Eficacia de rituximab en dermatomiositis y polimiositis refractarias al tratamiento convencional

We report one case of dermatomyositis and one of polymyositis refractory to several conventional inmunosupressive therapies, which present a response after treatment with rituximab, enabling steroid dose reduction and a prolonged remission.     

Factores asociados al desarrollo de efectos secundarios en pacientes con artritis reumatoide tratados con anti-factor de necrosis tumoral alfa

This article reviews the papers published on the factors related to the development of adverse effects in rheumatoid arthritis patients treated with anti-tumor necrosis factor-α drugs.The adverse effects studied were: infectious disease, cardiovascular complications, tumor development and mortality risk.     

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 300 mm 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.     

Factores asociados con el control del asma en pacientes de atención primaria en España: el estudio CHAS

Background

Asthma control is inadequate in all populations studied to date, leading to a major part of the cost of the disease. The aim of our study was to evaluate the prevalence of uncontrolled asthma in primary care patients and identify the associated factors.

Methods

We carried out a cross-sectional study of the population of primary care asthmatic patients over 18 years old in Spain (n=2159). Asthma control was measured with the Asthma Control Questionnaire (ACQ). The sociodemographic variables and treatment compliance were measured using a questionnaire. We built logistic-regression models using Asthma control, a dichotomous variable generated from ACQ score.

Results

The prevalence of uncontrolled asthma was 63.9%. Treatment with oral corticosteroids (OCS) (OR=6.55), greater asthma severity (OR=3.11), presence of a distressing event (OR=2.44), lower significance given to treatment compliance (OR=1.66) and living in a rural area (OR=1.29) are associated with uncontrolled asthma. On the contrary, sex, age, obesity, smoking, alcohol intake and educational level had no effect on asthma control.

Conclusions

In Spain asthma is still uncontrolled and some factors leading to this situation appear to be modifiable by the health system.     

Factores asociados y análisis descriptivo de la endocarditis infecciosa adquirida en el entorno hospitalario de un centro terciario de referencia

Introduction and objectives

The primary aim of this study was to evaluate associated factors, clinical features and prognosis of healthcare-related infective endocarditis cases compared with community-acquired and intravenous drug user-related episodes. Changes in the distribution of healthcare-related infective endocarditis were also analysed over time in our setting.

Methods

A prospective, observational, comparative study was performed. We included all the cases of infective endocarditis from January 2003 to June 2010, which were then classified into 2 groups: group 1: community-acquired and intravenous drug user origin, and group 2: nosocomial and non-nosocomial healthcare-related cases. The episodes were classified into 2 periods: period I: January/2003-June/2006 and period II: July/2006-June 2010. Univariate and multivariate analyses were performed.

Results

A total of 212 cases were included (group 1: 138, group 2: 74). The variables of age (risk ratio 1.026; 95% CI, 1.003 to 1.049), Charlson index (risk radio 1.242; 95% CI, 1.067 to 1.445), and previous heart surgery (risk ratio 2.522; 95% CI, 1.353 to 4.701) were independently associated with healthcare-related infective endocarditis on multivariate analysis. A non-significant increase was observed in healthcare-related cases of infective endocarditis in period II (40/104; 38.4% vs. 34/108; 31.4%).

Conclusions

The recent increase in healthcare-related infective endocarditis seems to be associated with the use of invasive procedures in elderly patients with prosthetic cardiac valve, and those with a greater number of underlying diseases, especially patients with chronic renal failure on haemodialysis.     

Absceso del músculo iliopsoas: tratamiento y evolución en una serie de 35 pacientes

Introduction

The present study was aimed at reviewing the iliopsoas abscess (IPA) from a contemporary perspective, on the basis of experience from two tertiary referral centres.

Material and methods

We performed a retrospective analysis of 35 cases of IPA diagnosed between 1998 and 2009. Their clinical and microbiological features were recorded, as well as their long-term outcome according to the type of treatment: antibiotics alone (10 patients), or antibiotics plus percutaneous drainage or surgery (25 patients).

Results

Primary abscess occurred in 8 patients. The most frequent source of secondary abscesses was spondylodiscitis. The classic clinical triad (fever, pain and functional impairment) was present in 10 patients, with a median duration of symptoms before diagnosis of 12 days. Staphylococcus aureus was the most frequently isolated microorganism. At the end of a median follow-up of 454 days, the risk of poor outcome (related death and/or relapse) was higher among patients with diabetes mellitus (44.4% vs. 7.7%; P=.027), with no significant differences according to the therapeutic approach (20.0% in the group of antibiotics alone vs. 28.0% in the group with drainage or surgery).

Conclusions

In our series, most cases of IPA were due to S. aureus and secondary to a skeletal source. Antibiotic therapy seems effective in the long-term, although diabetic patients had a higher risk of relapse.     

Factores asociados a la presencia del virus de Epstein-Barr en la cavidad oral de adolescentes de la ciudad de Cali (Colombia)

IntroductionThe Epstein-Barr virus (EBV) is classified as a group 1 carcinogen. The main route of EBV transmission is oral, through saliva. The present study aimed to determine the frequency of EBV detection in the oral cavity in high school students in the city of Cali (Colombia).Materials and methodsAnalytical cross-sectional study in order to determine the frequency of EBV detection in the oral cavity, the reasons for its prevalence and its association with several factors, in 1,565 individuals. The variables analyzed were sociodemographic factors, oral hygiene, oral health, sexual behavior, cigarrete smoking and alcohol intake. The association between the EBV detection and the variables evaluated was done through a generalized linear regression model with logarithmic linkage and Poisson distribution with robust variance.ResultsThe percentage of exposure to EBV in the oral cavity was 38.40% (CI 95%: 36.02-40.84). The frequency of presenting EBV exposure was 22% higher in men and the risk increased according to sexual behaviour. An inverse association with the school grade was found: the eleventh-grade participants had 27% less frequency of exposure to EBV than the lower grades (sixth to eighth). When analyzing the logistic model to study the association between EBV detection and independent variables, the association was overestimated. The overestimation ranged from 27 to 47% depending on the type of variable.ConclusionsThe frequency of EBV detection in the oral cavity of healthy students was similar to that previously described. Factors associated to sexual behavior increased the risk of opportunity to be exposed to EBV.     

Evidencias de la posición en decúbito prono para el tratamiento del síndrome de distrés respiratorio agudo: una puesta al día

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) have high incidence and mortality rates. Most of the recently introduced treatments have failed to improve the prognosis of patients with ALI or ARDS or to reduce mortality. Several studies have shown improved oxygenation in the prone position during mechanical ventilation in patients with ARDS. However, current evidence strongly suggests that placing ARDS patients in prone position does not improve survival or reduce the duration of mechanical ventilation. Therefore, though in clinical practice this position may improve refractory hypoxemia in patients with ARDS, there is no evidence to support its systematic use.     

Encuesta de adherencia al tratamiento en enfermedad inflamatoria intestinal. Estudio ENADEII

The rate of non-adherence to medical treatment in inflammatory bowel disease (IBD) is around 50%, with the consequent negative impact on treatment results, morbidity and cost.ObjectivesTo determine through an online survey among gastroenterologists with special dedication to IBD, their knowledge about the adherence to treatment of their patients and the methods used to improve it.MethodsAn email was sent to gastroenterologists from the technical office of the Crohn's disease and ulcerative colitis Spanish working group (GETECCU), with a link to the online survey.Results760 physicians were invited. One hundred eighty-four surveys were obtained (28.5%). A total of 68% of respondents had indexed IBD publications, 13% of which were on adherence. Although almost 99% considered adherence as very important/important, 25% of physicians did not assess it. Even though 100% considered that improving adherence would imply a better prognosis, 47% did not use any system to improve it. The factors associated with the assessment and improvement of adherence were: university hospital (81.4%), combined treatment with thiopurines and biological drugs (44.6%), physician gender (female) (63.1%), dedicating ≥ 6 hours weekly to IBD (71.6%), previous published indexed papers on IBD (68.5%) and on adherence in IBD (12.5%), and considering adherence as important/very important (98.9%).ConclusionsAlthough knowledge about the relevance of adherence to medical treatment in IBD is widespread, among the gastroenterologists with special dedication to IBD who were surveyed, almost half do not use any objective system to quantify it. An effort must be made to quantify and improve adherence to the treatment of these patients.     

Implantación de un sistema de vigilancia de infección de la herida quirúrgica al alta en herniorrafia y mastectomía

Introduction

Monitoring surgical site infection (SSI) performed during hospitalization can underestimate its rates due to the shortening in hospital stay. The aim of this study was to determine the actual rates of SSI using a post-discharge monitoring system.

Methods

All patients who underwent herniorraphy or mastectomy in the Hospital Universitario Ramón y Cajal from 1 January 2011 to 31 December 2011 were included. SSI data were collected prospectively according to the continuous quality improvement indicators (Indicadores Clinicos de Mejora Continua de la Calidad [INCLIMECC]) monitoring system. Post-discharge follow-up was conducted by telephone survey.

Results

A total of 409 patients were included in the study, of whom 299 underwent a herniorraphy procedure, and 110 underwent a mastectomy procedure. For herniorrhaphy, the SSI rate increased from 6.02% to 7.6% (the post-discharge survey detected 21.7% of SSI). For mastectomy, the SSI rate increased from 1.8% to 3.6% (the post-discharge survey detected 50% of SSI).

Conclusions

Post-discharge monitoring showed an increased detection of SSI incidence. Post-discharge monitoring is useful to analyze the real trend of SSI, and evaluate improvement actions. Post-discharge follow-up methods need to standardised.     

Candidemia y candidiasis invasora en el adulto. Formas clínicas y tratamiento

Invasive candidiasis is progressively increasing in frequency as a complication of the hospitalised adult patient. The availability of new antifungal drugs with lower toxicity and high efficacy has increased the complexity of managing of these infections. In parallel, the costs of the treatment of invasive fungal infections have considerably increased. Finding of a balance between the best benefit for the patient with the less costs is, nowadays, one of the main objectives of the current recommendations for the management of invasive candidiasis. In this review, the recommendations for the management of candidemia and other forms of invasive candidiasis (esophagitis, peritonitis, ocular, cardiovascular and osteoarticular candidiasis, central nervous system and urinary tract candidiasis, and chronic disseminated candidiasis) are analysed.     

Termoplastia bronquial en el tratamiento del asma

Despite the numerous guidelines and treatments available for asthma, the disease remains poorly controlled in some patients, who remain symptomatic, are a considerable burden on the health system, and account for most of the hospitalizations due to asthma.