Manejo médico y quirúrgico en pacientes con insuficiencia venosa mixta : comparación de características clínicas y hemodinámicas

La insuficiencia venosa superficial puede ser causa de insuficiencia venosa profunda, por tanto el manejo quirúrgico del sistema superficial puede mejorar la insuficiencia profunda En nuestro medio no se acostumbra a intervenir quirúrgicamente pacientes con insuficiencia venosa mixta bajo la creencia de exacerbar la enfermedad o generar complicaciones. METODOLOGIA: Se realizó un estudio retrospectivo, tomando pacientes con insuficiencia venosa mixta, entre el año 2006 y 2010, comparando parámetros hemodinámicos por duplex, y parámetros clínicos, según la clasificación CEAP, en los pacientes sometidos a cirugía convencional y en pacientes que recibieron manejo médico conservador. RESULTADOS: Se obtuvieron 45 pacientes, 65% con manejo quirúrgico y 35% manejo médico, con características sociodemograficas y comorbilidades comparables. Sin diferencia en el número de complicaciones (p=0,64), existió una mejoría en el 77% de los pacientes del grupo quirúrgico en parámetros hemodinámicos y de ningún paciente en el grupo de manejo médico, y en mejoría de ulceras activas de 83% y de 33%, respectivamente. DISCUSION: Nuestro estudio constituye una primera aproximación en la investigación en pacientes con esta patología en nuestro medio que son llevados a manejo quirúrgico. Estos resultados sugieren un posible beneficio en cuanto a los parámetros hemodinámicos venosos profundos y en las características clínicas, especialmente cuando existen ulcera activas, cuando los pacientes con insuficiencia venosa mixta son llevados a manejo quirúrgico. Sin embargo, se requieren de estudios futuros que permitan demostrar así estos resultados en nuestro medio.

Cáncer gástrico en Colombia entre 2000 y 2009

Introducción: De todos los casos de cáncer en el mundo el 80% se presentan en países en vía de desarrollo siendo el cáncer de estómago o cáncer gástrico la segunda causa de muerte por cáncer en el mundo con aproximadamente 700.000 muertes cada año. En Colombia, el cáncer gástrico es la primera causa de muerte por tumores malignos en ambos sexos, aún cuando no es la primera neoplasia en frecuencia. Metodología: Estudio observacional descriptivo, de registros de defunción del DANE, Colombia 2000 a 2009. Se analizaron tasas anuales crudas y por grupos de edad, género, procedencia geográfica, estado civil, nivel educativo y área de residencia habitual estableciendo diferencias estadísticas entre las variables y sus categorías. Resultados: En el período estudiado se registraron 43759 defunciones por cáncer gástrico, con mayor frecuencia en hombres 1,5:1. Las tasas de mortalidad por cáncer gástrico ajustadas por grupos etáreos aumentan después de la quinta década de la vida. Se encontraron diferencias estadísticamente significativas en todos los años estudiados y el departamento de residencia habitual del fallecido presentando Cauca (18,11- 19) y Boyacá (14,54-1742) las tasas más altas por 100.000 habitantes. Las tasas más altas se concentran en la zona de la Cordillera de los Andes, al estandarizar por grupos etáreos el Cauca tiene una tasa de 114,98 casos por 100.000 habitantes. Conclusión: El cáncer gástrico es la neoplasia que causa más muertes en Colombia por lo cual es necesario diseñar e implementar programas de detección precoz que vayan dirigidos al control de la mortalidad.

Tratamiento de la ulcera venosa con escleroespuma versus manejo conservador

La úlcera venosa es una revelación clínica severa de la insuficiencia venosa crónica. Es la causa del 54-76% de las úlceras venosas de miembros inferiores. La ciencia médica ha generado diversos procedimientos en el manejo de esta patología, es así como a partir de conocimientos en fisiopatología de la ulceración venosa, se han aplicado procedimientos como opción de tratamiento. Objetivos: Valorar si el uso de rutina de la oclusión endoluminal con espuma guiada por ecografía del sistema venoso superficial insuficiente, en adicción al manejo convencional de la ulcera venosa (vendaje no compresivo, gasa vaselinada y curaciones) podría mejorar la tasa de curación a las 24 semanas de tratamiento. Diseño: Estudio clínico aleatorizado prospectivo de pacientes de la consulta externa de cirugía vascular del Hospital Occidente de Kennedy-Bogotá, durante el 01 de junio del 2011 hasta el 30 junio del 2012. Métodos: Un total de 44 pacientes con ulcera activa que cumplieron criterios de selección ingresaron al estudio, correspondientes a 48 extremidades con clasificación CEAP (C6), los pacientes fueron a aleatorizados a manejo convencional (control) o con manejo adicional de oclusión endoluminal con espuma eco-guiada. El objetivo principal fue el cierre de la ulcera a las 24 semanas. Resultados: La Curación de la ulcera a las 24 semanas de la aleatorización fue de 20 (83.3%) extremidades del grupo de oclusión endoluminal con espuma eco-guiada Vs 3(12.5%) para el grupo de control P: 0.0005 Discusión: Las tasas de curación de la ulcera luego de la oclusión endoluminal con espuma eco-guiada es muy superior al manejo convencional con curaciones y vendaje no compresivo, las tasa de curación son tan altas como las reportadas con sistemas de alta compresión y cirugía a las 24 semanas. La oclusión endoluminal eco-guiada es segura, mínimamente invasiva y clínicamente efectiva.

Caracterización de los pacientes con hemorragia de vías digestivas altas no varicosa atendidos en el Hospital Universitario de la Samaritana, Cundinamarca

La hemorragia de vías digestivas altas (HVDA) es una emergencia frecuente. La etiología más común es la úlcera péptica. La restauración del volumen intravascular y la presión arterial son la prioridad del manejo. La endoscopia (EGD) debe realizarse luego de la reanimación inicial y lograda la estabilización hemodinámica, tratar la lesión subyacente mediante hemostasia. Se realiza un estudio en un hospital de referencia de tercer nivel, Cundinamarca, Colombia Materiales y métodos: Estudio descriptivo retrospectivo, datos obtenidos de la historia clínica electrónica de pacientes adultos que consultaron por urgencias en el Hospital Universitario de la Samaritana (HUS) por HVDA, diagnosticada por hematemesis, melenas, hematoquezia y/o anemia; a quienes se les realizó EGD durante abril del 2010 - abril del 2011. Resultados: Se atendieron 385 pacientes en el período de estudio, 100 fueron excluidos debido a hemorragia secundaria a várices esofágicas, historia incompleta y hemorragia digestiva baja, para un total de 285 pacientes analizados. El 69.1% eran mayores de 60 años. El 73.3% presentaba hipertensión arterial, el 55.1% reportaba ingesta de Anti-inflamatorios no esteroideos (AINES) y Aspirina (ASA). El 19.6% reportaba episodios de sangrado previos y 17.9% presentó inestabilidad hemodinámica. Sesenta y tres pacientes (22,1%) requirieron hemostasia endoscópica, treinta y dos (11.2%) presentaron resangrado. La mortalidad reportada fue del 13.1%, del cual 55.3% correspondía a hombres. Discusión: La mayoría de la población atendida en el HUS por HVDA son adultos mayores de 60 años. La úlcera péptica, continúa siendo el diagnóstico más frecuente asociado al uso de AINES y ASA.

Dispepsia: un real desafío diagnóstico

La presente es una revisión no sistemática de literatura con la siguiente estrategia de búsqueda: (((((“Dyspepsia” [Mesh] OR “Peptic Ulcer” [Mesh]) OR “Helicobacter pylori” [Mesh]) AND (“Diagnosis”[Mesh] OR (“Therapeutics” [Mesh OR “therapy “[Subheading])) OR “Epidemiology” [Mesh]. La indagación contempló el periodo comprendido entre los años 1966 y 2007. La estrategia de búsqueda fue adaptada a cada una de las bases de datos consultadas: MEDLINE, COCHRANE, LILACS y SCIELO. Se encontraron, por título y abstract, 689 artículos, a criterio de los autores, de los cuales fueron seleccionados 138 para esta revisión. No se obtuvieron 6 artículos por no tener acceso a los correspondientes journals. El propósito de esta revisión es dar a conocer y aclarar algunos puntos sobre el diagnóstico y tratamiento de la dispepsia.

Comparación de cambios clínicos y hemodinámicos en pacientes con insuficiencia venosa mixta según tipo de manejo.

Existen varias causas de la insuficiencia venosa profunda, la insuficiencia venosa superficial es una de ellas; por tal motivo, una intervención activa de la insuficiencia superficial ya sea cirugía convencional, esclerosis o radiofrecuencia mejora el reflujo del sistema venoso profundo. En nuestro medio no se acostumbra a intervenir los pacientes con insuficiencia venosa mixta bajo la creencia de exacerbar la enfermedad o generar complicaciones. Se pretende documentar los cambios clínicos y hemodinámicos en pacientes con insuficiencia venosa mixta según tipo de manejo, médico vs quirúrgico

Pressure-relieving equipment: promoting its correct use amongst nurses via differing modes of educational delivery

Aims and objectives. To examine the impact of written and verbal education on bed-making practices, in an attempt to reduce the prevalence of pressure ulcers. Background. The Department of Health has set targets for a 5% reduction per annum in the incidence of pressure ulcers. Electric profiling beds with a visco-elastic polymer mattress are a new innovation in pressure ulcer prevention; however, mattress efficacy is reduced by tightly tucking sheets around the mattress. Design. A prospective randomized pre/post-test experimental design. Methods. Ward managers at a teaching hospital were approached to participate in the study. Two researchers independently examined the tightness of the sheets around the mattresses. Wards were randomized to one of two groups. Groups A and B received written education. In addition, group B received verbal education on alternate days for one week. Beds were re-examined one month later. One researcher was blinded to the educational delivery received by the wards. Results. Twelve wards agreed to participate in the study and 245 beds were examined. Before education, 113 beds (46%) had sheets tucked correctly around the mattresses. Following education, this increased to 215 beds (87.8%) (chi(2) = 68.03, P < 0.001). There was no significant difference in the number of correctly made beds between the two different education groups: 100 (87.72%) beds correctly made in group A vs. 115 (87.79%) beds in group B (chi(2) = 0, P 0.987). Conclusions. Clear, concise written instruction improved practice but verbal education was not additionally beneficial. Relevance to clinical practice. Nurses are receptive to clear, concise written evidence regarding pressure ulcer prevention and incorporate this into clinical practice.

The role of the gastrointestinal microbiota in colorectal cancer

Both environmental and genetic factors contribute to cancers of the gastrointestinal tract including, the stomach, colon and rectum. The mechanisms associated with gastrointestinal cancer causation and prevention are largely unknown and the subject of much research. Many of the proposed mechanisms implicate the metabolic activities of the bacterial biota normally resident in the gastrointestinal tract. This review examines both the adverse and beneficial consequences of bacterial activity of the gastrointestinal tract focusing, in particularly on the stomach and large intestine. Studies on the role of the bacterial biota in colon carcinogenesis have also resulted in several useful biomarkers for use in human.

Hypothesis about mechanisms through which nicotine might exert its effect on the interdependence of inflammation and gut barrier function in ulcerative colitis

Ulcerative colitis (UC) is characterized by impairment of the epithelial barrier and the formation of ulcer-type lesions, which result in local leaks and generalized alterations of mucosal tight junctions. Ultimately, this results in increased basal permeability. Although disruption of the epithelial barrier in the gut is a hallmark of inflammatory bowel disease and intestinal infections, it remains unclear whether barrier breakdown is an initiating event of UC or rather a consequence of an underlying inflammation, evidenced by increased production of proinflammatory cytokines. UC is less common in smokers, suggesting that the nicotine in cigarettes may ameliorate disease severity. The mechanism behind this therapeutic effect is still not fully understood, and indeed it remains unclear if nicotine is the true protective agent in cigarettes. Nicotine is metabolized in the body into a variety of metabolites and can also be degraded to form various breakdown products. It is possible these metabolites or degradation products may be the true protective or curative agents. A greater understanding of the pharmacodynamics and kinetics of nicotine in relation to the immune system and enhanced knowledge of out permeability defects in UC are required to establish the exact protective nature of nicotine and its metabolites in UC. This review suggests possible hypotheses for the protective mechanism of nicotine in UC, highlighting the relationship between gut permeability and inflammation, and indicates where in the pathogenesis of the disease nicotine may mediate its effect.

Absorption, tissue distribution and excretion of pelargonidin and its metabolites following oral administration to rats

Recent reports have demonstrated various cardiovascular and neurological benefits associated with the consumption of foods rich in anthocyanidins. However, information regarding absorption, metabolism, and especially, tissue distribution are only beginning to accumulate. In the present study, we investigated the occurrence and the kinetics of various circulating pelargonidin metabolites, and we aimed at providing initial information with regard to tissue distribution. Based on HPLC and LC-MS analyses we demonstrate that pelargonidin is absorbed and present in plasma following oral gavage to rats. In addition, the main structurally related pelargonidin metabolite identified in plasma and urine was pelargonidin glucuronide. Furthermore, p-hydroxybenzoic acid, a ring fission product of pelargonidin, was detected in plasma and urine samples obtained at 2 and 18 h after ingestion. At 2 h post-gavage, pelargonidin glucuronide was the major metabolite detected in kidney and liver, with levels reaching 0.5 and 0.15 nmol pelargonidin equivalents/g tissue, respectively. Brain and lung tissues contained detectable levels of the aglycone, with the glucuronide also present in the lungs. Other tissues, including spleen and heart, did not contain detectable levels of pelargonidin or ensuing metabolites. At 18 h post-gavage, tissue analyses did not reveal detectable levels of the aglycone nor of pelargonidin glucuronides. Taken together, our results demonstrate that the overall uptake of the administered pelargonidin was 18 % after 2 h, with the majority of the detected levels located in the stomach. However, the amounts recovered dropped to 1.2 % only 18 h post-gavage, with the urine and faecal content constituting almost 90 % of the total recovered pelargonidin.

The fate of olive oil polyphenols in the gastrointestinal tract: implications of gastric and colonic microflora-dependent biotransformation

We have conducted a detailed investigation into the absorption, metabolism and microflora-dependent transformation of hydroxytyrosol ( HT), tyrosol (TYR) and their conjugated forms, such as oleuropein (OL). Conjugated forms underwent rapid hydrolysis under gastric conditions, resulting in significant increases in the amount of free HT and TYR entering the small intestine. Both HT and TYR transferred across human Caco-2 cell monolayers and rat segments of jejunum and ileum and were subject to classic phase I/II biotransformation. The major metabolites identified were an O-methylated derivative of HT, glucuronides of HT and TYR and a novel glutathionylated conjugate of HT. In contrast, there was no absorption of OL in either model. However, OL was rapidly degraded by the colonic microflora resulting in the formation of HT. Our study provides additional information regarding the breakdown of complex olive oil polyphenols in the GI tract, in particular the stomach and the large intestine.

Mucoadhesive interactions of amphiphilic cationic copolymers based on [2-(methacryloyloxy)ethyl]trimethylammonium chloride

Three series of water-soluble cationic copolymers have been synthesised by free-radical copolymerisation of [2-(methacryloyloxy)ethyl]-trimethylammonium chloride (MADQUAT) with methyl acrylate (MA), butyl acrylate (BA) and butyl methacrylate (BMA). The interactions between these copolymers and porcine stomach mucin have been studied in aqueous solutions using dynamic light scattering, zeta-potential measurements, turbidimetric titration and transmission electron microscopy (TEM). It was demonstrated that mixing aqueous dispersions of mucin with solutions of the cationic copolymers results in significant changes in size distribution and zeta-potential of its particles. It was found that an increase in the content of hydrophobic groups in copolymers leads to more efficient adsorption of macromolecules on the surface of mucin particles, which evidences the importance of hydrophobic effects in mucoadhesion. The efficiency of mucoadhesive interactions was found to be significantly dependent on pH, which affects the surface charge and aggregation stability of mucin. (C) 2007 Elsevier B.V. All rights reserved.

Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods: Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

The effect of dietary nitrate on salivary, plasma, and urinary nitrate metabolism in humans

Dietary nitrate is metabolized to nitrite by bacterial flora on the posterior surface of the tongue leading to increased salivary nitrite concentrations. In the acidic environment of the stomach, nitrite forms nitrous acid, a potent nitrating/nitrosating agent. The aim of this study was to examine the pharmacokinetics of dietary nitrate in relation to the formation of salivary, plasma, and urinary nitrite and nitrate in healthy subjects. A secondary aim was to determine whether dietary nitrate increases the formation of protein-bound 3-nitrotyrosine in plasma, and if dietary nitrate improves platelet function. The pharmacokinetic profile of urinary nitrate excretion indicates total clearance of consumed nitrate in a 24 h period. While urinary, salivary, and plasma nitrate concentrations increased between 4- and 7-fold, a significant increase in nitrite was only detected in saliva (7-fold). High dietary nitrate consumption does not cause a significant acute change in plasma concentrations of 3-nitrotyrosine or in platelet function.

Colon extended physiologically based extraction test (CE-PBET) increases bioaccessibility of soil-bound PAH

Assessment of the risk to human health posed by contaminated land may be seriously overestimated if reliant on total pollutant concentration. In vitro extraction tests, such as the physiologically based extraction test (PBET), imitate the physicochemical conditions of the human gastro-intestinal tract and offer a more practicable alternative for routine testing purposes. However, even though passage through the colon accounts for approximately 80% of the transit time through the human digestive tract and the typical contents of the colon in vivo are a carbohydrate-rich aqueous medium with the potential to promote desorption of organic pollutants, PBET comprises stomach and small intestine compartments only. Through addition of an eight-hour colon compartment to PBET and use of a carbohydrate-rich fed-state medium we demonstrated that colon-extended PBET (CE-PBET) in- creased assessments of soil-bound PAH bioaccessibility by up to 50% in laboratory soils and a factor of 4 in field soils. We attribute this increased bioaccessibility to a combination of the additional extraction time and the presence of carbohydrates in the colon compartment, both of which favor PAH desorption from soil. We propose that future assessments of the bioaccessibility of organic pollutants in soils using physiologically based extraction tests should have a colon compartment as in CE-PBET.