Gastrointestinal endoscopy sedation and monitoring practices in Spain: a nationwide survey in the year 2014.

BACKGROUND AND STUDY AIMS: The introduction of new sedative agents and a desire for improved patient care have encouraged the use of sedation for gastrointestinal (GI) endoscopy over the last decade. This survey aims to provide, within Spain, national and regional data on gastroenterologists' endoscopic sedation and monitoring practices, and on their attitudes concerning these practices. METHODS: A 19-item survey covering the current practices of sedation and monitoring in GI endoscopy was electronically mailed to all members of the three nationwide scientific societies. RESULTS: Of 2476 e-mailed questionnaires, a total of 569 (23 %) were returned, proportionally representing the structure of the Spanish health care system. Monitoring and resuscitation resources were universally available, as well as post-endoscopy recovery rooms. Endoscopy teams usually included a registered nurse (98.5 %), an auxiliary nurse (80.5 %), and other physicians (25.7 %), generally anesthesiologists. More than half of esophagogastroduodenoscopies (EGDs) are performed with the patient under sedation; in 25 % of centers, more than 95 % colonoscopies are performed with the patient sedated, but a wide variation was observed. Pre-endoscopic risk is assessed in the vast majority of procedures. Propofol is the most commonly used sedative, either alone (in 70 % of EGDs and 80 % of colonoscopies) or in combination with other drugs. Private funding of a clinic was the only predictor of a significant increase in the use of sedation; 57.7 % of the respondents stated having difficulties in implementing sedation, with the limited availability of anesthesiologists and resuscitation training for the auxiliary staff the most common complaints. CONCLUSIONS: The use of sedation during GI endoscopy in Spain varies widely but is on the increase and is more common in private practice. Propofol is the preferred sedative in all procedures.

Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy (PEG) tube insertion under antiplatelet therapy: a systematic review with a meta-analysis.

BACKGROUND AND AIM: Patients undergoing percutaneous endoscopic gastrostomy (PEG) tube placement often are under antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. This systematic review aims to assess if maintaining aspirin and/or clopidogrel treatment increases the risk of bleeding following PEG placement. METHODS: A systematic search of the MEDLINE, EMBASE, and SCOPUS databases was developed for studies investigating the risk of bleeding in patients on antiplatelet therapy undergoing PEG tube insertion. Summary estimates, including 95 % confidence intervals (CI), were calculated. A fixed or random effects model was used depending on heterogeneity (I2). Publication bias risks were assessed by means of funnel plot analysis. RESULTS: Eleven studies with a total of 6,233 patients (among whom 3,665 were undergoing antiplatelet treatment), met the inclusion criteria and were included in the quantitative summary.Any PEG tube placement-related bleeding was found in 2.67 % (95 % CI 1.66 %, 3.91 %) of the entire population and in 2.7 % (95 % CI 1.5 %, 4.1 %) of patients not receiving antiplatelet therapy. Pooled relative risk (RR) for bleeding in patients under aspirin, when compared to controls, was 1.43 (95 % CI 0.89, 2.29; I2 = 0 %); pooled RR for clopidogrel was 1.21 (95 % CI 0.48, 3.04; I2 = 0 %) and for dual antiplatelet therapy, 2.13; (95 % CI 0.77,5.91; I2 = 47 %). No significant publication bias was evident for the different medications analyzed. CONCLUSION: Antiplatelet therapy was safe among patients undergoing PEG tube insertion. Future prospective and randomized studies with larger sample sizes are required to confirm the results of this study.

Risk of bleeding in patients undergoing percutaneous endoscopic gastrotrostomy (PEG) tube insertion under antiplatelet therapy: a systematic review with a meta-analysis / Riesgo de sangrado en pacientes sometidos a inserción de un tubo de gastrostomía percutánea endoscópica y en tratamiento antiplaquetario: una revisión sistemática con metaanálisis

BACKGROUND AND AIM: Patients undergoing percutaneous endoscopic gastrostomy (PEG) tube placement often are under antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. This systematic review aims to assess if maintaining aspirin and/or clopidogrel treatment increases the risk of bleeding following PEG placement. METHODS: A systematic search of the MEDLINE, EMBASE, and SCOPUS databases was developed for studies investigating the risk of bleeding in patients on antiplatelet therapy undergoing PEG tube insertion. Summary estimates, including 95 % confidence intervals (CI), were calculated. A fixed or random effects model was used depending on heterogeneity (I2). Publication bias risks were assessed by means of funnel plot analysis. RESULTS: Eleven studies with a total of 6,233 patients (among whom 3,665 were undergoing antiplatelet treatment), met the inclusion criteria and were included in the quantitative summary. Any PEG tube placement-related bleeding was found in 2.67 % (95 % CI 1.66 %, 3.91 %) of the entire population and in 2.7 % (95 % CI 1.5 %, 4.1 %) of patients not receiving antiplatelet therapy. Pooled relative risk (RR) for bleeding in patients under aspirin, when compared to controls, was 1.43 (95 % CI 0.89, 2.29; I 2 = 0 %); pooled RR for clopidogrel was 1.21 (95 % CI 0.48, 3.04; I 2 = 0 %) and for dual antiplatelet therapy, 2.13; (95 % CI 0.77, 5.91; I2 = 47 %). No significant publication bias was evident for the different medications analyzed. CONCLUSION: Antiplatelet therapy was safe among patients undergoing PEG tube insertion. Future prospective and randomized studies with larger sample sizes are required to confirm the results of this study

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Efficacy of Dietary Treatment for Inducing Disease Remission in Eosinophilic Gastroenteritis.

OBJECTIVES: Various dietary interventions have been used to treat patients with eosinophilic gastroenteritis (EGE). Concrete evidence as to the effectiveness of such treatments in inducing disease remission is, however, lacking. The aim of the study was to systematically review the efficacy of dietary therapies in inducing EGE remission. METHODS: We performed a systematic search for the MEDLINE, EMBASE, and SCOPUS libraries for studies investigating the efficacy of dietary interventions (in both histological and symptomatic remission) for children and adults with EGE and colitis. RESULTS: The search yielded 490 references; 30 were included in the review, with most of these references being "low-quality" individual cases or short case series. No significant publication bias was found. Elemental diets in children were linked to 75.8% of clinical improvement, but few of these patients underwent a histological evaluation. Allergy-testing results have been used scarcely in EGE. Empiric elimination of allergy-associated foods was the most commonly used option. The variable results in terms of symptom relief, however, were scarcely accompanied by histological confirmation. Clinical and methodological heterogeneity hindered the performance of quantitative summaries for the efficacy of dietary therapies in inducing disease remission. CONCLUSIONS: Symptomatic improvements reported for dietary treatment in EGE by most of the available literature are questionable because of the lack of objective evaluation of clinical changes and the very limited assessment of histological remission. Because of the relative lack of well-designed, high-quality studies, the unequivocal use of dietary treatment for patients with EGE and colitis cannot be supported. Further research should be undertaken.

Transcultural adaptation and validation of the "Adult Eosinophilic Esophagitis Quality of Life Questionnaire" into Spanish.

BACKGROUND: The "Adult Eosinophilic Esophagitis Quality of Life (EoE-QoL-A) Questionnaire" was developed in English as a valid, reliable, and disease-specific health-related QoL measure.This research aims to adapt and validate this questionnaire for Spanish-speaking patients. PATIENTS AND METHODS: A multicenter, observational, prospective study was conducted at 8 Spanish hospitals. The cultural adaptation of the original EoE-QoL-A questionnaire was undertaken through a standardized 3-phase procedure: 1. Translation; 2. Retrotranslation; and 3. Pilot study. Patients completed the Hospital Anxiety and Depression Scale (HADS), the Short Form (SF)-12, the Brief Illness Perception Questionnaire (BIPQ), and the adapted EoE-QoL-A, with a retest 3 months later.Statistical analysis included construct validity, internal consistency, criterion validity, and reproducibility. RESULTS: One hundred and seventy adult EoE patients (73.5 % male; aged 33.5 ± 11.4-y) were included in the study.With regard to internal validity, all Cronbach alpha values were > 0.75. A significant correlation between items assessed in the SF-12, BIPQ and EoE-QoL-A questionnaires (p < 0.001) was observed. Correlations with the HADS were stronger for anxiety than for depression levels. Anxiety related to disease diagnosis and choking were the most affected dimensions; less affected were the dimensions related to eating, social, and emotional development. Intraclass correlation coefficients between the test and retest assessments were acceptable for all questionnaires, with the highest values (0.73-0.84) calculated for the EoE-QoL-A Spanish version. CONCLUSION: The Spanish version of the EoE-QoL-A is a reliable, valid, and responsive questionnaire. Diagnosis and choking anxiety were the most affected dimensions in the health-related QoL in adult EoE patients.

Relation between eosinophilic esophagitis and oral immunotherapy for food allergy: a systematic review with meta-analysis.

BACKGROUND: The onset of eosinophilic esophagitis (EoE) after oral immunotherapy (OIT) has been repeatedly described in patients with immunoglobulin E (IgE)-mediated food allergy in recent years, but the relation between the 2 conditions has not been fully assessed and quantified. OBJECTIVE: To provide a systematic review of the evidence for an association between OIT and EoE. METHODS: Electronic searches were performed with keywords relating to EoE and OIT in the MEDLINE, EMBASE, and SCOPUS databases. Summary estimates were calculated. A fixed-effects model was used depending on heterogeneity (I(2)). Risk of publication bias was assessed by funnel plot analysis and the Egger test. RESULTS: The search yielded 118 documents, 15 of which were included in the quantitative summary. Most reported information came from children undergoing peanut, milk, and egg OIT. Significant publication bias in favor of studies reporting the development of EoE after OIT was documented. The overall prevalence of EoE after OIT was 2.7% (95% confidence interval 1.7%-4.0%, I(2) = 0%). Differences between medium-to high-quality studies and those of low quality were documented (3.5% vs 2.5%, respectively). EoE often resolved after OIT discontinuation; histologic remission of EoE achieved after allergen immunotherapy also was documented in 2 patients whose topical fluticasone treatment failed. CONCLUSION: New onset of EoE after OIT occurs in up to 2.7% of patients with IgE-mediated food allergy undergoing this treatment strategy. The limited data on the utility of allergen immunotherapy as a therapy for EoE prevent a recommendation for this treatment option.

Transcultural adaptation and validation of the "Adult Eosinophilic Esophagitis Quality of Life Questionnaire" into Spanish / Adaptación transcultural y validación al español del "Adult Eosinophilic Esophagitis Quality of Life Questionnaire"

Background: The "Adult Eosinophilic Esophagitis Quality of Life (EoE-QoL-A) Questionnaire" was developed in English as a valid, reliable, and disease-specific health-related QoL measure. This research aims to adapt and validate this questionnaire for Spanish-speaking patients. Patients and methods: A multicenter, observational, prospective study was conducted at 8 Spanish hospitals. The cultural adaptation of the original EoE-QoL-A questionnaire was undertaken through a standardized 3-phase procedure: 1. Translation; 2. Retrotranslation; and 3. Pilot study. Patients completed the Hospital Anxiety and Depression Scale (HADS), the Short Form (SF)-12, the Brief Illness Perception Questionnaire (BIPQ), and the adapted EoE-QoL-A, with a retest 3 months later. Statistical analysis included construct validity, internal consistency, criterion validity, and reproducibility. Results: One hundred and seventy adult EoE patients (73.5 % male; aged 33.5 ± 11.4-y) were included in the study. With regard to internal validity, all Cronbach alpha values were > 0.75. A significant correlation between items assessed in the SF-12, BIPQ and EoE-QoL-A questionnaires (p < 0.001) was observed. Correlations with the HADS were stronger for anxiety than for depression levels. Anxiety related to disease diagnosis and choking were the most affected dimensions; less affected were the dimensions related to eating, social, and emotional development. Intraclass correlation coefficients between the test and retest assessments were acceptable for all questionnaires, with the highest values (0.73-0.84) calculated for the EoE-QoL-A Spanish version. Conclusion: The Spanish version of the EoE-QoL-A is a reliable, valid, and responsive questionnaire. Diagnosis and choking anxiety were the most affected dimensions in the health-related QoL in adult EoE patients (AU)

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Efficacy of dietary interventions for inducing histologic remission in patients with eosinophilic esophagitis: a systematic review and meta-analysis.

BACKGROUND & AIMS: Various dietary interventions have been used to treat patients with eosinophilic esophagitis (EoE), yielding varied results. This systematic review assesses the efficacy of different dietary therapies in inducing disease remission. METHODS: We performed a systematic search of the MEDLINE, EMBASE, and SCOPUS databases for studies investigating the efficacy of dietary interventions (reducing infiltration by immune cells <15 eosinophils/high-power field in esophageal biopsies) for pediatric and adult patients with EoE. Summary estimates, including 95% confidence intervals (CI), were calculated for exclusive feeding with amino acid-based elemental formulas, allergy test result-directed food elimination diets, and 6-food elimination diets (SFED). A fixed- or random-effects model was used depending on heterogeneity (I(2)); publication bias risks were assessed by means of funnel plot analysis. RESULTS: The search yielded 581 references; of these, 33 were included in the quantitative summary. We analyzed data on a total of 1317 patients with EoE (1128 children and 189 adults) who received different dietary treatments. Elemental diets were effective for 90.8% of cases (95% CI, 84.7%-95.5%; I(2) = 52.3%), SFED for 72.1% (95% CI, 65.8%-78.1%; I(2) = 0), and allergy test result-directed food elimination for 45.5% of cases (95% CI, 35.4%-55.7%; I(2) = 75.1%). Additional strategies (elimination of cow's milk, gluten-free diets, and 4-food elimination diet) were also evaluated. Adults vs children had no significant differences in remission after dietary interventions (67.2% vs 63.3%). CONCLUSIONS: Dietary interventions are effective in producing histologic remission in patients with EoE. Elemental diets and SFEDs were the most effective, achieving <15 eosinophils/high-power field in 90.8% and 72.1% of patients, respectively.

Same-day bidirectional endoscopy with nonanesthesiologist administration of propofol: safety and cost-effectiveness compared with separated exams.

BACKGROUND AND AIM: The safety and cost-effectiveness of a combination of esophagogastroduodenoscopy (EGD) and colonoscopy [or bidirectional endoscopy (BDE)] versus alternative-day EGD and colonoscopy when using nonanesthesiologist administration of propofol have never been evaluated. PATIENTS AND METHODS: This was a single-center prospective registry of consecutive American Society of Anaesthesiology class I-III outpatients undergoing EGD, colonoscopy, and BDE. Propofol was the sole sedative used. Adverse events, recovery time, and procedure-related costs were analyzed. RESULTS: Among the 1500 study participants (51.5% women), EGD, colonoscopy, and BDE were carried out on 449, 702, and 349 patients, respectively. All patients were discharged directly from the endoscopy unit. No sex differences were found with respect to age (mean 54.4, range 18-96 years), BMI, or procedure type. Propofol doses for BDE were 25.9% less than when EGD and colonoscopy were performed separately (P<0.001). Adverse events, including transient O2 saturation less than 90%, systolic blood pressure less than 90 mmHg, and bradycardia (<50 bpm), appeared in 10.7% of single EGD and 8.6% of EGD within BDE; for colonoscopies, the figures were 8.6 and 9.5%, respectively (P=NS). Recovery time to discharge after BDE was 47.9% shorter than when EGD and colonoscopy were performed separately (P<0.001). The cost of same-day BDE was 28.1% lower than that of EGD and colonoscopy performed as separated procedures (P<0.001). CONCLUSION: Same-day BDE with nonanesthesiologist administration of propofol resulted in reductions in propofol doses, recovery time, and procedure-related costs as compared with carrying out EGD and colonoscopy separately, without an increase in adverse events.

The relationship between proximal and distal colonic adenomas: is screening sigmoidoscopy enough in the presence of a changing epidemiology?

BACKGROUND AND STUDY AIMS: Because the relationship between distal and proximal colonic findings remains uncertain, controversy exists over whether proctosigmoidoscopy or colonoscopy is more suitable for colorectal cancer (CRC) screening. We aim to describe the distribution and characteristics of polyps removed in colonoscopy screening. PATIENTS AND METHODS: A prospective registry of a colonoscopy-based CRC screening program was developed on asymptomatic individuals over 50 years. All polyps were removed and characterized. Polyp size and histology were noted. Adenomas were considered advanced if they measured greater than 10 mm or were tubulovillous, villous, or malignant. The prevalence of advanced proximal polyps was determined and patients were categorized according to their family history of CRC. RESULTS: A total of 696 individuals (418 women), aged 57.7 ± 10.3 years, were examined; 45.8% presented a colonic lesion, being adenomatous polyps in 32.7% individuals. Among these, 24.7% were advanced adenomas. Three patients (0.6%) presented invasive CRC. There were no significant differences with respect to sex and family history of CRC between patients with or without adenomas. Adenomas were more prevalent in individuals aged at least 65, irrespective of location (P<0.001). In 65.1% of individuals with adenomatous polyps in the right colon, there were no synchronous adenomas in the left colon (P<0.001). More adenomas were also present in the right colon of patients with no family history of CRC (P<0.001). CONCLUSION: Most patients with adenomatous polyps in the right colon showed no synchronic adenomas on the left side. Lesions on the right side would have gone undetected if the individuals undergoing CRC screening had been explored with proctosigmoidoscopy.

Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease.

BACKGROUND: Although empiric exclusion from the diet of the 6 food groups most likely to trigger allergies achieves eosinophilic esophagitis (EoE) remission in children, data on its prolonged efficacy and effects on adults are lacking. OBJECTIVE: We sought to evaluate the efficacy of a 6-food elimination diet in inducing and maintaining prolonged remission in patients with adult EoE. METHODS: Sixty-seven consecutive patients with adult EoE were prospectively recruited and treated exclusively with a diet avoiding cereals, milk, eggs, fish/seafood, legumes/peanuts, and soy for 6 weeks. Subsequent challenge was undertaken by sequentially reintroducing all excluded single foods, followed by endoscopy and biopsies, which were developed every 6 weeks in case of response (eosinophil peak count reduction to <15/high-power field [hpf]). A food was considered a trigger for EoE and removed from the diet if pathologic eosinophilic infiltration (≥15 eosinophils/hpf) reappeared. Food-specific serum IgE measurements and skin prick tests were performed before initiating the diet. RESULTS: Forty-nine (73.1%) patients exhibited significantly reduced eosinophil peak counts (<15 eosinophils/hpf) before sequential single-food reintroduction. A single offending food antigen was identified in 35.71% of patients, 2 food triggers were identified in 30.95%, and 3 or more food triggers were identified in 33.3%. Cow's milk was the most common food antigen (61.9%), followed by wheat (28.6%), eggs (26.2%), and legumes (23.8%). Prior allergy tests showed no concordance with food-reintroduction challenge results. All patients who continued to avoid the offending foods maintained histopathologic and clinical EoE remission for up to 3 years. CONCLUSIONS: An empiric 6-food elimination diet effectively induced remission of active adult EoE, which was maintained for up to 3 years with individually tailored, limited exclusion diets.

Bone mineral density directly correlates with duodenal Marsh stage in newly diagnosed adult celiac patients.

OBJECTIVES: To estimate the prevalence of low bone mineral density (BMD) in a prospective series of adult celiac patients and to identify nutritional and metabolic factors associated with osteoporosis and osteopenia. METHODS: Patients over 18 years of age who were consecutively and newly diagnosed with celiac disease (CD) were recruited. A bone density scan with dual-energy X-ray absorptiometry was carried out on the left hip and lumbar spine; nutritional parameters were analyzed and a hormone study conducted in order to exclude secondary low BMD. RESULTS: 40 patients (36 females/4 males) between the ages of 18 and 68 (mean 44.25 years) were recruited. Overall, at the moment of diagnosis 45% of patients exhibited low BMD at both demarcations. Risk of hip fracture was generally low, but ascended to mild in patients with villous atrophy (p = 0.011). Differences in major fracture risk were also observed depending on Marsh stage (p = 0.015). Significant differences were observed in nutritional status between patients with and without duodenal villous atrophy, with body mass index and blood levels of prealbumin, iron, vitamin D and folic acid significantly lower in Marsh III stage patients. No differences were found in blood hormone levels between Marsh stages or BMDs. The degree of bone mass loss in the lumbar spine directly correlated to Marsh stage. In the hip, a parallel association between BMD and Marsh stage was also observed, but did not reach statistical significance. CONCLUSION: Duodenal villous atrophy, through malabsorption, was the main determinant factor for low BMD in adult-onset CD patients.

Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective: a prospective Spanish study over 1000 consecutive exams.

BACKGROUND AND STUDY AIMS: Propofol is increasingly being used in sedated colonoscopy. This paper assesses the safety and efficacy of nonanesthesiologist-administered propofol in a large series of colonoscopies. PATIENTS AND METHODS: A prospective registry of consecutive American Society of Anesthetics (ASA) class I and II outpatients undergoing colonoscopy was carried out. Propofol, administered by a nurse under an endoscopist's supervision, was the sole sedative agent used. RESULTS: Of the 1000 patients (563 women/437 men, mean age 57, range 8-89 years) included in the study, 57.4% showed ASA I and 42.6% ASA II characteristics. The cecal intubation rate was 96.9%. 48.2% of the procedures were for therapeutic purposes. The mean propofol dose was 177 mg (range 50-590 mg). Doses correlated inversely with patient age (r=-0.38; P<0.001) and were lower in ASA II patients (P<0.001) and in diagnostic (rather than therapeutic) exams (P<0.001). The average recovery time (from extracting the colonoscope to patient discharge) was 18.6 min (range 4-75) and longer in ASA II patients (P=0.05). A pulse oximetry saturation of less than 90% and a decrease in systolic blood pressure of more than 20 mmHg were observed in 24 (2.4%) and 385 (35.8%) patients, respectively. Both events were more frequent in patients older than 65 years (P<0.05); the latter was more common in ASA II patients. CONCLUSION: Colonoscopy under endoscopist-controlled propofol sedation in low-risk patients is safe and effective, allowing for a complete exploration, although patients at least 65 years old and/or classified as ASA II are more likely to present a decrease in blood pressure and have a prolonged recovery time.

Subepithelial collagen deposition, profibrogenic cytokine gene expression, and changes after prolonged fluticasone propionate treatment in adult eosinophilic esophagitis: a prospective study.

BACKGROUND: Recent research shows that both pediatric and adult patients with eosinophilic esophagitis (EoE) experience esophageal remodeling marked by increased collagen deposition in which TGF-ß plays an important role. However, limited data are available on the intensity and reversibility of fibrous remodeling in adults with EoE. OBJECTIVE: We sought to analyze differences in collagen deposition in the lamina propria (LP) and profibrogenic cytokine gene expression along with other changes induced by prolonged treatment with fluticasone propionate in adults with EoE. METHODS: Ten adults given consecutive diagnoses of EoE were studied prospectively. Deep esophageal biopsy specimens were obtained before and after 1 year of treatment with fluticasone propionate. Collagen deposition in the LP was assessed in tissue sections with the aid of the Masson trichrome technique. IL5, TGFB1, fibroblast growth factor 9 (FGF9), and CCL18 gene expression was quantified through real-time PCR. EoE results were compared among samples from 10 adult patients with gastroesophageal reflux disease and 10 control subjects with healthy esophagi. RESULTS: Patients with EoE showed a significant increase in subepithelial collagen deposition; this correlated positively with eosinophil density in the LP and the patient's age. Prolonged steroid treatment induced a nonsignificant reduction in subepithelial fibrosis, which remained significantly higher than in control subjects. Profibrogenic cytokine gene expression also increased in patients with EoE, with IL5 (P < .001), FGF9 (P = .005), and CCL18 (P = .008) all significantly upregulated. After 1 year of treatment, a reduction was observed in gene expression; for CCL18 expression, this decrease was statistically significant (P < .001). CONCLUSIONS: Esophageal remodeling is associated with upregulated gene expression of profibrogenic cytokines in adults with EoE. Prolonged treatment with fluticasone propionate leads to a nonsignificant reduction in subepithelial collagen deposition accompanied by downregulation of profibrogenic cytokine gene expression, with that of CCL18 being especially significant.

Hepatic osteodystrophy: An important matter for consideration in chronic liver disease.

Hepatic osteodystrophy (HO) is the generic term defining the group of alterations in bone mineral metabolism found in patients with chronic liver disease. This paper is a global review of HO and its main pathophysiological, epidemiological and therapeutic aspects. Studies examining the most relevant information concerning the prevalence, etiological factors, diagnostic and therapeutic aspects involved in HO were identified by a systematic literature search of the PubMed database. HO generically defines overall alterations in bone mineral density (BMD) (osteoporosis or osteopenia) which appear as a possible complication of chronic liver disease. The origin of HO is multifactorial and its etiology and severity vary in accordance with the underlying liver disease. Its exact prevalence is unknown, but different studies estimate that it could affect from 20% to 50% of patients. The reported mean prevalence of osteoporosis ranges from 13%-60% in chronic cholestasis to 20% in chronic viral hepatitis and 55% in viral cirrhosis. Alcoholic liver disease is not always related to osteopenia. HO has been commonly studied in chronic cholestatic disease (primary biliary cirrhosis and primary sclerosing cholangitis). Several risk factors and pathogenic mechanisms have been associated with the loss of BMD in patients with chronic liver disease. However, little information has been discovered in relationship to most of these mechanisms. Screening for osteopenia and osteoporosis is recommended in advanced chronic liver disease. There is a lack of randomized studies assessing specific management for HO.

Levels of pollutants in indoor air and respiratory health in preschool children: a systematic review.

The aim of this paper is thus to identify, evaluate, and summarize in a systematic fashion all the epidemiological studies that have analyzed the association between exposure to specific indoor air pollutants and respiratory disease among children under the age of five. A search was carried out in the main biomedical bibliographic sources in December 2006 and updated in February 2008. The study period covered 12 years (1996-2007). All the selected papers were carefully read. We focused on studies that analyzed at least one indicator of respiratory health and which included one or more indoor air pollutants in relation to the respiratory health of children under the age of 5. Studies that analyzed passive smoking as the sole source of indoor air pollution were not included. Fourteen studies were considered to be relevant. The most analyzed pollutant was nitrogen dioxide, followed by volatile organic compounds, airborne particulates and other pollutants; phthalates and CO(2). The literature reviewed within our criteria seems to indicate that several indoor pollutants, even at the moderate levels found in the developed countries, could be harmful to the respiratory health of very young children. Future research should focus on conducting more studies, preferably making use of cohorts, with adequate techniques for measuring indoor pollution levels.

Environmental factors affecting children's respiratory health in the first years of life: a review of the scientific literature.

The aim of this paper is to quantitatively summarize the original articles on the relationship between environmental hazards and respiratory health in young children. A search was carried out in the main biomedical bibliographical sources in December 2006 and then the results were updated in June 2007. The study period covered 11 years (1996-2006). The information was assessed by reviewing the abstracts. Six hundred and forty documents were recovered. Documents from the United States accounted for 23.5% of articles. The production tended to increase over the study period. The factor most widely studied was air pollution, with outdoor air pollution being studied more (just over 50% of articles) than indoor air pollution (40%). Asthma was the most often studied condition (75% of articles). In a third of the cases, the information was obtained from hospital or health center records, and in 20% from questionnaires. The main diagnostic criterion was clinical. Infection of the inferior respiratory tracts predominated in children less than 3 years of age. An awareness of the role played by pollution and environmental hazards is fundamental in the management and prevention of respiratory problems in childhood, and this is reflected in the literature reviewed. However, very few synthesis studies have been carried out on this matter.

Prognostic factors in gastrointestinal bleeding due to peptic ulcer: construction of a predictive model.

OBJECTIVES: The identification of prognostic factors of easy application in clinical practice can improve the diagnostic and therapeutic decision making process in upper gastrointestinal bleeding (UGB). The present study estimates the capacity to predict an unfavorable clinical course (mortality, unstable bleeding, and/or interventional therapy) on the basis of the preendoscopic and endoscopic clinical analytical findings in patients with UGB owing to peptic ulcer. METHOD: A retrospective cohort study was made of 473 adult patients seen in the Emergency Service of a District Hospital, and diagnosed with UGB secondary to gastroduodenal ulcer. Logistic regression analysis was used to construct different models, with the evaluation of their predictive capacity based on calculation of the area under the receiver operating curve (ROC). The final model was used to calculate the probabilities of an unfavorable clinical course for different profiles, with the purpose of constructing an algorithm of help in the decision making process applied to patients initially considered to be at low risk (Forrest classification IIb and III). RESULTS: The model with the Forrest variable showed a high predictive capacity: ROCa=0.81 (95% confidence interval, 0.76-0.85). Incorporation to the model of clinical and preendoscopic factors (type of UGB, hematocrit, kidney failure, and liver disease) significantly increased its predictive capacity: ROCa=0.87 (95% confidence interval, 0.83-0.91). This model allows the differentiation of different complication risk levels in patients initially at low risk according to the Forrest classification (IIb and III). CONCLUSIONS: The Forrest classification is the principal predictive factor for an unfavorable course in patients with gastrointestinal bleeding owing to peptic ulcer, though clinical factors are also important and should complement the decision taking process.

[Antibiotic treatment onset delay and clinical evolution in admitted patients with community-acquired pneumonia]. / Demora del tratamiento antibiótico y evolución de los pacientes con neumonía adquirida en la comunidad que requieren hospitalización.

BACKGROUND AND OBJECTIVE: The delay in the initiation of antibiotic treatment in patients with community-acquired pneumonia (CAP) could influence their prognostic. The aim of our study was to evaluate the influence of a delay in antibiotic treatment on mortality, occurrence of complications, and length of stay in the hospital, in relation to the prior duration of the fever. PATIENTS AND METHOD: This is a cohort study which includes all patients over 18 years of age admitted with CAP over a 4 year period. The response variables analysed were in-hospital mortality, average stay in days and occurrence of complications during evolution. The relationship between the delay in antibiotic treatment and the outcome variables was estimated by logistic regression models, adjusting the estimations by PSI (Pneumonia Severity Index) and APACHE II (Acute Physiology and Chronic Health Evaluation). RESULTS: Six hundred fifty-nine patients were included (average age of 71 years, 71% males). Seventy-six (11.6%) patients died, 12.1% of those who arrived after 48 hours (55.4% of patients) and 10.9% of those who came early. The delay in antibiotic treatment was associated with a higher mortality (odds ratio [OR] = 3.05; 95% confidence interval [CI], 0.86-10.9; threshold of 8 h), prolonged stay (OR = 2.38; CI 95%, 1.11-5.14; threshold of 5 h) and a higher rate of complications (OR = 2.24; CI 95%, 0.90-5.53; threshold of 3 h). CONCLUSIONS: Our results suggest the importance of the early administration of antibiotics in patients with CAP. There is also an increased risk for each of these outcomes in those patients with a history of fever of more than 2 days before arriving in hospital.

Demora del tratamiento antibiótico y evolución de los pacientes con neumonía adquirida en la comunidad que requieren hospitalización / Antibiotic treatment onset delay and clinical evolution in admitted patients with community-acquired pneumonia

Fundamento y objetivo: La demora del tratamiento antibiótico en pacientes con neumonía adquirida en la comunidad (NAC) puede influir en su pronóstico. El objetivo del estudio ha sido estimar la influencia del retraso en el tratamiento antibiótico sobre la mortalidad, la estancia hospitalaria y la aparición de complicaciones, teniendo en cuenta la duración previa de la fiebre. Pacientes y método: Se trata de un estudio de cohortes en pacientes mayores de 18 años que ingresaron por NAC durante un período de 4 años. La relación entre la demora del tratamiento (para diferentes umbrales) y las variables de respuesta (mortalidad, estancia prolongada y complicaciones) se estimó mediante regresión logística, ajustando por la gravedad inicial. Resultados: Incluimos a 659 pacientes (un 71% varones), con una edad media de 71 años. Fallecieron 76 (11,6%), un 12,1% de los que acudieron con más de 2 días de fiebre (el 55,4% de los pacientes) y un 10,9% de los que acudieron precozmente. La demora del tratamiento antibiótico se asoció con un incremento de la mortalidad (odds ratio [OR] = 3,05; intervalo de confianza [IC] del 95%, 0,86-10,9; umbral de 8 h), una estancia prolongada (OR = 2,38; IC del 95%, 1,11-5,14; umbral de 5 h) y una mayor incidencia de complicaciones (OR = 2,24; IC del 95%, 0,90-5,53; umbral de 3 h). Las asociaciones fueron de mayor magnitud en los casos con fiebre de más de 48 h. Conclusiones: Nuestros resultados apoyan la importancia de la administración precoz de antibióticos en los pacientes con NAC. El incremento del riesgo es mayor si la demora del tratamiento se asocia a una duración previa de la fiebre superior a 2 días

Background and objective: The delay in the initiation of antibiotic treatment in patients with community-acquired pneumonia (CAP) could influence their prognostic. The aim of our study was to evaluate the influence of a delay in antibiotic treatment on mortality, occurrence of complications, and length of stay in the hospital, in relation to the prior duration of the fever. Patients and method: This is a cohort study which includes all patients over 18 years of age admitted with CAP over a 4 year period. The response variables analysed were in-hospital mortality, average stay in days and occurrence of complications during evolution. The relationship between the delay in antibiotic treatment and the outcome variables was estimated by logistic regression models, adjusting the estimations by PSI (Pneumonia Severity Index) and APACHE II (Acute Physiology and Chronic Health Evaluation). Results: Six hundred fifty-nine patients were included (average age of 71 years, 71% males). Seventy-six (11.6%) patients died, 12.1% of those who arrived after 48 hours (55.4% of patients) and 10.9% of those who came early. The delay in antibiotic treatment was associated with a higher mortality (odds ratio [OR] = 3.05; 95% confidence interval [CI], 0.86-10.9; threshold of 8 h), prolonged stay (OR = 2.38; CI 95%, 1.11-5.14; threshold of 5 h) and a higher rate of complications (OR = 2.24; CI 95%, 0.90-5.53; threshold of 3 h). Conclusions: Our results suggest the importance of the early administration of antibiotics in patients with CAP. There is also an increased risk for each of these outcomes in those patients with a history of fever of more than 2 days before arriving in hospital