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Background There is no consensus on the duration of immobilization for nonoperatively treated proximal humeral fractures (PHFs). The main objective of the study was to determine the differences in pain between PHFs that were treated nonoperatively with 3-week immobilization and those treated with 1-week immobilization. Methods A prospective randomized trial was designed to evaluate whether the immobilization time frame (1-week immobilization [group I] versus 3-week immobilization [group II]) for nonoperatively treated PHFs had any influence on pain and functional outcomes. Pain was assessed using a 10-cm visual analog scale (VAS) that was administrated 1 week after the fracture, at 3 weeks, and then at the 3, 6, 12, and 24-month follow-up. The functional outcome was evaluated using the Constant score. To assess the functional disability of the shoulder, a self-reported shoulder-specific questionnaire, the Simple Shoulder Test (SST), was used. The Constant score and the SST were recorded at the 3, 6, 12, and 24-month follow-up. Complications and secondary displacement were also recorded. Results One hundred and forty-three patients were randomized, and 111 (88 females and 23 males) who had been allocated to group I (55 patients) or group II (56 patients) were included in the final analysis. The mean age of the patients was 70.4 years (range, 42 to 94 years). No significant differences were found between the 2 groups in terms of pain as measured with the VAS at any time point (1 week [5.9 versus 5.6; p = 0.648], 3 weeks [4.8 versus 4.1; p = 0.059], 3 months [1.9 versus 2.4; p = 0.372], 6 months [1.0 versus 1.2; p = 0.605], 1 year [0.65 versus 0.66; p = 0.718], and 2 years [0.63 versus 0.31; p = 0.381]). No significant differences were found in the Constant score or SST score at any time point. No significant differences were noted in the complication rate. Conclusions Short and long periods of immobilization yield similar results for nonoperatively treated PHFs, independent of the fracture pattern. These fractures can be successfully managed with a short immobilization period of 1 week in order to not compromise patients' independence for an overly extended period. Level of evidence Randomized controlled trial Level II. See Instructions for Authors for a complete description of levels of evidence.

Background & Aims Guidelines recommend routine antibiotic prophylaxis for patients undergoing endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of pancreatic cysts, but there is conflicting evidence for its necessity. We investigated whether performing the procedure without antimicrobial prophylaxis increases the incidence of infection. Methods We performed a multicenter, randomized, noninferiority trial to compare prophylaxis with ciprofloxacin vs placebo in patients with a pancreatic cyst requiring EUS-FNA at multiple centers in Spain. From September 2014 to June 2018, patients were randomly assigned to groups that received the prophylaxis with ciprofloxacin (n = 112) or saline solution (n = 114, placebo). We recorded patients' demographic data, lesion characteristics, and procedure data and followed patients for 21 days. A total of 205 patients completed the trial (90.7%), receiving ciprofloxacin or the control, with no statistically significant differences in demographics, baseline data, or procedure characteristics between groups. The primary outcome was FNA-related infection. Secondary outcomes were incidence of fever, procedure complications, and medication-related adverse events. Results The only case of FNA-related infection (0.44%) occurred in a patient in the placebo group (0.87%); this patient developed acute pancreatitis and bacteremia after the procedure. Prevention of infection was not inferior in the control group; the difference between proportions was 0.87% (95% confidence interval, –0.84% to 2.59%). There were no differences between groups in fever (2 patients in each group: 1.78% vs 1.76%; P = 1.00) or other adverse events. Conclusions In a randomized trial of patients undergoing EUS-FNA for pancreatic cyst evaluation, we found the risk of infection to be low. The incidence of infections did not differ significantly with vs without ciprofloxacin prophylaxis. (ClinicalTrials.gov, Number: NCT02261896).

Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions.

Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions.

Background: Guidelines recommend using prognostic scales for risk stratification in patients with non-variceal upper gastrointestinal bleeding. It remains unclear whether risk scores offer greater accuracy than clinical evaluation. Objective: Compare the diagnostic accuracy of the endoscopist&rsquo, s judgment against different risk-scoring systems (Rockall, Glasgow&ndash, Blatchford, Baylor and the Cedars&ndash, Sinai scores) for predicting outcomes in peptic ulcer bleeding (PUB). Methods: Between February 2006 and April 2010 we prospectively recruited 401 patients with peptic ulcer bleeding, 225 received endoscopic treatment. The endoscopist recorded his/her subjective assessment (&ldquo, endoscopist judgment&rdquo, ) of the risk of rebleeding and death immediately after endoscopy for each patient. Independent evaluators calculated the different scores. Area under the receiver-operating-characteristics (ROC) curve, sensitivity, specificity, positive and negative predictive values were calculated for rebleeding and mortality. Results: The areas under ROC curve of the endoscopist&rsquo, s clinical judgment for rebleeding (0.67&ndash, 0.75) and mortality (0.84&ndash, 0.9) were similar or even superior to the different risk scores in both the whole group and in patients receiving endoscopic therapy. Conclusions: The accuracy of the currently available risk scores for predicting rebleeding and mortality in PUB patients was moderate and not superior to the endoscopist&rsquo, s judgment. More precise prognostic scales are needed.

Introduccion La prevalencia de homocigosidad para C282Y en pacientes con hemocromatosis hereditaria (HH) originarios de algunos paises de la cuenca mediterranea puede ser sustancialmente inferior a la observada en el norte de Europa. Los datos referidos a Espana son contradictorios y basados en series pequenas de ambito regional. El objetivo de nuestro estudio es determinar la prevalencia de las 2 principales mutaciones del gen HFE en una serie de pacientes espanoles con HH, no relacionados y de diferente procedencia geografica. Pacientes y mEtodo Los criterios para el diagnostico de HH fueron: indice de saturacion de transferrina superior al 45% en 2 determinaciones y homocigosidad para C282Y y/o indice de hierro hepatico mayor de 1,9 de tejido hepatico seco en pacientes no cirroticos o superior a 4,1 en presencia de cirrosis. Se excluyeron los casos detectados en familiares. Se evaluaron los datos demograficos, la expresion clinica, los parametros del hierro y las mutaciones C282Y y H63D del gen HFE en un total de 222 pacientes. Resultados El 83,3% de los pacientes fueron homocigotos para C282Y y el 5% dobles heterocigotos (C282Y/H63D). No se observaron diferencias significativas en la expresion fenotipica ni en la frecuencia de homocigosidad para C282Y en los pacientes nacidos en el norte o en el sur de Espana. Conclusion El patron genotipico y la expresion fenotipica de la HH en Espana son muy similares a los observados en el norte de Europa. Por tanto, la heterogeneidad genetica descrita en algunas regiones del sur de Europa no puede considerarse una caracteristica comun a todos los paises de la cuenca mediterranea.

Background/Aims : The most rational treatment of moderate ascites is spironolactone alone or in combination with furosemide. However, it is unknown which of these two treatment schedules is preferable. Methods : One hundred nonazotemic cirrhotic patients with moderate ascites were randomly assigned to be treated with spironolactone and furosemide (Group 1: 50 patients) or with spironolactone alone (Group 2: 50 patients). If no response was obtained, the doses of diuretics were increased up to 400 mg/day of spironolactone and 160 mg/day of furosemide. In patients of group 2 not responding to 400 mg/day of spironolactone, furosemide was added. In cases with an excessive response, the dosage of diuretics was reduced. Results : The response rate (98% in Group 1 vs. 94% in Group 2), the rapidity of ascites mobilization and the incidence of complications induced by diuretic therapy was similar in both groups. The need to reduce the diuretic dosage was significantly higher in Group 1 than Group 2 (68% vs. 34%; P =0.002). Conclusions : In the treatment of moderate ascites, spironolactone alone seems to be as safe and effective as spironolactone associated with furosemide. Since spironolactone alone requires less dose adjustment, it would be more suitable for treating ascites on an outpatient basis.

Background/Aims : The efficacy and safety of rifaximin in comparison with lactitol in the treatment of acute hepatic encephalopathy was assessed in a prospective randomized, double-blind, double-dummy, controlled trial. Methods : A total of 103 patients with grade I–III acute hepatic encephalopathy were randomized to receive rifaximin (50 patients, 1200 mg/day) or lactitol (53 patients, 60 g/day) for 5–10 days. Changes in the portal-systemic encephalopathy (PSE) index on entry and at the end of the study were used to evaluate the efficacy of the two therapies. Results : Both groups were comparable before treatment with regard to demographic data and characteristics of the hepatic encephalopathy episode. The global efficacy of both therapies was similar: 81.6% in the rifaximin group and 80.4% in the lactitol group showed improvement or total regression of the episode. A significantly better evolution of the PSE index was observed in the rifaximin group, due to a greater effect of rifaximin in two components of the index: EEG abnormalities and ammonia levels. No serious adverse events related to either treatment were found during the study. Conclusions : Rifaximin may be considered a useful and safe alternative therapy to lactitol in the treatment of acute hepatic encephalopathy in cirrhosis.

Deranged intestinal motility, which occurs in cirrhosis, may facilitate the development of intestinal bacterial overgrowth (IBO), which can lead to bacterial translocation (BT). To assess the effect of cisapride on IBO and BT in cirrhosis, cirrhotic rats received cisapride or a placebo for 7 days, and measurements of jejunal bacterial content and BT studies were performed. In addition, jejunal fluid from 46 cirrhotic patients was obtained for quantitative bacterial culture. Those patients in whom gram-negative IBO was detected were randomized to receive or not to receive cisapride (20 mg twice per day) for 1 week. Cisapride significantly reduced IBO in cirrhotic rats. In addition, no BT was documented in treated animals, whereas it occurred in 40% in nontreated cirrhotic rats. Total IBO was documented in 23 of 46 cirrhotic patients, which was caused by gram-negative organisms in 10 cases. Orocecal transit time (OCT) significantly decreased after cisapride therapy, and was associated with the abolishment of bacterial overgrowth caused by gram-negative organisms in 4 out of 5 treated patients, whereas it persisted in nontreated cases. Cisapride administration to cirrhotic rats resulted in a reduction of the IBO, which is associated with a marked decrease in BT. On the other hand, cisapride facilitates the abolition of IBO caused by gram-negative organisms in cirrhotic patients.

Background/Aims: Selective intestinal decontamination with norfloxacin is widely used to prevent spontaneous bacterial infections in cirrhosis. The study was performed to compared the spontaneous bacterial peritonitis occurring in patients with and without prophylactic norfloxacin. Methods: Two hundred and twenty-nine consecutive episodes of spontaneous bacterial peritonitis, (193 patients without (Group A) and 36 in patients with norfloxacin prophylaxis (Group B)), were retorspectively analyzed. In 100 episodes (86 and 14, respectively), the responsible organism was isolated in ascitic fluid. Results: Clinical and laboratory data at diagnosis were comparable in both groups. There were marked differences ( p Conclusions: Spontaneous bacterial peritonitis in patients with and without prophylaxis with norfloxacin are not different in clinical features, response to treatment and prognosis. Spontaneous bacterial peritonitis caused by gram-negative organisms resistant to quinolones is extremely uncommon in patients with cirrhosis receiving prophylatic norfloxacin.

Idiopathic pylephlebitis and primary sclerosing peritonitis are two highly unusual entities. To our knowledge, the association of the two diseases has not been described previously. We report a 42-year-old patient with a protein S deficiency who presented with fever and chills, in whom idiopathic pylephlebitis was diagnosed. A year later, the patient was readmitted because of recurrent vomiting and weight loss. An exploratory laparotomy yielded diagnosis of sclerosing peritonitis, which resolved after surgery. The short time interval between the processes suggests that they were related to each other, and also to the protein S deficiency.

Backgrounds/Aims: Diuretic requirements after mobilization of ascites by paracentesis have never been assessed in cirrhosis, It is also unknown whether diuretics increase the incidence of postparacentesis circulatory dysfunction, The aim of this study was to investigate these features and to assess whether measurement of plasma renin activity and aldosterone prior to paracentesis predicts diuretic response after this procedure. Methods: Thirty-six patients with non-azotemic cirrhosis and ascites treated by total paracentesis plus i.v. albumin were randomly assigned to receive placebo (n=17) or spironolactone 225 mg/day (n=19) immediately after paracentesis and followed-up for 4 weeks. Results: Five patients (three in the placebo and two in the spironolactone group) abandoned the treatment prior to ascites recurrence or the end of the study due to complications or lack of compliance, The analysis was performed in the remaining 31 patients, Ascites recurrence was more common in the placebo group (13 cases, 93%) than in the spironolactone group (3 cases, 18%) (p

Introduccion No existen estudios comparativos entre los diferentes modelos matematicos para la prediccion de recidiva y mortalidad en pacientes con hemorragia digestiva alta por ulcera peptica (HDAxUP). Se desconoce tambien si dichos modelos predictivos son superiores al juicio clinico. Objetivo Comparar la precision de los modelos de Rockall, Baylor, Cedars-Sinai y Blatchford frente al juicio clinico del endoscopista en la prediccion de recidiva y mortalidad en pacientes con HDAxUP. Pacientes y metodo Durante un periodo de 2 anos se incluyeron 238 pacientes con HDAxUP en los 3 centros participantes. Todos los pacientes se trataron con IBP i.v, y se realizo endoscopia urgente entre las 12 horas siguientes al ingreso. Se practico tratamiento endoscopico combinado (inyeccion de adrenalina mas polidocanol o clip) en 136 pacientes con ulcera de alto riesgo. Tras ello, el endoscopista clasifico a los pacientes segun su juicio clinico como de riesgo alto-medio-bajo para recidiva y mortalidad, y posteriormente calculo los diferentes modelos matematicos. Se calcularon las curvas ROC, sensibilidad, especificidad, valores predictivos positivo (VPP) y negativo (VPN) para recidiva y mortalidad de cada modelo matematico y del juicio clinico del endoscopista. Resultados Las tasas de recidiva y mortalidad fueron 14% (19/136) y 5,1% (7/136) respectivamente. Las comparaciones entre el juicio clinico del endoscopista y los diferentes modelos matematicos se muestran las tablas. Conclusion Los resultados del presente estudio sugieren que los modelos matematicos disponibles no son mejores que el juicio clinico del endoscopista para la prediccion de recidiva. Ademas, tanto el juicio clinico como dichos modelos no identifican entre un 4% y 10% de pacientes que resangran tras tratamiento endoscopico. Parece adecuado el desarrollo de modelos mas precisos para prediccion de recidiva en pacientes con HDAxUP de alto riesgo. Prediccion Recidiva Juicio clinico Rockall Cedars-Sinai Baylor Blatchford Sensib. (%) 84 79 95 63 79 Especifi. (%) 34 49 21 59 61 VPP (%) 17 20 16 20 25 VPN (%) 93 93 96 91 95 Area bj ROC 0,680 0,665 0,666 0,661 0,695 Prediccion Mortalidad Juicio clinico Rockall Cedars-Sinai Baylor Blatchford Sensi. (%) 100 100 100 71 86 Especifi. (% 71 24 19 57 57 VPP (%) 16 7 6 8 10 VPN (%) 100 100 100 97.5 97 Area ROC 0,866 0,874 0,701 0,735 0,804

Introduccion La precision de las tecnicas de imagen en el diagnostico de las lesiones quisticas pancreaticas no es alta y la rentabilidad de la PAAF limitada. Se ha sugerido que el cepillado guiado por USE podria ser eficaz en el diagnostico de estas lesiones. Objetivo Comparar la USE-PAAF con el cepillado-USE en la obtencion de celulas de lesiones quisticas pancreaticas y evaluar las complicaciones. Metodo Se incluyeron los pacientes con una lesion quistica pancreatica de diametro >15 mm. Se practico PAAF con aguja de 19 G (EchoTip 3. Cook, Winston-Salem, NC) aspirandose el liquido intraquistico que se proceso para estudio citologico. Posteriormente se introdujo el cepillo a traves de la misma aguja (Echobrush, Cook) para cepillado de las paredes del quiste. Las muestras fueron evaluadas por un anatomopatologo a ciegas para evitar sesgos. Se registraron las complicaciones durante las primeras 24 horas y se contacto telefonicamente el dia 7 post-procedimiento. Resultados Se han incluido 30 pacientes. En 8 pacientes no fue posible por razones tecnicas. La USE-PAAF consiguio celularidad para el diagnostico en 6 (27%) y el cepillado en 16 (73%) (p=0,035). El diagnostico de neoplasia mucinosa probable se obtuvo en 5 (23%) pacientes con el estudio citologico convencional y en 11 (50%) pacientes con el cepillado (p=0,016). 8 paciente fueron operados. En 5 de ellos la pieza quirurgica fue compatible con el resultado de la PAAF y del cepillado y en 3, en los que la PAAF fue acelular, el diagnostico fue consistente con el obtenido mediante el cepillado. Se han registrado 2 casos de hemorragia post-puncion; 1 caso de hemosuccus pancreaticus que se resolvio de forma conservadora y otro grave de hemorragia retroperitoneal en una paciente en tratamiento con anticoagulantes orales que requirio intervencion quirurgica. Conclusiones El cepillado-USE es mas eficaz que la USE-PAAFen la obtencion de celularidad para el diagnostico de las lesiones quisticas del pancreas. Sin embargo, son necesarios mas estudios que evaluen la seguridad de este procedimiento.