage of primary nonalcoholic fatty liver disease confront a poorly understood pathogenesis. It appears to develop in two steps. First, a high adipocyte protein production in the context of a silent inflammatory background causes insulin resistance in adipose tissue. It leads both to lipolysis, with increase of the circulating and hepatic uptake of free fatty acids, and hyperinsulinemia. Within hepatocytes, the subsequent lipogenesis, together with a decreased secretion of lipoproteins, induces an accumulation of excessive hepatic triglycerides (steatosis), impliying some oxidative damage, but it remain balanced by uncoupling protein upregulation and antioxidant systems activation. Second, a more forceful fat catabolism by beta and omega oxidation results in respiratory chain hyperactivity with overproduction of free radicals and reactive oxygen species that exceed the antioxidant capacity. These agents lead to hepatocellular injury and necrosis, inflammatory infiltration and fibrosis (steatohepatitis) through induction of Fas ligand and cytokines (tumor necrosis factor alpha, transforming growth factor beta, interleukin-8), and lipid peroxidation and by-products (malondialdehyde and 4-hydroxynonenal). Other mechanisms (hepatic iron, Kupffer cells dysfunction or endotoxemia) play uncertain roles.

Patogenia de la hepatopatía grasa no alcohólica primaria / Pathogenesis of primary nonalcoholic fatty liver disease

Los retos de la creciente prevalencia e indudable tendencia a la progresividad lesional de la hepatopatía grasa no alcohólica primaria contrastan con el limitado conocimiento de su patogenia. Parece desarrollarse en 2 fases. En la primera, la hiperproducción de adipocinas, en el contexto de un proceso inflamatorio subclínico, conduce a resistencia a la insulina en el tejido adiposo. Ello lleva tanto a lipólisis, con aumento de ácidos grasos circulantes y su captación hepática, como a hiperinsulinemia. En el hepatocito la lipogénesis resultante, junto a la disminución de excreción de lipoproteínas, induce la acumulación grasa(esteatosis), que supone cierta agresión oxidativa pero que queda contrarrestada por la activación de proteínas desacoplantes mitocondrialesy sistemas antioxidantes. En la segunda fase, la exacerbación del catabolismo graso por beta y omegaoxidación promueve una hiperactividad de la cadena respiratoria, con sobreproducción de radicales libres y especies reactivas del oxígeno que superan la capacidad antioxidante. Esos agentes conducirán a lesión hepatocelular y necrosis, inflamación y fibrosis (esteatohepatitis), merced a la inducción tanto delligando Fas como de citocinas (factor de necrosis tumoral alfa, factorbetatransformador del crecimiento e interleucina 8) y de peroxidaciónlipídica y sus subproductos (malondialdehído e hidroxinonenal). La implicaciónde otros factores (hierro hepático, disfunción de células deKupffer o endotoxemia) es incierta

The challenges of growing prevalence and evident trend to progressive damage of primary nonalcoholic fatty liver disease confront a poorly understood pathogenesis. It appears to develop in two steps. First, a high adipocyte protein production in the context of a silent inflammatory background causes insulin resistance in adipose tissue. It leads both to lipolysis, with increase of the circulating and hepatic uptake of free fatty acids, and hyperinsulinemia. Within hepatocytes, the subsequent lipogenesis, together with a decreased secretion of lipoproteins, induces an accumulation of excessive hepatic triglycerides (steatosis), impliying some oxidative damage, but it remain balanced by uncoupling protein upregulation and antioxidant systems activation. Second, a more forceful fat catabolism by beta and omega oxidation results in respiratory chain hyperactivity with overproduction of free radicals and reactive oxygen species that exceed the antioxidant capacity. These agents lead to hepatocellular injury and necrosis, inflammatory infiltration and fibrosis (steatohepatitis) through induction of Fas ligand and cytokines (tumor necrosis factor *, transforming growth factor ß, interleukin-8), and lipid peroxidation and by-products (malondialdehyde and 4-hydroxynonenal). Other mechanisms (hepatic iron, Kupffer cells dysfunction or endotoxemia) play uncertain roles