Adherence to a predefined vaccination program in patients with inflammatory bowel disease / La adhesión a un programa de vacunación predefinido en pacientes con enfermedad inflamatoria intestinal

INTRODUCTION: The application of vaccination programs in patients with inflammatory bowel disease (IBD) is heterogeneous and generally deficient. As a result, adherence in these patients to a predefined vaccination program has not been clearly established. The aim of this study was to estimate adherence to a predefined vaccination program among patients with IBD and to identify the factors that may predict poor adherence. METHODS: All patients diagnosed with IBD and followed-up between January and March 2012 were referred to the Department of Preventive Medicine for evaluation of their immune status (with serological testing for hepatitis A, B and C viruses, varicella-zoster virus, mumps, rubella and measles), followed by vaccination based on the test results obtained and on the patient's vaccination history. The percentage of adherence to the vaccination program was determined, along with the factors associated with low adherence. RESULTS: A total of 153 patients with IBD (ulcerative colitis in 50.3% and Crohn's disease in 49.7%) were included (45.1% men and 54.9% women; mean age 43.30 ± 14.19 years, range 17-83). The vaccination program adherence rate was 84.3%. The factors associated with poor adherence were drugs related to IBD (patients not receiving immunosuppressants and/or biological agents showed lower adherence than those receiving these treatments; p = 0.021), adherence to medical treatment (poor adherence to treatment was also associated with poor adherence to vaccination; p = 0.016), and marital status (single, divorced or separated patients showed lower adherence than married individuals; p = 0.015). CONCLUSION: Adherence to vaccination is acceptable among patients with IBD. However, specific actions, such as optimization of patient information on the disease and emphasis on the need for adequate vaccination, are to improve adherence

INTRODUCCIÓN: La implantación de programas de vacunación en pacientes con enfermedad inflamatoria intestinal (EII) es heterogénea y en general, deficiente, por lo que no es bien conocida la adherencia de nuestros pacientes con EII a un programa de vacunación previamente establecido. El objetivo fue determinar la adherencia a un programa de vacunación establecido en nuestro centro en pacientes con diagnóstico de EII y definir qué factores pueden predecir una baja adherencia a dicho programa. MATERIAL Y MÉTODOS: Se derivaron al Servicio de Medicina Preventiva todos los pacientes con diagnóstico de EII revisados en consulta entre enero y marzo de 2012, con el fin de determinar su estado de inmunización (mediante la extracción de analítica con serologías del virus de la hepatitis A, B y C, virus varicela-zoster, parotiditis, rubeola y sarampión) y, posteriormente, ser vacunados teniendo en cuenta sus resultados así como el calendario vacunal previo. Se determinó el porcentaje de adherencia a dicho programa así como los factores relacionados con una baja adherencia. RESULTADOS: Se incluyeron 153 pacientes (45.1% hombres y 54.9% mujeres, con una edad media de 43.30±14.19 años, rango 17-83) con diagnóstico de EII (50.3% colitis ulcerosa y 49.7% enfermedad de Crohn). La adherencia al programa de vacunación fue del 84.3%. Los factores que se asociaron con una baja adherencia fueron: fármacos en relación con la EII (los pacientes que no tomaban inmunosupresores y/o biológicos presentaron una menor adherencia frente aquellos que sí los recibían, p 0.021), adherencia al tratamiento médico (aquellos con mala adherencia al tratamiento presentaron también baja adherencia a la vacunación, p 0.016), estado civil (solteros, divorciados o separados presentaron menor adherencia respecto a los casados, p 0.015). CONCLUSIÓN: La adherencia a la vacunación no es adecuada en pacientes con EII. Acciones específicas como la optimización de la información que se le proporciona al paciente acerca de su enfermedad y la necesidad de una adecuada vacunación, constituye un pilar fundamental para lograr mejorarla

Impact of MELD Allocation System on Waiting List and Early Post-Liver Transplant Mortality.

BACKGROUND AND AIMS: MELD allocation system has changed the clinical consequences on waiting list (WL) for LT, but its impact on mortality has been seldom studied. We aimed to assess the ability of MELD and other prognostic scores to predict mortality after LT. METHODS: 301 consecutive patients enlisted for LT were included, and prioritized within WL by using the MELD-score according to: hepatic insufficiency (HI), refractory ascites (RA) and hepatocellular carcinoma (HCC). The analysis was performed to predict early mortality after LT (8 weeks). RESULTS: Patients were enlisted as HI (44.9%), RA (19.3%) and HCC (35.9%). The major aetiologies of liver disease were HCV (45.5%). Ninety-four patients (31.3%) were excluded from WL, with no differences among the three groups (p = 0.23). The remaining 207 patients (68.7%) underwent LT, being HI the most frequent indication (42.5%). HI patients had the shortest length within WL (113.6 days vs 215.8 and 308.9 respectively; p<0.001), but the highest early post-LT mortality rates (18.2% vs 6.8% and 6.7% respectively; p<0.001). The independent predictors of early post-LT mortality in the HI group were higher bilirubin (OR = 1.08; p = 0.038), increased iMELD (OR = 1.06; p = 0.046) and non-alcoholic cirrhosis (OR = 4.13; p = 0.017). Among the prognostic scores the iMELD had the best predictive accuracy (AUC = 0.66), which was strengthened in non-alcoholic cirrhosis (AUC = 0.77). CONCLUSION: Patients enlisted due to HI had the highest early post-LT mortality rates despite of the shortest length within WL. The iMELD had the best accuracy to predict early post-LT mortality in patients with HI, and thus it may benefit the WL management.

Adherence to a predefined vaccination program in patients with inflammatory bowel disease.

INTRODUCTION: The application of vaccination programs in patients with inflammatory bowel disease (IBD) is heterogeneous and generally deficient. As a result, adherence in these patients to a predefined vaccination program has not been clearly established. The aim of this study was to estimate adherence to a predefined vaccination program among patients with IBD and to identify the factors that may predict poor adherence. METHODS: All patients diagnosed with IBD and followed-up between January and March 2012 were referred to the Department of Preventive Medicine for evaluation of their immune status (with serological testing for hepatitis A, B and C viruses, varicella-zoster virus, mumps, rubella and measles), followed by vaccination based on the test results obtained and on the patient's vaccination history. The percentage of adherence to the vaccination program was determined, along with the factors associated with low adherence. RESULTS: A total of 153 patients with IBD (ulcerative colitis in 50.3% and Crohn's disease in 49.7%) were included (45.1% men and 54.9% women; mean age 43.30±14.19 years, range 17-83). The vaccination program adherence rate was 84.3%. The factors associated with poor adherence were drugs related to IBD (patients not receiving immunosuppressants and/or biological agents showed lower adherence than those receiving these treatments; p=0.021), adherence to medical treatment (poor adherence to treatment was also associated with poor adherence to vaccination; p=0.016), and marital status (single, divorced or separated patients showed lower adherence than married individuals; p=0.015). CONCLUSION: Adherence to vaccination is acceptable among patients with IBD. However, specific actions, such as optimization of patient information on the disease and emphasis on the need for adequate vaccination, are to improve adherence.

Metástasis gástrica tardía de melanoma cutáneo / Late gastric metastasis from cutaneous melanoma

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Colangiopancreatografía retrógrada endoscópica en pacientes con alteraciones de la anatomía gástrica por cambios posquirúrgicos / Endoscopic retrograde cholangiopancreatography in patients with anatomic abnormalities of the stomach due to surgery

Introducción: En los pacientes que han recibido resecciones gástricas parciales, las dificultades para realizar la colangiopancreatografía retrógrada endoscópica (CPRE) se ven aumentadas debido a la alteración anatómica regional. Objetivo Revisar la experiencia de la CPRE en pacientes con gastrectomía parcial y gastroenteroanastomosis (GE) tipo Billroth II o con otras GE (Billroth I e indeterminadas) en nuestro centro. Material y métodos Se incluyeron todos los pacientes con gastrectomía parcial y GE que recibieron CPRE en un periodo de 19 años. Resultados Se incluyeron 233 pacientes (91% varones y 9% mujeres) desde 1993 a 2012. El 88,4% los pacientes presentaban gastrectomía con GE Billroth II y el 11,6% otras GE, siendo la tasa de éxito de la CPRE del 51,9 y 55,6%, respectivamente. Las causas más frecuentes de fracaso fueron en primer lugar la imposibilidad de canulación (44%) y la no identificación de la papila (39,6%). El 31,8% de los pacientes presentó coledocolitiasis como diagnóstico final. El número medio de sesiones fue de 1,09. El porcentaje de complicaciones fue del 2,6%.ConclusionesEl grado de dificultad técnica influye en el éxito de la CPRE, por este motivo, en nuestro centro, tuvo una tasa de éxito algo superior al 50%, pero con un escaso número de complicaciones (AU)

Introduction: In patients who have undergone partial gastric resections, the difficulty of performing endoscopic retrograde cholangiopancreatography (ERCP) is increased due to the resulting anatomic abnormality. Aim: To review our experience of ERCP in patients with Billroth II gastrectomy and other types of gastrectomy (Billroth I and indeterminate) in our center. Material and methods: We included all patients with Billroth II gastrectomy or other types of gastrectomy undergoing ERCP in a 19-year period. Results: We included 233 patients (91% men and 9% women) from 1993 to 2012. A total of88.4% of the patients had undergone Billroth II and 11.6% had undergone other types of gastrectomy, with an ERCP success rate of 51.9% and 55.6%, respectively. The most common causes offailure were inability to cannulate (44%) and failure to identify the papilla (39.6%). The final diagnosis was choledocholithiasis in 31.8%. The mean number of sessions was 1.09.The complications rate was 2.6%.Conclusions: The success of ERCP is influenced by the technical difficulty. For this reason, the success rate in our center was slightly over 50%, but with few complications (AU)

[Endoscopic retrograde cholangiopancreatography in patients with anatomic abnormalities of the stomach due to surgery]. / Colangiopancreatografía retrógrada endoscópica en pacientes con alteraciones de la anatomía gástrica por cambios posquirúrgicos.

INTRODUCTION: In patients who have undergone partial gastric resections, the difficulty of performing endoscopic retrograde cholangiopancreatography (ERCP) is increased due to the resulting anatomic abnormality. AIM: To review our experience of ERCP in patients with Billroth II gastrectomy and other types of gastrectomy (Billroth I and indeterminate) in our center. MATERIAL AND METHODS: We included all patients with Billroth II gastrectomy or other types of gastrectomy undergoing ERCP in a 19-year period. RESULTS: We included 233 patients (91% men and 9% women) from 1993 to 2012. A total of 88.4% of the patients had undergone Billroth II and 11.6% had undergone other types of gastrectomy, with an ERCP success rate of 51.9% and 55.6%, respectively. The most common causes of failure were inability to cannulate (44%) and failure to identify the papilla (39.6%). The final diagnosis was choledocholithiasis in 31.8%. The mean number of sessions was 1.09. The complications rate was 2.6%. CONCLUSIONS: The success of ERCP is influenced by the technical difficulty. For this reason, the success rate in our center was slightly over 50%, but with few complications.

Valoración precoz de la anemia en el paciente con hemorragia digestiva aguda: concordancia entre gasometría venosa y laboratorio convencional / Early evaluation of anaemia in patients with acute gastrointestinal bleeding: venous blood gas analysis compared to conventional laboratory

Fundamento y objetivo: La valoración del paciente con hemorragia digestiva (HD) aguda requiere de una evaluación clínica y analítica precoz. El objetivo de este estudio es valorar la concordancia de la determinación de hemoglobina (Hb) y hematocrito (HTC) precozmente mediante gasometría venosa (GSV) y de forma convencional por el Laboratorio (LAB) de Urgencias. Pacientes y método: Estudio observacional y prospectivo de pacientes ingresados en la Unidad de Hemorragias Digestivas por HD aguda alta y baja. Se recogieron variables demográficas, clínicas y muestras de sangre venosa simultáneas para la determinación de Hb y HTC por GSV y LAB. Se analizó la concordancia de ambos métodos mediante el coeficiente de correlación intraclase (CCI) y el análisis de Bland-Altman. Resultados: Se incluyeron 132 pacientes. Un total de 87 (65,9%) eran varones y la edad media fue de 66,8 años. La GSV sobreestimó la Hb en 0,49 g/dl (intervalo de confianza del 95% 0,21-0,76) respecto al LAB. La concordancia fue muy buena en la Hb (CCI 0,931) y buena en el HTC (CCI 0,899), mostrando las gráficas de Bland-Altman tanto la concordancia como la sobreestimación de la determinación de la Hb por GSV. En 19 pacientes (14,39%) la Hb por GSV superó en más de 1 g/dl la determinación final obtenida por LAB. Conclusiones: La determinación precoz de Hb y HTC en pacientes con HD aguda mediante GSV resulta fiable en la valoración inicial de la anemia. La GSV sobreestima sistemáticamente el valor de Hb en al menos 0,5 g/dl, por lo que la evaluación clínica y hemodinámica del sangrante debe prevalecer sobre el resultado analítico (AU)

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Dilatación neumática en el tratamiento de pacientes con acalasia / Pneumatic dilation in the treatment of achalasia

INTRODUCCIÓN: La dilatación neumática y la miotomía quirúrgica son actualmente los tratamientos de elección de la acalasia sintomática. La selección de una u otra como primera opción depende de la experiencia de cada centro y de las preferencias del paciente. OBJETIVO: Revisar la experiencia en nuestro centro de la dilatación neumática en pacientes con acalasia. MATERIAL Y MÉTODOS: Se incluyeron todos los pacientes con diagnóstico clínico, endoscópico y manométrico compatible con acalasia a los que se les practicó una dilatación neumática en un periodo de 19 años. Todas las dilataciones se realizaron de forma sistemática con un balón Rigiflex(R), en la mayoría de los casos con presiones de 250, 250 y 300 mmHg en 3 tiempos de un minuto separados por un minuto de duración. Se evaluó el éxito de la dilatación en función de la sintomatología del paciente, número de sesiones requeridas y necesidad de cirugía, así como la presencia de complicaciones. RESULTADOS: Se incluyeron 171 pacientes, 53,2% varones y 46,8% mujeres, con una edad media de 51,53 ± 17,78 años (16-87), desde junio de 1993 hasta octubre de 2012. En 157 pacientes se utilizó un balón de 35mm, en 9 pacientes un balón de 30 mm y en 7 pacientes, uno de 40 mm. Del total de pacientes: 108 requirieron una sola sesión de dilatación, 56 dos sesiones con un tiempo medio entre la primera y la segunda sesión de 25,23 ± 43,25 meses (1-215) y 7 pacientes, 3 sesiones con un tiempo medio entre la segunda y la tercera sesión de 6,86 ± 5,33 meses (1-15). El 82% de los pacientes presentaron una buena evolución tras la dilatación, considerándose esta exitosa. De los 140 pacientes que presentaron respuesta, 121 tuvieron respuesta completa (desaparición total de los síntomas sin reaparición de los mismos) y 19 respuesta parcial (desaparición inicial de los síntomas con posterior reaparición). Un 15,8% de los pacientes requirieron cirugía (miotomía de Heller). En 4 de los 171 pacientes hubo complicación de la técnica, siendo todas ellas perforaciones que se resolvieron satisfactoriamente, 2 de ellas con tratamiento conservador y otras 2 de forma quirúrgica. No hubo ningún evento de mortalidad en relación con la técnica ni con las complicaciones de la misma. CONCLUSIONES: En nuestra serie, la dilatación neumática presentó una alta tasa de éxito, en la mayoría de los casos con una única sesión, y un escaso porcentaje de complicaciones, por lo que demuestra ser una técnica eficaz y segura para estos pacientes, evitando un gran número de intervenciones quirúrgicas

INTRODUCTION: Pneumatic dilation and surgical myotomy are currently the procedures of choice to treat achalasia. The selection of one or other treatment depends on the experience of each center and patient preferences. Background and aims: To review the experience of pneumatic dilation in patients with achalasia in our center. MATERIAL AND METHODS: We included all patients with a clinical, endoscopic and manometric diagnosis compatible with achalasia who underwent pneumatic dilation in a 19-year period. All dilations were routinely performed with a Rigiflex(R) balloon, usually at pressures of 250, 250 and 300mm Hg in three inflations of one minute, each separated by one minute. The success of the dilation was assessed on the basis of the patient's symptoms, the number of sessions, the need for surgery, and the presence of complications. RESULTS: A total of 171 patients were included, 53.2% men and 46.8% women, with a mean age of 51.53 ± 17.78 years (16-87 years), from June 1993 to October 2012. A 35-mm balloon was used in 157 patients, a 30-mm balloon in 9 patients and a 40-mm balloon in 7 patients. A single dilation session was required in 108 patients, two sessions were required in 56 patients, with a mean time between the first and second sessions of 25.23 ± 43.25 months (1-215 months), and 3 sessions were required in 7 patients with a mean time between the second and third sessions of 6.86±5.33 months (1-15 months). Outcome after dilation was successful in 81% of the patients. Of the 140 responders, 121 had complete response (complete disappearance of symptoms without recurrence) and 19 partial response (initial disappearance of symptoms with subsequent reappearance). Surgery (Heller myotomy) was required in 15.8% of the patients. Perforation occurred in 4 of the 171 patients as a complication of the technique; these perforations were satisfactorily resolved, two by conservative treatment and two by surgery. There was no mortality associated with the technique or its complications. CONCLUSIONS: In our series, pneumatic dilation had a high success rate. In most patients, a single session was required and the complications rate was low. These results show that this technique is safe and effective in these patients, avoiding a large number of surgical interventions

[Pneumatic dilation in the treatment of achalasia]. / Dilatación neumática en el tratamiento de pacientes con acalasia.

INTRODUCTION: Pneumatic dilation and surgical myotomy are currently the procedures of choice to treat achalasia. The selection of one or other treatment depends on the experience of each center and patient preferences. BACKGROUND AND AIMS: To review the experience of pneumatic dilation in patients with achalasia in our center. MATERIAL AND METHODS: We included all patients with a clinical, endoscopic and manometric diagnosis compatible with achalasia who underwent pneumatic dilation in a 19-year period. All dilations were routinely performed with a Rigiflex(®) balloon, usually at pressures of 250, 250 and 300mm Hg in three inflations of one minute, each separated by one minute. The success of the dilation was assessed on the basis of the patient's symptoms, the number of sessions, the need for surgery, and the presence of complications. RESULTS: A total of 171 patients were included, 53.2% men and 46.8% women, with a mean age of 51.53±17.78 years (16-87 years), from June 1993 to October 2012. A 35-mm balloon was used in 157 patients, a 30-mm balloon in 9 patients and a 40-mm balloon in 7 patients. A single dilation session was required in 108 patients, two sessions were required in 56 patients, with a mean time between the first and second sessions of 25.23±43.25 months (1-215 months), and 3 sessions were required in 7 patients with a mean time between the second and third sessions of 6.86±5.33 months (1-15 months). Outcome after dilation was successful in 81% of the patients. Of the 140 responders, 121 had complete response (complete disappearance of symptoms without recurrence) and 19 partial response (initial disappearance of symptoms with subsequent reappearance). Surgery (Heller myotomy) was required in 15.8% of the patients. Perforation occurred in 4 of the 171 patients as a complication of the technique; these perforations were satisfactorily resolved, two by conservative treatment and two by surgery. There was no mortality associated with the technique or its complications. CONCLUSIONS: In our series, pneumatic dilation had a high success rate. In most patients, a single session was required and the complications rate was low. These results show that this technique is safe and effective in these patients, avoiding a large number of surgical interventions.

[Early evaluation of anaemia in patients with acute gastrointestinal bleeding: venous blood gas analysis compared to conventional laboratory]. / Valoración precoz de la anemia en el paciente con hemorragia digestiva aguda: concordancia entre gasometría venosa y laboratorio convencional.

BACKGROUND AND OBJECTIVE: Evaluation of patients with acute gastrointestinal bleeding (AGB) requires early clinical evaluation and analysis. The aim of this study is to evaluate early concordance of hemoglobin (Hb) and hematocrit (HTC) levels determined by conventional venous blood gas analysis (VBG) and by conventional Laboratory in Emergencies (LAB). PATIENTS AND METHODS: Observational and prospective study of patients admitted in the Gastrointestinal Haemorrhage Unit with both high and low AGB. Demographic and clinical variables and simultaneous venous blood samples were obtained to determine Hb and HTC by VBG and LAB. Concordance in both methods was analysed by intra-class correlation coefficient (ICC) and Bland-Altman analysis. RESULTS: One hundred and thirty-two patients were included: 87 (65.9%) males, average age 66.8 years. VBG overestimated Hb in 0.49 g/dl (95% confidence interval: 0.21-0.76) with respect to LAB. Concordance was very high in Hb (ICC 0.931) and high in HTC (0.899), with the Bland-Altman graphs showing both concordance and overestimation of Hb levels determined by VBG. In 19 patients (14.39%), Hb by VBG exceeded in more than 1g/dL the final determination obtained by LAB. CONCLUSIONS: Early determination of Hb and HTC in patients with AGB by VBG provides reliable results in the initial evaluation of anaemia. VBG systematically overestimates Hb values by less than 0.5 g/dl, and therefore clinical and hemodynamic evaluation of the bleeding patient should prevail over analytical results.