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INTRODUCTION: The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital. METHODS: Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1–54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema. RESULTS: Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p

One of the most common complications of the surgical treatment of breast cancer is limited range-of-motion in the shoulder. Scapular winging is one of the most underdiagnosed shoulder mobility impairments. The main objective of this study was to determine the incidence of scapular winging in patients who underwent breast cancer surgery as the basis for expanding the protocol to patients who have had a sentinel lymph node biopsy. The secondary objective was to determine the risk factors that lead to the development of a winged scapula presented after breast cancer treatment in our sample. This was a prospective, observational, and multidisciplinary study. Between 2013 and 2018, 214 consecutive patients who had been diagnosed with breast cancer and treated for it surgically were followed by Rehabilitation Department for 3 years. The patients were evaluated in the 1st, 6th, 12th, 18th, 24th and 36th months following surgery. Scapular winging was evaluated at each visit by means of static and dynamic tests. The cumulative incidence of scapular winging was 3.6% and seven cases of winged scapula were diagnosed. All the cases were diagnosed at the first visit, 1 month after the intervention. In the univariate analysis, the axillary lymph node dissection technique was a more significant risk factor for a winged scapula than sentinel lymph node biopsy. The axillary lymph node dissection technique is a risk factor for developing a winged scapula. No evidence was found for any other significant risk factor.

Facial lymphedema secondary to treatment by a neoplastic process is a rare and disabling pathology, causing functional and aesthetic alterations. A case report of facial and labial lymphedema describing the functional repercussion and aesthetic defect. We present a 61-years-old female patient suffered a tongue neoplasia and bilateral cervical lymphadenectomy in 2015. After several treatments, including diverse surgical interventions and adjuvant radiotherapy, developed facial and labial lymphedema. The patient was sent to our Rehabilitation Department complaining about swelling of the face and lips, dysphagia, sialorrhea, xerostomia, dysarthria and decubitus in lower lip by labia protusion. Due to the functional repercussion that it caused in the patient, rehabilitating physical treatment was planned with manual lymph drainage, facial silicone orthosis and lymphatic taping. The patient improved both subjectively as well as objectively in terms of hardness, volume and slight improvement of lip lymphedema.

Peripheral facial nerve palsy (PFNP) has a substantial physical, psychological and social impact on patients. Neurophysiological study quantifies the degree of nerve injury and assesses prognosis. We present the case of a woman with a 3-month history of left PFNP after a dental implant, with facial functionality of 85.5% and with a normal neurophysiological study performed according to the standard protocol. By modifying the technique centred on the orbicularis oris in its upper portion, the procedure showed an asymmetry of amplitude and signs of denervation. This allowed us to detect a deficit and differentiate a possible asymmetry or simulation by the patient.

Conservative treatment of lymphedema usually includes complex decongestive therapy in order to reduce the volume of the lymphedema, and compression garments in the maintenance phase. Follow-up is carried out in the Rehabilitation Services. Surgical treatment of lymphedema is a therapeutic option, the interest of which has increased in recent years, although there is no current evidence that it can cure lymphedema and it is always accompanied by conservative treatment. Most studies focus on results according to the type of surgery and there is no standardized protocol for conservative treatment before or after surgery. The objective of this work is to prepare a compendium about the most frequent lymphedema surgeries and their indications, focusing on the rehabilitation treatment for each surgery.

Introduction: We aimed to investigate the incidence of lymphedema after breast cancer treatment, to analyze the risk factors involved, and to improve existing protocols for the prevention of lymphedema. Patients and methods: This was a prospective cohort study of 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, as well as local and systemic therapies, were analyzed as possible risk factors for lymphedema. Results: In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1–54 months). Most cases of lymphedema cases appeared in the first 2 years. 13.9% developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92–18.16) and 3.9 (1.60–9.49), respectively. Conclusions: The main risk factors for lymphedema were the most radical surgeries (ALND and mastectomy), while the risk associated with these appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND for at least two years, where these risk factors are recognized, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

Resumen El linfedema de mama (LM) secundario a cirugia tras un proceso neoplasico se manifiesta con edema o rubefaccion en la zona de la mama. Presentamos 2 casos de pacientes intervenidas de cancer de mama izquierda, hemimastectomia y linfadedectomia, que recibieron quimioterapia (QT) y radioterapia (RT) adyuvante. Fueron remitidas al Servicio de Rehabilitacion (RHB) por aumento de volumen y sensacion de dureza en extremidad superior izquierda (ESI) y mama. Tras objetivar el edema en la mama, tratamos el LM con taping linfatico. Se las cito para revision a la semana, y refirieron mejoria en la sensacion de dureza e hinchazon en mama en la escala visual analogica (EVA). El LM es una dolencia infradiagnosticada aunque relativamente frecuente, de dificil cuantificacion, y no hay descrito en la literatura un tratamiento especifico. El taping linfatico es una opcion de tratamiento para el LM, ya que mejora la sensacion subjetiva de dureza e hinchazon asi como la clinica de induracion y edema.

Introduction When co-administered with interferon and ribavirin, the prescription drug telaprevir significantly improves treatment response in patients with chronic hepatitis C virus (HCV) infection. Its use, however, also increases the likelihood of adverse effects that may lead to discontinuation of treatment. Cutaneous adverse effects are particularly common. Objective To determine the frequency and clinical characteristics of drug eruptions induced by telaprevir in patients receiving HCV treatment and to analyze the clinical course of lesions and response to treatment. Material and methods We performed a prospective observational study of all patients who started a treatment regimen that included telaprevir between May 2012 and July 2013. We recorded the demographic characteristics of the patients who developed telaprevir-induced eruptions, and analyzed the clinical characteristics of the lesions and their clinical course following the application of guideline-based treatment recommendations. Results Twenty (46%) of the 43 patients who received triple therapy with interferon, ribavirin, and telaprevir during the study period developed drug reactions attributable to telaprevir. The reaction was classified as mild or moderate (grades 1 or 2) in 90% of cases and consisted of an exanthem with erythematous-edematous scaling plaques and papules. The rash worsened, mainly by spreading, in about one-third of cases. The skin lesions led to discontinuation of treatment in 2 patients (4.6%). Sustained viral response was achieved in 34 patients (79%). Conclusions Telaprevir-induced eruptions are common and often progress, but they rarely require patients to discontinue treatment.

Resumen Introduccion Telaprevir es un farmaco que administrado junto a interferon y ribavirina incrementa de forma significativa la respuesta al tratamiento de la infeccion por el virus de la hepatitis C. Sin embargo, su empleo incrementa tambien la probabilidad de desarrollar efectos adversos, en muchos casos cutaneos que pueden condicionar el mantenimiento del tratamiento. Objetivo Conocer la incidencia, caracteristicas clinicas y evolutivas y respuesta al tratamiento de las toxicodermias por telaprevir en el contexto del tratamiento de la infeccion por el virus de la hepatitis C. Material y metodos Estudio prospectivo observacional realizado entre mayo de 2012 y julio de 2013 en el que se incluyeron aquellos pacientes que iniciaron tratamiento con telaprevir durante ese periodo. En aquellos en los que se detectaron toxicodermia se recogieron los datos demograficos de los pacientes, las caracteristicas clinicas de las lesiones y la evolucion tras la aplicacion de las recomendaciones de las guias clinicas. Resultados De un total de 43 pacientes que recibieron tratamiento triple un 46% presento toxicodermia atribuible a telaprevir. En el 90% de los casos esta fue leve o moderada (grados 1 o 2) y consistio en un exantema constituido por papulas y placas eritematoedematosas y descamativas. En alrededor de un tercio de los pacientes se comprobo la progresion de la toxicodermia, principalmente en extension, durante el curso del tratamiento. En 2 casos (4,6%) las lesiones cutaneas condicionaron la suspension del farmaco. Un 79% de los tratados (34 pacientes) alcanzo una respuesta viral sostenida tras el tratamiento. Conclusiones Las toxicodermias asociadas a telaprevir son frecuentes en el curso del tratamiento y a menudo progresivas. Sin embargo, solo de forma excepcional condicionan su suspension.

When co-administered with interferon and ribavirin, the prescription drug telaprevir significantly improves treatment response in patients with chronic hepatitis C virus (HCV) infection. Its use, however, also increases the likelihood of adverse effects that may lead to discontinuation of treatment. Cutaneous adverse effects are particularly common.To determine the frequency and clinical characteristics of drug eruptions induced by telaprevir in patients receiving HCV treatment and to analyze the clinical course of lesions and response to treatment.We performed a prospective observational study of all patients who started a treatment regimen that included telaprevir between May 2012 and July 2013. We recorded the demographic characteristics of the patients who developed telaprevir-induced eruptions, and analyzed the clinical characteristics of the lesions and their clinical course following the application of guideline-based treatment recommendations.Twenty (46%) of the 43 patients who received triple therapy with interferon, ribavirin, and telaprevir during the study period developed drug reactions attributable to telaprevir. The reaction was classified as mild or moderate (grades 1 or 2) in 90% of cases and consisted of an exanthem with erythematous-edematous scaling plaques and papules. The rash worsened, mainly by spreading, in about one-third of cases. The skin lesions led to discontinuation of treatment in 2 patients (4.6%). Sustained viral response was achieved in 34 patients (79%).Telaprevir-induced eruptions are common and often progress, but they rarely require patients to discontinue treatment.

The aim of the study was to assess the progression of liver fibrosis in HIV/hepatitis C virus (HCV)-coinfected patients with no or mild-to-moderate fibrosis (stages F0-F2).Liver fibrosis was reassessed by transient elastometry (TE) between January 2009 and November 2011 in HIV/HCV-coinfected patients with stage F0-F2 fibrosis in a liver biopsy performed between January 1997 and December 2007. Patients with liver stiffness at the end of follow-up 7.1 kPa were defined as nonprogressors, and those with values ≥ 9.5 kPa or who died from liver disease were defined as progressors. Cirrhosis was defined as a cut-off of 14.6 kPa. The follow-up period was the time between liver biopsy and TE. Cox regression models adjusted for age, gender and liver fibrosis stage at baseline were applied.The median follow-up time was 7.8 years [interquartile range (IQR) 5.5-10 years]. The study population comprised 162 patients [115 (71%) nonprogressors and 47 (29%) progressors; 19 patients (11.7%) had cirrhosis]. The median time from the diagnosis of HCV infection to the end of follow-up was 20 years (IQR 16.3-23.1 years). Three progressors died from liver disease (1.8%). The variables associated with a lower risk of progression were age ≤ 38 years (hazard ratio (HR) 0.32; 95% confidence interval (CI) 0.16-0.62; P = 0.001], having received interferon (HR 2.18; 95% CI 1.14-4.15; P = 0.017), being hepatitis B virus surface antigen (HBsAg) negative (HR 0.20; 95% CI 0.04-0.92; P = 0.039), and baseline F0-F1 (HR 0.43; 95% CI 0.28-0.86; P = 0.017).A high proportion of patients with stage F0-F2 fibrosis progress to advanced liver fibrosis. Advanced liver fibrosis must be included in the list of diseases associated with aging. Our results support the recommendation to offer HCV antiviral therapy to HIV/HCV-coinfected patients at early stages of liver fibrosis.

Despite numerous preventive strategies on bacterial adhesion, pathogenic biofilm formation remained the major cause of medical device-related infections. Bacterial interference is a promising strategy that uses pre-established biofilms of benign bacteria to serve as live, protective coating against pathogen colonization. However, the application of this strategy to silicone urinary catheters was hampered by low adherence of benign bacteria onto silicone materials. In this work, we present a general method for biofunctionalization of silicone (PDMS) as one of the most widely used materials for biomedical devices. We used mild CO2 plasma to activate PDMS surface followed by simple attachment of generation 5 (G5) poly(amidoamine) (PAMAM) dendrimers to generate an amino-terminated surface that were maintained even after storage in PBS buffer for 36 days. We then covalently attach a carboxy-terminated mannose derivative to the modified PDMS to promote the adherence of benign Escherichia coli 83972 expressing mannose-binding type 1 fimbriae. We demonstrated that dense, stable biofilms of E. coli 83972 could be established within 48 h on the mannose-coated PDMS. Significantly, this benign biofilm reduced the adherence of the uropathogenic Enterococcus faecalis by 104-fold after 72 hours, while the benign bacteria on the unmodified substrate by only 5.5-fold.

Les auteurs presentent un cas d’ulcerations multiples duodeno-jejunales consecutives a des lesions vasculaires mesenteriques. Le diagnostic differenciel et les mecanismes pathogeniques de cette enterite ulcerative diffuse sont discutes.

Resolution of hepatitis C virus (HCV) infection requires a complex interplay between innate and adaptative immune responses. The role of lymphocyte subpopulations during combined antiviral treatment remains to be defined. This study was conducted to assess the effect of pegylated interferon-alpha2a (pegIFN-α2a) and ribavirin treatment on peripheral blood lymphocytes, mainly on CD81 expression on B cells and CD4(+) CD25(+) CD127(low/-) FoxP3(+) regulatory T cells (Tregs) in patients with chronic HCV infection. Thirty-five patients with chronic HCV infection who started pegIFN-α2a and ribavirin treatment were enrolled. Peripheral blood mononuclear cells (PBMC) were obtained at baseline before treatment (BT), mid-treatment (MT), the end of treatment (ET) and 24weeks post-treatment (PT). During combined antiviral treatment, a significant decrease in the percentage of CD3(+) , CD8(+) , CD3(+) gamma/delta (γδ)(+) , CD19(+) lymphocyte subpopulations and Tregs was observed. There was also a significant increase in the percentage of the CD4(+) lymphocyte subpopulation and in CD81 expression levels on CD19(+) B cells when BT was compared with ET (all P0.05). Seventeen patients were nonresponders (NR) and 18 had a sustained virological response (SVR). At baseline, NR patients had higher CD81 expression levels on CD19(+) B cells (P=0.017) and a higher Tregs percentage (P=0.025) than SVR patients. Our results suggest that immunomodulation fluctuates during antiviral treatment and that percentage CD81 expression levels on B cells and Tregs might be useful as an immunological prognostic factor for pegIFN-α2a and ribavirin treatment response in chronic HCV infection.

We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor.All colonoscopies performed between 1995 and 2008 were reviewed. Demographic data, endoscopic procedure information, incidence of CP and PPB, and endoscopist experience were recorded.In the 14-year period, 25,214 endoscopic colonic procedures were performed, and 3991 patients underwent polypectomy. The overall CP risk was 0.51/1000 procedures; and PPB 14.7/1000. The relative risk (RR) ratio of complications was 2.8/1000 procedures. The RR rate was highest for endoscopists performing less than 591 procedures per year (4.0/1000 [95% CI, 3.7-4.3] vs 2.9/1000 [95% CI, 2.6-3.2]), P0.001).The complication rate after colonoscopy was comparable to that previously reported. Colonoscopy carried out by a low-volume endoscopist was independently associated with bleeding and perforation.

toxic liver damage associated with the use of natural remedies is a growing health problem.to analyze the demographics, and clinical and epidemiological characteristics of patients developing liver injury related to these remedies.all DILI cases associated with the use of herbal remedies (HR) or dietary supplements (DS) submitted to the Spanish Registry were analyzed. Type of liver damage, severity, and outcome were specifically evaluated.thirteen cases out of 521 DILI cases (2%) submitted to the Spanish Liver Toxicity Registry between 1994 and 2006 were related to HR/DS, which ranked as the 10th therapeutic group with a greater number of cases and above pain killers, anxiolytics, and antipsychotic drugs. Nine patients (69%) were female (mean age 45 years). Nine cases (69%) had jaundice at presentation. The predominating type of liver damage was hepatocellular (12; 92%), and 31% of cases exhibited the common features of hypersensitivity. Camellia sinensis (3, 23%) was the main causative herb, followed by Rhamnus purshianus and isoflavones (Fitosoja(R), Biosoja(R)) (2 cases each, 15%). Three cases (23%) were rechallenged with the offending product.the incidence of hepatic damage related to HR/DS is not so rare, the most common profile of affected patients being a woman with acute hepatocellular hepatitis. Low suspicion regarding the putative role of herbs in hepatotoxicity makes diagnosis more difficult, and probably increases the incidence of inadvertent rechallenge in these patients.

Depression and anxiety have been associated with interferon treatment and low treatment adherence.To study the incidence and associated risk factors of depressive and anxiety disorders during pegylated interferon plus ribavirin and treatment adherence in a prospective cohort of 176 patients with chronic hepatitis C patients.Patients were interviewed at baseline using the Structured Clinical Interview for DSM-IV Mental Disorders and the Patient Health Questionnaire and the Hospital Anxiety and Depression Scale were completed. Both questionnaires were completed also after 4, 12 and 24 weeks of treatment.De novo depressive and/or anxiety disorders were diagnosed in 53 (36%) patients, in whom antidepressants and/or anxiolytics were administered. Higher baseline depression-subscale score (OR = 27.8, 95% CI = 2.82-333), primary education level (OR = 3.1, 95% CI = 1.40-7.03) and being an immigrant (OR = 3.2, 95% CI = 1.12-9.47) were predictors of psychiatric disorders during anti-viral therapy. The percentage of patients with good adherence was lower in those with depression and/or anxiety (79% vs. 90%, P0.04). Only one patient (1%) discontinued treatment because of a major depressive episode. Depression and/or anxiety disorders had no effect on attainment of sustained virological response.Early detection and treatment of depressive and anxiety disorders favours good adherence to anti-viral treatment in hepatitis C.

Sustained virological response rates of up to 52% have been obtained with peginterferon alpha2a (40 kDa) plus ribavirin in patients suffering from chronic hepatitis C genotype 1 in randomized-controlled trials.To assess early virological response and its clinical utility in predicting an sustained virological response in patients suffering from chronic hepatitis C genotype 1 in routine clinical practice in Spain.Treatment-naïve patients received pegylated interferon alpha2a (40 kDa) 180 microg/week plus ribavirin 1000/1200 mg/day for 48 weeks, and were followed for a further 24 weeks. Overall, 475 patients received at least one dose of medication and were included in the efficacy population.The overall sustained virological response rate was 48%. Of those with week 12 virological data, 83% had an early virological response. The negative predictive value of an early virological response was 93%.If sustained virological response is the goal, a treatment-decision based on a 12-week evaluation during routine clinical practice is feasible.

Hepatocarcinoma (HCC) is the most frequent primary malignant hepatic tumour. These tumours usually develop in cirrhotic liver; for this reason, periodic screening using alphafetoprotein determination and abdominal ultrasonography is considered in cirrhotic patients with preserved hepatocellular function. This strategy allows early detection of HCC, increasing the proportion of curable tumours. The most frequent metastasic dissemination is portal vein neoplasic thrombosis, being unusual the occurrence of spread metastases in other organs. We present 3 cases of atypical HCC metastasis with non specific clinical manifestations which initial diagnosis was wrong. Because of a longer survival of these patients in recent years, spread metastasis might be considered in patients with known HCC and non specific symptoms.

Gas exchange alterations have been described in cirrhotic patients; but by the moment, a few prospective studies have focused in them. The aim of this study was to describe the frequency and severity of gasometric alterations in hospitalized cirrhotic patients, a their correlation with hepatocellular disfunction.50 consecutive cirrhotic patients (41 males) admitted for liver decompensation (ascites, liver encephalopathy, alcoholic hepatitis and upper gastrointestinal bleeding) without acute or chronic cardiopulmonary disfunction were included in the study. Patients were classified according with Child-Pugh score (A, n = 13; B, n = 21; C, n = 16). Severe alcoholic hepatitis (SAH) was confirmed in 7 patients. Arterial gasometry was performed in all patients before discharge. Contrast echocardiography was performed in any case of suspicion of hepatopulmonary syndrome (HPS).Light hypoxemia was observed (80.9 mmHg), without differences with Child-Pugh. Hypocapnia was significantly more evident in Child C than in A and B (31.2 +/- 3.1 vs. 38.1 +/- 4.3 y 36.3 +/- 5 mmHg; p0,05), respectively. Cirrhotic patients with SAH showed a significantly higher hypocapnia by comparison with others (31.2 +/- 3.1 vs. a 36.3+/-5 mmHg; p0.05). In multivariate analysis, independent prognostic variables for hypocapnica were plasmatic levels of protrombin time, albumin and sodium. HPS was confirmed in 8 patients (16%).The most prevalent gas exchange abnormality in cirrhosis was the alteration of alveolar-arterial oxygen tension gradient, directly correlated with hepatocellur disfunction. Hypocapnia could be a compensatory mechanism or the result of the activation of central respiratory centres by non-depurated substances by the liver.

Introducción y objetivos: Aunque se ha descrito la existencia de diversas alteraciones del intercambio gaseoso en la cirrosis, existen pocos estudios que las hayan estudiado de forma prospectiva. El objetivo de este trabajo fue conocer la frecuencia y gravedad de dichas alteraciones en los pacientes cirróticos hospitalizados, correlacionándolas con el grado de disfunción hepática. Pacientes y métodos: Se estudiaron 50 pacientes cirróticos consecutivos (41 varones) que requirieron ingreso hospitalario por descompensación de su hepatopatia (ascitis, encefalopatía hepática, hepatitis alcohólica y hemorragia digestiva alta), y que no presentaban procesos pulmonares ni cardiacos agudos o crónicos que pudiesen producir hipoxemia. Los pacientes fueron agrupados según su estadio de Child-Pugh (A, n = 13; B, n = 21; C, n = 16). En siete pacientes se constató la presencia de una hepatitis alcohólica sobreañadida grave (HAAG). En todos ellos se realizó una gasometría arterial basal antes de ser dados de alta, y se efectuó un ecocardiograma transtorácico con contraste en caso de sospecha de síndrome hepatopulmonar (SHP). Resultados: Se observó una discreta hipoxemia global (80,9 mmHg) sin diferencias según el grado de Child-Pugh. La hipocapnia fue significativamente más marcada en los pacientes con estadio Child C que en aquellos con estadios A y B (31,2 ± 3,1 frente a 38,1 ± 4,3 y 36,3 ± 5 mmHg; p < 0,05), respectivamente. En cambio, los pacientes cirróticos con HAAG presentaron un hipocapnia significativamente menor que aquellos otros sin HAAG (31,2 ± 3,1 frente a 36,3 ± 5 mmHg; p < 0,05). En el análisis multivariante, las variables con valor pronóstico independiente para la presencia de hipocapnia fueron la protrombina, la albúmina y el sodio plasmáticos. Se constató la presencia de SHP en 8 pacientes (16%). Conclusiones: La alteración gasométrica más frecuentes de la cirrosis es la alteración del gradiente alvéolo-arterial de oxígeno, que se acentúa conforme empeora la función hepática. La hipocapnia, aunque su patogenia no es bien conocida, podría constituir una mecanismo compensador de la hipoxemia o bien ser el resultado de la activación de los centros respiratorios centrales por sustancias no aclaradas en el hígado.

We present the case of a 16-year old woman with Alagille's syndrome, who had upper gastrointestinal bleeding due to rupture of esophageal varices secondary to presinusoidal portal hypertension without liver fibrosis. Portal thrombosis is a manifestation previously unreported in association to this syndrome.

Nonselective beta-blockers (beta-blockers) are very effective in preventing first variceal bleeding (FVB) in patients with cirrhosis. However, 15%-25% of patients have contraindications or develop severe side effects precluding its use. The present study evaluates whether isosorbide-5-mononitrate (Is-MN) effectively prevents variceal bleeding in patients with contraindications or who could not tolerate beta-blockers.One hundred thirty-three consecutive cirrhotic patients with gastro-esophageal varices and contraindications or intolerance to beta-blockers were included in a multicenter, prospective, double-blind randomized controlled trial. Sixty-seven were randomized to receive Is-MN, and 66 to receive placebo.There were no significant differences in the 1- and 2-year actuarial probability of experiencing a FVB between the 2 treatment groups. Presence of variceal red signs at endoscopy was the only variable independently associated with an increased risk of variceal bleeding on follow-up (relative risk 3.4; P0.01). Survival and adverse events were similar in the 2 groups. There were no significant differences in the incidence of ascites or changes in renal function.Is-MN does not reduce the incidence of FVB in patients with cirrhosis and esophageal varices who cannot be treated with beta-blockers because contraindications or intolerance to these drugs, suggesting that Is-MN has no place in the primary prophylaxis of variceal bleeding.

Early rebleeding is a very frequent complication of variceal hemorrhage. Sclerotherapy effectively controls variceal hemorrhage and prevents early rebleeding. Somatostatin infusion is as effective as sclerotherapy in controlling variceal hemorrhage, but no study has evaluated the efficacy of 5-day somatostatin infusion in preventing early rebleeding after the initial control of bleeding. The aim of the study was to compare the efficacy and safety of somatostatin and sclerotherapy in the prevention of early variceal rebleeding in cirrhotic patients.The study included 169 patients with acute variceal hemorrhage who were randomized within 24 h of controlling the acute bleeding to receive either sclerotherapy (n=79) or continuous somatostatin infusion for 5 days (250 microg/h after a 250-microg bolus, repeated every 24 h, n=90). Success of therapy was defined by absence of rebleeding during the 5 days following randomization.Early (5 days) rebleeding occurred in 12/79 patients treated with sclerotherapy vs 14/90 of those receiving somatostatin (NS). The treatment was equally effective in Child's C patients (sclerotherapy: 18/20; somatostatin: 17/20; NS) and Child's A+B patients (sclerotherapy: 49/59; somatostatin: 59/70; NS). Complications occurred in 19/79 patients receiving sclerotherapy vs 4/90 in the somatostatin group (p= 0.00019), being severe in 6 vs 0 patients (p=0.0094). There were no differences between the two groups in the incidence of 6-week rebleeding (14% vs 15%, NS) and mortality (9% vs 9%).Continuous somatostatin infusion is as effective as sclerotherapy in preventing early variceal rebleeding and maintaining low mortality following acute variceal hemorrhage. Somatostatin is associated with a lower rate of complications than sclerotherapy.

The type of emergency treatment administered to patients with suspected variceal bleeding is important, as the episode is associated with a high mortality rate. Moreover, rebleeding is common during the first few days after the initial haemorrhage. Several techniques are available to control variceal haemorrhage including pharmacotherapy (vasopressin, terlipressin, somatostatin and octreotide), balloon tamponade, endoscopic techniques, transjugular intrahepatic portosystemic shunt and shunt surgery. The majority of these require specialized equipment and/or experienced personnel, which are not always available in every hospital. In such situations, pharmacotherapy represents the most practical method of establishing haemodynamic control prior to the administration of definitive treatment. Pharmacotherapy can be initiated immediately upon admission to stabilize the patient prior to diagnostic endoscopy, which subsequently improves the efficacy and ease of administration of further endoscopic intervention. The optimal pharmacological agent should be both effective and safe. A drug with no side effects will not complicate the management of critical patients and can be administered over an extended period to reduce the incidence of rebleeding and improve prognosis. Meta-analysis of clinical studies has revealed that of the vasoactive drugs available somatostatin is effective with significantly fewer side effects and currently appears to represent the best choice for treatment. The available evidence suggests that the early administration of pharmacotherapy, as part of a specific treatment regimen, offers significant benefit to patients with variceal bleeding and its administration optimizes emergency care.

Spontaneous bacterial peritonitis (SBP) is associated with an important production of inflammatory mediators. However, it is unknown whether there is a relationship between the abdominal production of these mediators and the development of renal impairment, one of the most important prognostic parameters in spontaneous bacterial peritonitis. We studied 52 cirrhotic patients at diagnosis and resolution of the infection, by measuring endotoxin, tumor necrosis factor (TNF), and interleukin-6 (IL-6) levels in plasma and ascitic fluid. Thirteen patients (25%) developed renal impairment. Patients developing renal impairment showed significantly higher plasma and ascitic fluid cytokine levels at diagnosis of infection than patients who did not (plasma TNF-alpha: 96.0+/-38.7 vs. 39.1+/-3.6 pg/mL, P=.0209; ascitic fluid TNF-alpha: 474.5+/-118.1 vs. 160.8+/-42.7 pg/mL, P=.0173; plasma IL-6: 6,635+/-2,897 vs. 458+/-109 pg/mL, P=.0004; ascitic fluid IL-6: 182,559+/-47,328 vs. 39,250+/-10,803 pg/mL, P=.0001). Independent predictors of development of renal impairment at diagnosis were: renal failure (blood urea nitrogen30 mg/dL or serum creatinine1.5 mg/dL) (P.001), IL-6 levels in ascitic fluid (P.001), and mean arterial pressure (P.05). Ten of the 13 (77%) patients who developed renal impairment died during hospitalization, but only 2 of the 39 (5%) patients who did not (P=.0001). In addition, renal failure at diagnosis of the infection was the only independent predictor of hospital mortality (P.001). In conclusion, the inflammatory response to the infection may be an important mechanism of renal impairment and the associated mortality in SBP.

Selective intestinal decontamination with norfloxacin is widely used to prevent spontaneous bacterial infections in cirrhosis. The study was performed to compare the spontaneous bacterial peritonitis occurring in patients with and without prophylactic norfloxacin.Two hundred and twenty-nine consecutive episodes of spontaneous bacterial peritonitis, (193 in patients without (Group A) and 36 in patients with norfloxacin prophylaxis (Group B)), were retrospectively analyzed. In 100 episodes (86 and 14, respectively), the responsible organism was isolated in ascitic fluid.Clinical and laboratory data at diagnosis were comparable in both groups. There were marked differences (p0.001) between group A and B in the frequency of peritonitis caused by gram-negative (67.4% vs. 14.3%) and gram-positive (30.2% vs. 78.6%) bacteria. There were three polymicrobial episodes. Bacteria resistant to cefotaxime and gram-negative bacilli resistant to quinolones were isolated in ascitic fluid in nine (seven in Group A and two in Group B) and three episodes (all in Group A), respectively. No differences in the course of infection and patient survival were observed between groups.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 prophylactic norfloxacin.

Therapeutic regimens with intravenous (i.v.) cyclosporine followed by oral cyclosporine maintenance therapy reduce the need for immediate surgery in steroid-refractory severe ulcerative colitis, but the short-term colectomy rate is still as high as 70%. We report our experience with long-term azathioprine maintenance therapy in a small series of ulcerative colitis patients with i.v. cyclosporine-induced remission.Twelve of thirteen patients with severe ulcerative colitis refractory to i.v. prednisone (1 mg/kg/day for at least 10 days) went into remission after adding i.v. cyclosporine (4 mg/kg/day) and are the subjects of this report. After a discouraging initial experience with oral cyclosporine plus mesalazine as maintenance therapy in the first four patients, we treated the following patients with azathioprine plus mesalazine starting immediately after response to i.v. cyclosporine was obtained. Overall, only 1 of 10 patients treated with azathioprine relapsed after a mean follow-up of 16.3 months (range: 6-48). Moreover, this relapse probably occurred when the drug was still not therapeutically active because, after reinducing remission with oral prednisone, the patient remained symptomless on azathioprine. Steroids could be discontinued in all patients.The relapse rate on maintenance therapy with azathioprine (10%) is a figure considerably lower than that previously reported with oral cyclosporine. This promising experience should be confirmed in randomized controlled trials.

Bioelectric impedance analysis (BIA) was carried out in 55 cirrhotic patients (32 with and 23 without ascites) and 20 healthy controls with the aim of evaluating its usefulness in cirrhosis. Furthermore, in 13 of the ascitic patients BIA was performed immediately before and 24 hours after paracentesis. No differences were observed among the three groups in either resistance or the values of total body water (TBW), lean body mass (LBM) and fatty body mass (FBM) estimated by BIA. On the other hand, reactance and the phase angle were lower in cirrhotic patients. Likewise, the percentage of body cell mass (BCM) was lower in ascitic patients than in the non ascitic patients and the controls (37.7 +/- 1.2 vs 42.3 +/- 1.2 vs 45.5 +/- 1.6%; p = 0.0003). Mid-arm muscle circumference was correlated with TBW and LBM in all the groups and with only BCM in the controls and those without ascites. In general, the precision of the regression lines was lower in the ascitic patients than in the non ascitic patients and controls. TBW decreased following paracentesis (28.3 +/- 1.7 vs 30.3 +/- 2.0 kg; p = 0.008) but this decrease did not correspond with the volume of ascitic fluid obtained in any case. The mean BCM did not change with paracentesis although individual differences ranged between -8.0 and +11.2% (CI 95%). It is concluded that BIA is not a reliable method for nutrition evaluation in cirrhotic patients with ascites in clinical practice and that the anthropometric parameters are still preferable in these cases.

In this article, authors reviewed etiology, diagnosis, prognosis and treatment of spontaneous bacterial peritonitis. The role of primary prophylaxis is discussed.

Cefotaxime (CTX) is considered one of the first-choice antibiotics in the therapy of spontaneous bacterial peritonitis (SBP) in cirrhosis. Because CTX is largely metabolized in the liver, this drug may also be effective in SBP by administering lower doses than those habitually used. To investigate this possibility, a prospective, randomized, multicenter study was performed to compare the therapeutic efficacy of two different dosages of CTX in 143 patients with SBP: 71 (group I) were allocated to receive a high dose (2 g every 6 hours, which is one of the most frequently recommended doses in this infection), and 72 (group II) were allocated to receive a low dose (2 g every 12 hours). At inclusion, both groups were similar in relation to clinical and laboratory data, with the exception of a higher incidence of positive ascitic fluid culture in group I than in group II (59% vs. 40%; P = .029). The rate of infection resolution was similar for both groups (77% vs. 79%). Hospital survival was also similar in both groups (69% vs. 79%). No difference was observed between patients with positive or negative ascitic fluid cultures with regard to infection resolution and patient survival. The duration of antibiotic therapy was similar in both groups (9.0 +/- 3.3 days in group I vs. 8.8 +/- 3.1 days in group II). In a subset of 13 patients from group I and 11 patients from group II CTX levels were determined in serum (peak and trough) and ascitic fluid (concomitantly with trough serum). Peak serum levels were similar in patients from both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Despite the efficacy of shunt surgery in the treatment of variceal bleeding, less effective nonoperative therapies are being substituted because surgical shunt does not modify survival and increases hepatic encephalopathy. However, the real impact of shunt surgery on the natural history of ascites and its complications has not been established. The course of 204 Child-Pugh A and B cirrhotic patients with variceal bleeding included in three controlled trials of our units who survived first hospitalization was updated. Ninety-eight patients (group I) were treated by portacaval (56 patients) or distal splenorenal (42 patients) shunt, whereas 106 (group II) were treated by nonshunt procedures (sclerotherapy in 89 patients and staple transection in 17 patients). As expected, the 5-yr probability of variceal rebleeding was lower (13% vs. 44%) and hepatic encephalopathy higher (50% vs. 28%) in group I than in group II, and survival was similar (67% vs. 60%). Shunt surgery had a great impact on the natural history of ascites and its complications. The probability of occurrence of ascites (15% vs. 73%; p0.0001), spontaneous bacterial peritonitis (2% vs. 21%; p0.0001) and hepatorenal syndrome (4% vs. 21%; p0.01) was greatly reduced. These beneficial effects accounted for the lower percentage patients requiring readmissions (51% vs. 70%; p = 0.02) and shorter total time spent in hospital (14 +/- 22 vs. 26 +/- 39 days/patient; p = 0.01) in group I. These data indicate that shunt surgery, in addition to reducing the probability of rebleeding, markedly decreases the probability of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome development.(ABSTRACT TRUNCATED AT 250 WORDS)

Somatostatin and endoscopic sclerotherapy are widely used in the treatment of acute variceal bleeding. Although objective evidence does exist about the advantages of either treatment, data comparing both procedures are scarce. In order to compare the effectiveness and safety of somatostatin and sclerotherapy in the treatment of acute variceal bleeding, 70 consecutive cirrhotic patients suffering from esophageal variceal hemorrhage and meeting the inclusion criteria were randomly assigned to treatment with somatostatin (35 patients) or sclerotherapy (35 patients). No differences in age, sex, alcohol intake, etiology of cirrhosis and severity of liver failure were found between groups. Failure of treatment (defined as persistence of bleeding despite therapy or subsequent rebleeding within the 48-hr trial period) occurred in seven patients (20%) in the somatostatin group and in six (17.1%) in the sclerotherapy group (NS). Early rebleeding occurred in seven of 28 patients (25%) in the somatostatin group and in five of 29 (17.2%) in the sclerotherapy group (NS). Mortality within the first 6 wk was no different between both groups: 10 (28.5%) and eight (22.8%) in the somatostatin and sclerotherapy groups, respectively. Sclerotherapy, but not somatostatin, was associated with major complications in five cases (14.2%) (p = 0.026), two of which resulted in patient's death. These results suggest that somatostatin is safer, and as effective as sclerotherapy, in controlling acute variceal bleeding until an elective treatment can be established.

983 INCIDENCE OF HEPATOCELLULAR CARCINOMA IN HCV MONOINFECTED AND HIV COINFECTED PATIENTS WHO RECEIVED ANTIVIRAL TREATMENT C. Leal Valdivieso, B. Revollo Barriga, I. Serra Matamala, R.M. Morillas Cunill, M. Sala Llinas, H. Masnou Ridaura, A. Bargallo Garcia, C. Tural Llacher, R. Planas Vila. Hepatology Unit, CIBERehd, Department of Gastroenterology, HIV Unit, Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Spain E-mail: carles.leal@gmail.com

The LeVeen peritoneovenous shunt has been used for nearly 20 yr in the treatment of refractory ascites due to liver cirrhosis. However, the technique encompasses a high incidence of serious complications. We report the case of a 59-yr-old man presenting with right pulmonary artery embolization caused by ruptured venous segment of a LeVeen shunt. After localizing it arteriographically, we were able to satisfactorily remove the segment by tying it up with a catheter introduced through the femoral vein.

Portacaval anastomosis has proved to be effective in avoiding active and recurrent hemorrhage from gastroesophageal varices in liver cirrhosis. However, hepatic encephalopathy is the most common and serious complication of this procedure. The aim of this study was to investigate by multivariate analysis the predictive factors of development of hepatic encephalopathy in 50 Child's A and B cirrhotic patients whose variceal bleeding was treated with emergency (n = 17) or elective (n = 33) portacaval anastomosis. The etiology of the cirrhosis was alcoholic in 74% of cases. The mean follow-up was 22.7 +/- 16.6 months (range 1-60 months). The 2-yr probability of suffering from at least one episode of hepatic encephalopathy in the overall group was 43%. The multivariate analyses (Cox's regression method) of 37 variables based upon clinical history, physical examination, and laboratory data disclosed that only five of these variables had independent predictive value: need for diuretic treatment in the days prior to surgery, absence of hepatomegaly, and serum levels of total bilirubin, gamma-globulin, and hemoglobin. According to the contribution of each one of these factors to the final model, a prognostic index was obtained which allowed the division of patients in two different groups of risk for developing hepatic encephalopathy (20% and 74%, respectively, after 2 yr of surgery; p = 0.0002). This index may help to better choose those candidates for portacaval anastomosis.