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Background and study aims Data from Japanese series show that surface morphology of laterally spreading tumors (LST) in the colon identifies lesions with different incidence and pattern of submucosal invasion. Such data from western countries are scarce. We compared clinical and histological features of LST in a western country and an eastern country, with special interest on mucosal invasiveness of LST, and investigated the effect of clinical factors on invasiveness in both countries. Patients and methods Patients with LST lesions ≥20 mm were included from a multicenter prospective registry in Spain and from a retrospective registry from the National Cancer Center Hospital East, Japan. The primary outcome was the presence of submucosal invasion in LST. The secondary outcome was the presence of high-risk histology, defined as high-grade dysplasia or submucosal invasion. Results We evaluated 1102 patients in Spain and 663 in Japan. Morphological and histological characteristics differed. The prevalence of submucosal invasion in Japan was six-fold the prevalence in Spain (Prevalence Ratio PR = 5.66; 95%CI: 3.96, 8.08), and the prevalence of high-risk histology was 1.5 higher (PR = 1.44; 95%CI: 1.31, 1.58). Compared to the granular homogeneous type and adjusted by clinical features, granular mixed, flat elevated, and pseudo-depressed types were associated with higher odds of submucosal invasion in Japan, whereas only the pseudo-depressed type showed higher risk in Spain. Regarding high-risk histology, both granular mixed and pseudo-depressed were associated with higher odds in Japan, compared with only the granular mixed type in Spain. Conclusion This study reveals differences in location, morphology and invasiveness of LST in an eastern and a western cohort.

Gastric outlet obstruction is a complication of advanced tumors. It causes upper gastrointestinal obstruction, with progressive malnutrition and reduced survival. Currently, gastrojejunostomy or stent placement (SP) are feasible alternatives for the treatment of malignant gastric outlet obstruction. The aim of this study is to compare the efficacy and survival of both techniques.Single-center observational and prospective study of 58 patients with gastric outlet obstruction who underwent surgical treatment with stomach-partitioning gastrojejunostomy (SPGJ) or SP with self-expanding intraluminal prostheses between 2007 and 2018.Thirty patients underwent SPGJ and 28 SP. The mean age of the first group was significantly lower (69 vs. 78 years, respectively; P=.001). There were no statistically significant differences in terms of sex, perioperative risk or tumor etiology. Postoperative complications were non-significantly higher in the SPGJ group (P=.156). SP was associated with a shorter hospital stay (P=.02) and faster oral intake (P.0001). However, SP had significantly higher rates of persistent and recurrent obstruction (P=.048 and .01, respectively), poorer energy targets (P=.009) and shorter survival (9.61 vs. 4.47 months; P=.008).SPGJ presents greater luminal permeability, better oral intake and greater survival than SP. SP is preferable for non-surgical patients with a limited short-term prognosis.

Resumen Introduccion El sindrome de obstruccion antroduodenal es una complicacion presente en neoplasias avanzadas. Se caracteriza por clinica de obstruccion gastrointestinal alta, con desnutricion progresiva, y se asocia con una disminucion de la supervivencia. La derivacion mediante gastroyeyunostomia y el tratamiento endoscopico (TE) son las alternativas para el tratamiento del sindrome de obstruccion antroduodenal. El objetivo de este estudio es comparar la eficacia y la supervivencia de ambas. Metodos Estudio monocentro, observacional y prospectivo de 58 pacientes con sindrome de obstruccion antroduodenal que recibieron tratamiento quirurgico mediante gastroyeyunostomia con separacion gastrica parcial (GYSGP) o TE con protesis enterales autoexpandibles entre los anos 2007-2018. Resultados A 30 pacientes se les realizo GYSGP y a 28 pacientes TE. La edad media de los pacientes con GYSGP fue significativamente menor (69 vs. 78 anos, p = 0,001). No hubo diferencias en cuanto al sexo, el riesgo anestesico-quirurgico ni la etiologia de la neoplasia. Las complicaciones posprocedimiento fueron superiores, aunque no significativas, en el grupo de GYSGP (p = 0,156). El TE se asocio con una menor estancia hospitalaria (p = 0,02) y una mayor precocidad de la tolerancia oral (p Conclusiones La GYSGP obtiene una mayor permeabilidad luminal, una mejor tolerancia a la via oral y una mayor supervivencia. El TE estaria recomendado para pacientes no subsidiarios de la cirugia con un pronostico limitado a corto plazo.

The reception of American cinema in Spain after the Spanish Civil War was largely conditioned by the activity of censorship boards. American films were very popular in Spain in the decades followin...

Coronary artery endothelial cells (CAEC) exert an important role in the development of cardiovascular disease. Dysfunction of CAEC is associated with cardiovascular disease in subjects with type 2 diabetes mellitus (T2DM). However, comprehensive studies of the effects that a diabetic environment exerts on this cellular type scarce. The present study characterized the molecular perturbations occurring on cultured bovine CAEC subjected to a prolonged diabetic environment (high glucose [HG] and high insulin [HI]). Changes at the metabolite and peptide level were assessed by untargeted metabolomics and chemoinformatics, and the results were integrated with proteomics data using published SWATH-based proteomics on the same in vitro model. Our findings were consistent with reports on other endothelial cell types, but also identified novel signatures of DNA/RNA, aminoacid, peptide, and lipid metabolism in cells under a diabetic environment. Manual data inspection revealed disturbances on tryptophan catabolism and biosynthesis of phenylalanine-based, glutathione-based, and proline-based peptide metabolites. Fluorescence microscopy detected an increase in binucleation in cells under treatment that also occurred when human CAEC were used. This multi-omics study identified particular molecular perturbations in an induced diabetic environment that could help unravel the mechanisms underlying the development of cardiovascular disease in subjects with T2DM.

Over the last few years early esophageal tumors, whether squamous-cell or associated with Barrett's esophagus, have been excised using endoscopic resection techniques, primarily endoscopic submucosal dissection (ESD). Esophageal surgery-associated morbidity and mortality are thus avoided with similar oncologic outcomes. ESD is not without complications, many of which arise and are endoscopically solved during the procedure itself (bleeding, perforation, etc.). Other complications develop within days or weeks after resection, these including mainly esophageal stricture. Esophageal strictures following ESD are initially managed with endoscopic balloon dilation (EBD). Preventive measures have been suggested to alleviate this complication, primarily by using local or systemic steroids in association with early dilation. Even so, not always may they be prevented. Such complications are called refractory strictures, which require either esophageal stents (in a majority of cases) or surgery.

Introduccion: debido al envejecimiento poblacional, al aumento de patologia cardio y cerebrovascular y a la mayor carga de morbilidad en general de nuestros pacientes, nos encontramos con un mayor numero de pacientes antiagregados y anticoagulados que precisan de la realizacion de una colangiopancreatografia retrograda endoscopica (CPRE). Con un uso cada vez mas extendido de anticoagulantes orales de accion directa (ACOD), hemos querido reflejar la influencia de estos factores sobre la posibilidad de hemorragia tras realizacion de CPRE en nuestro hospital. Materiales y metodos: para ello, se han recuperado los datos de las exploraciones realizadas durante los anos 2017 y 2018, que incluyen un total de 797 exploraciones en 588 pacientes. Se recogieron antecedentes personales de los pacientes, resultados de la prueba y evolucion posterior. Resultados: en nuestro estudio, el porcentaje de hemorragia post-CPRE fue del 4,6 % (n = 37). Respecto a la gravedad, el 21,6 % (n = 8) de las hemorragias fueron leves, el 59,5 % (n = 22) fueron moderadas y el 18,9 % (n = 7), graves. La cardiopatia previa, la antiagregacion, la anticoagulacion, el tratamiento con ACOD, la colocacion de protesis pancreatica y la extraccion de litiasis duplican el riesgo de sufrir una hemorragia tras CPRE. La realizacion de esfinterotomia lo multiplica por mas de cinco veces. Conclusion: en el analisis multivariante, destaca el aumento de manera estadisticamente significativa de la hemorragia en pacientes tratados con ACOD frente a los anticoagulados con Sintrom® o heparinas de bajo peso molecular (HBPM).

This paper aims to determine the efficacy of persuasive strategies in the SME pitch by examining the discursive interaction that takes place in a televised corpus, taken from the Spanish TV programme “Tu Oportunidad” (“Your Chance”), the counterpart of the British Dragon’s Den and the American Shark Tank. Using the information gathered in the discursive analysis of the corpus, we address how the use of rational and emotional factors may influence the decisions taken by the investors and how the entrepreneurs may achieve credibility. The results show the importance of rational argumentation in entrepreneurial and SME pitches, relegating emotional aspects to a secondary role from the persuasive point of view, which should, however, not be disregarded. Entrepreneurs should anchor their discourse firmly in a rational cognitive framework, but without discarding those emotional appeals which may be naturally connected to rational arguments, reinforcing their validity.

Improvement and innovation have been ongoing in gastrointestinal (GI) endoscopy for the last few years, including highly maneuverable endoscopes, high-definition visualization, digital chromoendoscopy, and wide working channels, which allow a correct identification, catheterization, and delimitation of early neoplastic lesions. Technological innovation has also provided novel devices, both to perform treatments and prevent complications.

Aim: There is a limited access to endoscopic ultrasound (EUS) by a gastroenterologist (GE) in our centre, so we analyse the usefulness of EUS with echobronchoscope (EUSb) by a pulmonologist (P) for lung cancer (LC) diagnosis and staging. Material and Methods: All patients who underwent a EUSb in the study of LC were prospectively added (2016-2018). Both positive and negative samples for LC were considered as valid ones while non-representative as not valid ones. Surgical mediastinal biopsy was considered as a gold standard. Results: Seventy-three (14 diagnosis, 56 staging and 3 restaging) procedures were added, accounting for 83 punctures with 80.7% of valid samples (size in mm): 4Lp (7.7), 5 (9.2), 7p (10.3), 8 (10.8), celiac trunk (5.3), left adrenal gland (LGA) (31.9). According to the P’s criteria, same nodes by both EBUS and EUSb were sampled: in 2 cases in 4L (9.5%) and in 1 case in 7 (2.8%) the only valid sample was obtained by EUSb. The agreement (including not valid samples) between both approaches was moderate in 4L (κ 0.479) and good in 7 (κ 0.608). Diagnosis Group: in 3 cases (21%) the EUSb was the only positive result (a lung lesion and 2 LGA punctures which shortened the test). Staging Group: after excluding of the analysis those with no surgical confirmation, we had 11 positive and 23 negatives cases. Mediastinal involvement rate was 32.3%. EUSb never modified EBUS stage. The combined test EBUS+EUSb presented: S 0.92, NPV 0.95 and LR- 0.08. When compared to our historical series of EBUS+EUS (EUS by GE) (S 0.95, NPV 0.88, LR- 0.05), we found similar values. Conclusions: 1. EUS-b is a useful tool in LC diagnosis. 2. In LC staging, the utility of EBUS+EUSb is similar to EBUS+EUS by a P and a GE.

A través de la electroencefalografía se detecta la comunicación entre señales eléctricas creadas por las neuronas que, al conectarse entre sí, crean conexiones sinápticas. Esta técnica ha sido muy importante en la detección de trastornos neurológicos como laepilepsia. Caracterizada por cambios temporales en el funcionamiento bioeléctrico del cerebro, la epilepsia provoca convulsiones que afectan a la conciencia, el movimiento o la sensibilidad. Las redes neuronales artificiales (RNA) proporcionan modelos con diversas alternativas para detección, clasificación y predicción de muestras mediante el análisis del electroencefalograma a partir de la estructura de los datos, los cuales determinan la topología de la red. Este artículo propone la implementación de un modelo basado en RNA para analizar, clasificar y procesar señales epilépticas a partir del entrenamiento. Particularmente, la base de datos cuenta con muestras que registraron la actividad cerebral de pacientes sanos, pacientes que controlaron las crisis y pacientes que aún registraban oscilaciones en las señales emitidas por la actividad cerebral. Después de aplicar la transformada de Fourier, estas señales se integraron en una matriz aplicando tres tipos de umbral, procediendo a seleccionar los datos de entrada de la RNA para su entrenamiento y validación. Se consideran dos métodos de aprendizaje: redes neuronales multicapa con validación clásica (back propagation) y redes neuronales con validación cruzada (LOOCV, por sus siglas en inglés), para ello se calcula el error cuadrático medio (MSE, por sus siglas en inglés) así como la cantidad de errores por umbral con la finalidad de comparar los resultados obtenidos y precisar el método que proporciona los mejores resultados. Ambas redes se entrenaron usando un método híbrido basado en el templado simulado y el gradiente conjugado.Finalmente, se presenta el análisis de las RNA como sistemas de clasificación a través de los dos métodos en funcionamiento, alcanzando resultados satisfactorios que manifiestan la aplicación como herramienta de apoyo al diagnóstico médico para la detección de este trastorno

Gastric volvulus is a rare entity that occurs as a consequence of a rotation of the stomach of more than 180°, with gastric outlet obstruction and vascular compromise. It occurs secondary to diaphragmatic defects in most cases and is mainly reported in elderly patients who are fragile and present severe associated comorbidities. Here we present a nonsurgical treatment with the use of a single percutaneous endoscopic tube to perform gastropexy in patients with a high risk for surgery or inoperable patients. We present two cases that show that this therapeutic option is viable, with acceptable results under very specific clinical conditions.

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.

Cancer of the esophagus is a tumor with aggressive behavior that is usually diagnosed in advanced stages. The absence of serosa allows it to spread quickly to neighboring mediastinal structures, and an extensive lymphatic drainage network facilitates tumor spread even in early stages. The current TNM classification, harmonized with the classification for gastric cancer, provides new definitions for the anatomic classification, adds non-anatomic characteristics of the tumor, and includes tumors of the gastroesophageal junction. Combining endoscopic ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging provides greater accuracy in determining the initial clinical stage, and these imaging techniques play an essential role in the selection, planning, and evaluation of treatment. In this article, we review some particularities that explain the behavior of this tumor and we describe the current TNM staging system; furthermore, we discuss the different imaging tests available for its evaluation and include a diagnostic algorithm.

RESUMEN Antecedentes: el síndrome de intestino irritable tipo estreñimiento (SII-E) es una patología prevalente, compleja y multifactorial que representa un desafío tanto desde el punto de vista diagnóstico como terapéutico. Objetivo: evaluar la efectividad, seguridad y satisfacción de linaclotida en pacientes con SII-E. Métodos: estudio prospectivo, unicéntrico y observacional realizado en pacientes con diagnóstico de SII-E. Los pacientes recibieron tratamiento con linaclotida (Constella(r), Allergan Inc., Irvine, CA), 290 microgramos/24 horas, una cápsula 30 minutos antes del desayuno. La variable primaria de efectividad fue el número de deposiciones por semana. Las variables secundarias incluían el grado de satisfacción y el registro de la frecuencia e intensidad de los síntomas (dolor e hinchazón), medidos mediante una escala visual analógica (EVA) de once niveles (0-10), y recogidas mediante un diario que se entregó al paciente. Resultados: treinta pacientes, todas mujeres, fueron incluidas consecutivamente. La mediana del tiempo de seguimiento fue de 18 meses. La media (deviación estándar [DE]) de deposiciones por semana aumentó desde 0,9 (0,6) al inicio del estudio hasta 4,7 (3,7) al final del mismo (p < 0,0001). Resultados similares fueron observados con el dolor (5,7 [2,3] frente a 3,1 [2,8] al inicio y al final del estudio, respectivamente, p < 0,0001) y con la hinchazón (6,8 [1,6] frente a 2,9 [2,5] al inicio y final del estudio, respectivamente, p < 0,0001). El grado medio (DE) de satisfacción al final del estudio fue 6,7 (3,0). Conclusiones: el tratamiento con linaclotida en pacientes con SII-E en el entorno de la práctica clínica se ha mostrado eficaz y seguro a largo plazo. ABSTRACT Background: constipation-predominant irritable bowel syndrome (C-IBS) is a prevalent, complex and multifactorial disorder that represents a challenge in terms of diagnosis and therapeutic management. Objective: to evaluate the effectiveness, safety and treatment satisfaction of linaclotide in C-IBS patients. Methods: prospective, single-center and observational study conducted in patients diagnosed with C-IBS. The patients were treated with linaclotide (Constella(r), Allergan Inc., Irvine, CA), once-daily via an oral capsule of 290-µg, 30 minutes before breakfast. The primary effectiveness endpoint was the number of bowel movements per week. The secondary endpoints included treatment satisfaction and changes from baseline in frequency and severity of symptoms (abdominal pain and bloating). This was assessed via an 11-point visual analog scale (VAS) reported by the patients in a daily register. Results: thirty female patients were consecutively included. The median follow-up time was 18 months. The mean (standard deviation [SD]) number of weekly bowel movements significantly increased from 0.9 (0.6) at baseline to 4.7 (3.9) at the end of follow-up, p < 0.0001. Abdominal pain significantly decreased from 5.7 (2.3) at baseline to 3.1 (2.8) at the end of the follow-up period, p < 0.0001. Similarly, bloating significantly decreased from 6.8 (1.6) to 2.9 (2.5) at the beginning and end of the treatment period, respectively, p < 0.0001. The mean (SD) degree of satisfaction at the end of the study was 6.7 (3.0). Conclusions: long-term linaclotide treatment in patients with C-IBS is effective and safe in the clinical setting.

RESUMEN Introducción: el drenaje biliar endoscópico guiado por ultrasonografía (DBUSE) es una alternativa al drenaje biliar percutáneo transhepático (CTPH) ante fallo de la colangiografía retrógrada endoscópica (CPRE). Métodos: descripción retrospectiva de seis casos de drenaje biliar guiado por ultrasonografía endoscópica, mediante coledocoduodenostomía (USE-CDS), así como de sus características clínicas, procedimiento endoscópico, complicaciones y posterior seguimiento. Resultados: todos nuestros casos presentaban obstrucción biliar distal de etiología maligna. En cuatro de los seis pacientes se concluyó el procedimiento con buen drenaje posterior. Registramos dos complicaciones tardías por migración de prótesis, sin muertes relacionadas con el procedimiento. El tiempo medio de seguimiento fue de seis meses. Conclusión: la USE-CDS se plantea como una opción terapéutica válida, no exenta de complicaciones, en casos seleccionados y en manos de un equipo de endoscopistas expertos ante fallos del drenaje por CPRE, y como alternativa al CTPH. ABSTRACT Introduction: endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to percutaneous trans-hepatic biliary drainage (PTBD) in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). Methods: this is a retrospective description of six cases of endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy (EUCD), as well as the clinical characteristics, endoscopic procedure, complications and monitoring. Results: all cases had malignant distal biliary obstruction. The procedure was concluded with good drainage in four out of six patients. Two late complications were recorded that were caused by stent migration and there were no deaths related with the procedure. The average monitoring period was six months. Conclusions: EUCD can be considered as a valid therapeutic choice in some selected cases and when performed by a team of expert endoscopists in cases of failed ERCP drainage or as an alternative to PTBD. However, the procedure has some associated complications.

ResumenAntecedentesEn pacientes con cáncer gástrico irresecable con obstrucción antral, la gastro yeyuno anastomosis con separación gástrica parcial es una alternativa, que evitaría los inconvenientes de las técnicas habituales.ObjetivoComparar stent antroduodenal, gastro-yeyuno-anastomosis convencional y gastro-yeyuno-anastomosis con separación parcial gástrica.Material y métodosEstudio retrospectivo durante 12 años, transversal en enfermos con cáncer gástrico distal irresecable y obstrucción gástrica; tratados con 3 técnicas diferentes, comparando sus resultados en función de la tolerancia oral y las complicaciones. Se analizaron los resultados con la t de Student para variables independientes.ResultadosVeintidós pacientes divididos en 3 grupos: grupo i stent (6 casos), grupo ii (9 casos) gastro yeyuno anastomosis convencional y grupo iii (7 casos) gastro yeyuno anastomosis con separación gástrica parcial.El stent permite una estancia «postoperatoria» más corta e inicio de la tolerancia de alimentos precoz (p

Background Delivery of therapeutic agents as erythropoietin (EPO) into Central Nervous System through intranasal route could benefit patients with neurological disorders. A new nasal formulation containing a non-hematopoietic recombinant EPO (NeuroEPO) has shown neuroprotective actions in preclinical models. In the current study, the safety of NeuroEPO was evaluated for the first time in humans. Methods A phase I, randomized, parallel, open-label study was carried out in healthy volunteers. They received, intranasally, 1 mg of NeuroEPO every 8 h during 4 days (Group A) or 0.5 mg of NeuroEPO (Group B) with the same schedule. The working hypothesis was that intranasal NeuroEPO produce

Introduccion: La pancreatitis aguda post-CPRE (PAP) es la complicacion grave mas frecuente asociada a este procedimiento. Las guias clinicas ofrecen diferentes recomendaciones para reducir la incidencia y gravedad de PAP. Objetivo y metodos: Conocer el grado de cumplimiento en hospitales espanoles de 7 recomendaciones publicadas por ASGE/ESGE para evitar PAP (R1-R7) y su efectividad. Disenamos una encuesta con 16 items en el GSEED de via biliar y pancreas y fue remitida a todos los socios. Resultados: 40 hospitales contestaron la encuesta (tasa respuesta: 61%), total: 15.757 CPREs/ano. Volumen CPREs/centro: > 100/ano un 92,5% y 65% > 200/ano. Esfinterotomias/endoscopista: 95% > 1/semana; tasa canulacion biliar > 90% un 75%, 60 segundos (R5). El 77,5% utilizaban rutinariamente precorte si fallaba la canulacion convencional (45% hacian fistulotomia) (R6). Un 10% de las CPREs fueron ambulatorias y ningun endoscopista solicitaba amilasa/lipasa rutinaria 2 – 6 horas tras la prueba (R7). Conclusion: El grado de cumplimiento de las recomendaciones publicadas para evitar PAP fue elevado en la encuesta nacional espanola (incluyendo tasas de colocacion profilactica de protesis pancreaticas superiores a las reportadas previamente), asi como los criterios de calidad generales aconsejados en CPRE. Solamente en las recomendaciones con menor evidencia cientifica el grado de cumplimento fue inferior (R5-R7). Nuestra encuesta ademas proporciona evidencia sobre la efectividad del cumplimiento de las medidas recomendadas para evitar PAP.

Resumen El sindrome del intestino irritable (SII) es el trastorno gastrointestinal mas comun y un motivo de consulta frecuente. Se define por los criterios de Roma III. Su curso cronico y la gravedad tienen un importante impacto en la calidad de vida y en la utilizacion de recursos sanitarios. El papel de las alteraciones de la motilidad y de la hipersensibilidad visceral se consideraban un mecanismo fisiopatologico fundamental. Estudios mas recientes han resaltado el papel de la serotonina, la microinflamacion, las alteraciones de la flora intestinal y el sobrecrecimiento bacteriano. Su diagnostico esta basado en los sintomas y el uso de exploraciones complementarias debe ser limitado y protocolizado. El tratamiento farmacologico se realiza segun el sintoma predominante, y es muy importante desarrollar una relacion medico-paciente “terapeutica”. Se pueden realizar cambios en el estilo de vida, excluir aquellos alimentos o farmacos que pueden precipitar los sintomas y tratar las alteraciones psicologicas asociadas.

Autoimmune enteropathy (AIE) is an infrequent cause of malabsorption that is usually associated with the presence of circulating autoantibodies and a predisposition to autoimmune disorders. This disease is more frequent in children. The diagnosis of this disorder is based on five criteria: chronic diarrhea (>6 weeks), malabsorption, specific histological findings, exclusion of similar disorders, and the presence of specific antibodies such as anti-enterocyte and anti-goblet cell antibodies. We present the case of a 63-year-old patient with chronic diarrhea, weight loss and significant deterioration of nutritional status.

Emphysematous pancreatitis is a severe and rare complication of acute pancreatitis. This entity is diagnosed on clinical grounds and on the basis of the radiologic finding of gas in the retroperitoneum. Infected pancreatic necrosis is potentially lethal, with mortality rates of more than 35%. Surgery is associated with significant morbidity and mortality in these critically ill patients. Endoscopic ultrasonography techniques, laparoscopic surgery and percutaneous drainage have the potential to offer a safe and effective alternative treatment modality. However, the precise role of these procedures requires further investigation. The treatment of these patients should be individualized, dynamic and multidisciplinary. We present two cases of emphysematous pancreatitis with distinct therapeutic management.

Introduccion: Los polipos de colon sesiles y/o planos de gran tamano (mayores de 30 mms) son un desafio endoscopico, tanto para predecir la existencia de malignidad y/o invasion submucosa, como para su resecabilidad. La reseccion endoscopica mucosa (REM) es una tecnica util y aceptada para este tipo de lesiones. Objetivo: evaluar la eficacia y seguridad de la REM en los polipos de gran tamano en nuestro centro. Material y Metodo: De forma prospectiva desde enero 2015 a junio 2015 se incluyeron 13 pacientes (6 hombres y 7 mujeres, edad media 73 anos). Se realizaron 15 resecciones, dos polipos sesiles (Is) y 13 planos (la mayoria IIa o IIa + Is). Tamano medio de las lesiones 43 mms (30 – 60 mms). La localizacion mas frecuente de las lesiones fue sigma (40%), colon derecho-ciego (40%). La principal indicacion para la realizacion de la colonoscopia fue la rectorragia. Se usaron endoscopios de alta definicion Olympus 190 HQ con NBI para determinar resecabilidad. Resultados: Se consiguio la reseccion completa en todos los pacientes (REM en fragmentos 100%), en el 50% de los casos se trato con Argon los bordes de la reseccion. Dos complicaciones (13%) ambas por hemorragia que se resolvieron por via endoscopica. La histologia de las lesiones; adenoma tubular o tubulo-velloso (40%), adenoma tubulo-velloso con displasia de alto grado (20%), adenocarcinoma intramucoso (26,6%), adenocarcinoma pT1 (submucosa, 13,3%). En el seguimiento se han realizado endoscopia a los 3 meses en 6 pacientes (tejido residual o recurrencia 20%). Conclusiones: La seguridad y eficacia de la REM para polipos de gran tamano es alta en nuestra serie, aunque se requiere mayor numero de casos y un seguimiento de todas las resecciones. La REM es una tecnica compleja no exenta de complicaciones que requiere una curva de aprendizaje.

Background: the duodenum is the most common location for ectopic varices. Bleeding is rare, but when it appears, it is massive and difficult to control. Material and methods: retrospective description of five clinical cases of digestive bleeding secondary to duodenal varices that we observed between the years 2011 and 2012, together with their clinical characteristics, endoscopic diagnosis, endoscopic treatment with cyanoacrylate injection and the posterior follow-up and assessment of new bleeding. Results: all five patients were treated with an endoscopic cyanoacrylate injection and two of the patients experienced a digestive rebleeding. Three of the patients died during the follow-up period, only one due to cause digestive bleeding. Conclusion: in conclusion we can state that endoscopic treatment of duodenal varices with cyanoacrylate is technically possible, and it permits us to control the first bleeding before doing other definitive treatments, if the patient condition allows it.

Background The objective of this study is to analyze the factors that are associated with the adequacy of empirical antibiotic therapy and its impact in mortality in a large cohort of patients with extended-spectrum β-lactamase (ESBL) - producing Escherichia coli and Klebsiella spp. bacteremia. Methods Cases of ESBL producing Enterobacteriaceae (ESBL-E) bacteremia collected from 2003 through 2008 in 19 hospitals in Spain. Statistical analysis was performed using multivariate logistic regression. Results We analyzed 387 cases ESBL-E bloodstream infections. The main sources of bacteremia were urinary tract (55.3%), biliary tract (12.7%), intra-abdominal (8.8%) and unknown origin (9.6%). Among all the 387 episodes, E. coli was isolated from blood cultures in 343 and in 45.71% the ESBL-E was multidrug resistant. Empirical antibiotic treatment was adequate in 48.8% of the cases and the in hospital mortality was 20.9%. In a multivariate analysis adequacy was a risk factor for death [adjusted OR (95% CI): 0.39 (0.31-0.97); P = 0.04], but not in patients without severe sepsis or shock. The class of antibiotic used empirically was not associated with prognosis in adequately treated patients. Conclusion ESBL-E bacteremia has a relatively high mortality that is partly related with a low adequacy of empirical antibiotic treatment. In selected subgroups the relevance of the adequacy of empirical therapy is limited.

Background: the gastrointestinal (GI) tract is the major target site of the graft- versus -host disease (GVHD). Diagnosis is based on endoscopic and histological findings. Material and methods: we performed a retrospective study from January 1 st , 1990 to December 31 st , 2008 on 338 upper gas trointestinal endoscopies (gastroscopies) performed to 197 patients that underwent an allogeneic transplant with clinical suspicion of GI-GVHD. Results : endoscopic findings to the diagnosis of GVHD have a sensitivity (S) of 34%, specificity levels (SP) of 65%, a positive pre dictive value (PPV) of 73% and a negative predictive value (NPV) of 48%. The histological study of the endoscopic biopsies has a global sensibility of 85.6% SP = 34.6% PPV = 64.2% and NPV = 63.7%. Histological grade was correlated with the clinical grade of acute GVHD (p = 0.018). Conclusion : upper gastrointestinal endoscopy is useful for the diagnosis of GVHD, as it allows biopsies that can ultimately lead to the diagnosis, but with limited accuracy because the histological find ings have low sensitivity and specificity, while the endoscopic findings are generally nonspecific.

Introduction: It is estimated that chronic hepatitis B affects to than 350 million people around the world. Patients with eAgHB- minus account, in some areas, for between 50-80% of the total of the population with chronichepatitis B. Spontaneous clearance is rare within these patients, the response to interferon is low and the probability of developing cirrhosis and hepatocarcinoma is higher than in the wild type. Aim: To analyze the response to lamivudine treatment in patients with chronic hepatitis B which are eAgHB negative. Results: Seven of the 9 patients which were treated in our department for more than 3 months were eAgHB negative. Six of them responded to the treatment in an average time of 3.5 months (range 1-6 months). There were two patients that relapsed at 18 and 24 months and they were treated with adefovir. Four patients remained DNA negative and had normal aminotransferases values after an average treatment time of 25 months. Conclusion: In our series, the majority of the patients (77.7%) were eAgHB negative at the beginning of treatment. The efficacy of the treatment with lamivudine in these cases is high (85.7%) and with an early response (average 3,5 months). One third of patients treated relapsed after one and a half years of treatment.