Diagnosis of Ischemic Colitis. Case Report

Introduction: Ischemic colitis is the most common form of intestinal ischemia. It is frequently observed in patients older than 65 years, and the risk factors of the disease are already known.Objective: To consider the early diagnosis of the disease in a patient in whom risk factors for the disease are identified after performing specific diagnostic tests.Case Presentation:  A patient with rectal bleeding is presented. On questioning and physical examination, risk factors for ischemic colitis are identified. The diagnosis is confirmed by colonoscopy, and the radiological tests permitted to identify the cause and location of the ischemia.Conclusions: The identification of risk factors for ischemic colitis allowed to think on the possibility of the disease. Diagnostic tests, performed in an early period, confirmed the diagnosis and made a good response to treatment possible.Keywords: Ischemic colitis, emergency colonoscopy, colonoscopy with CO2, CT angiography, emergency angiography, risk factors.</p

Transformación de pólipos hiperplásicos a adenocarcinoma mucinoso ulcerado de colon

Introducción: el cáncer colorrectal incluye cualquier tipo de neoplasia de colon, recto y apéndice y muchos de los casos tienen su origen en un pólipo adenomatoso. Objetivo: describir la evolución de pólipos hiperplásicos a un cáncer mucinoso de colon a través del análisis de un caso donde el estudio de imágenes contribuyó al diagnóstico del mismo y a una intervención quirúrgica certera. Presentación del caso: mujer de 72 años de edad, que desde 2012 se atiende por presentar pólipos hiperplásicos de colon y colitis crónica. En 2014 presenta dolor abdominal en flanco derecho, vómitos y diarreas. La colonoscopía confirma la existencia de pólipos hiperplásicos en ciego y recto. En la ecografía abdominal se observa masa compleja, sólida, en hipocondrio y flanco derecho, muy próxima al peritoneo, impresionando lesión tumoral de vías digestivas. La radiografía de tránsito intestinal muestra un defecto de llenado en el ciego, infiltrando la válvula ileocecal. En la tomografía multicorte simple y contrastada vía oral y endovenosa se observa lesión tumoral que ocluye la luz del ciego con hipercaptación del contraste en ambas fases. La colonoscopia concluye una lesión en la válvula ileocecal y otra a nivel de colon ascendente, ambas de aspecto dudoso y pólipos en recto-sigmoides. La biopsia mediante colonoscopia confirma un adenocarcinoma mucinoso ulcerado e infiltrante. Conclusiones: se demuestra que uno de los orígenes de los adenocarcinomas mucinosos de colon son los pólipos benignos y los estudios imagenológicos son una herramienta útil en el estadiamiento del tumor y la conducta de tratamiento a seguir

Tumor extrínseco del estroma del intestino delgado. Presentación de caso

Introducción: Los tumores del estroma gastrointestinal son tumores raros, secundarios a una proliferación maligna de células mesenquimales y la resección quirúrgica completa de los mismos depende en gran medida de su diagnóstico rápido. Objetivo: Presentar un caso clínico de tumor extrínseco del estroma del intestino delgado diagnosticado en su estado inicial haciendo énfasis en los hallazgos imagenológicos. Presentación del caso: Paciente masculino de 56 años de edad que hasta 2014 no tenía un diagnóstico concluyente luego de aplicar diferentes pruebas diagnósticas por presentar anemia crónica y melena. En enero de 2015 se realiza ecografía abdominal, TAC multicorte simple y contrastada por vía oral y endovenosa, además de una colonoscopia virtual, y describiéndose una imagen hipodensa de aspecto tumoral, de densidad variable, sin infiltración de estructuras vasculares ni lesiones secundarias intraabdominales, compatible con GIST. Se decide realizar cirugía para la resección del tumor. Los estudios anatomopatológicos confirmaron un tumor fusocelular tipo GIST, de grado intermedio y de comportamiento agresivo. Conclusiones: El éxito en el diagnóstico temprano de los GIST depende de la competencia de varias especialidades, donde los estudios imagenológicos tienen un papel importante en la conducta a seguir, ya sea para el tratamiento quirúrgico adecuado o con coadyuvantes, debido a que son tumores complejos en su presentación.  Palabras clave: Tumor del estroma gastrointestinal, intestino delgado, tomografía axial computarizada. AbstractIntroduction: Gastrointestinal stromal tumors are rare tumors secondary to a malign proliferation of mesenchymal cells, and the complete surgical resection of these tumors depends in great measure of its quick diagnosis. Objective: To present a clinical case of an extrinsic tumor of the small intestine stromal diagnosed in its initial state making emphasis in imaging diagnostic. Case presentation: A 56 years old male patient that didn't have up a conclusive diagnostic until 2014 after applying different diagnostic tests because he presented chronic anemia and melena. In January 2015 was carried out an abdominal echography, a simple oral and  intravenous contrasted multilayer computerized axial tomography, an also a virtual colonoscopy, describing a hypodense image of tumoral appearance, with variable density, nor infiltration of vascular structures neither intra-abdominal secondary lesions, concordant with GIST. It was decided to carry out surgery for the complete tumor resection. The anatomic and pathological studies confirmed a GIST type fusocellular tumor, of intermediate degree and aggressive bearing. Conclusions: The success in GIST early diagnosis depends of several specialties domain, where the imaging studies play an important role in the behavior to be followed, either for an appropriate surgical treatment or with adjuvant, because they are complex tumors in its presentation.  Keywords: Gastrointestinal stromal tumors, small intestine, computerized axial tomography</p

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Diagnóstico de Colitis isquémica. A propósito de un caso

Introduction: Ischemic colitis is the most common form of intestinal ischemia. It is frequently observed in patients older than 65 years, and the risk factors of the disease are already known.Objective: To consider the early diagnosis of the disease in a patient in whom risk factors for the disease are identified after performing specific diagnostic tests.Case Presentation:  A patient with rectal bleeding is presented. On questioning and physical examination, risk factors for ischemic colitis are identified. The diagnosis is confirmed by colonoscopy, and the radiological tests permitted to identify the cause and location of the ischemia.Conclusions: The identification of risk factors for ischemic colitis allowed to think on the possibility of the disease. Diagnostic tests, performed in an early period, confirmed the diagnosis and made a good response to treatment possible.Keywords: Ischemic colitis, emergency colonoscopy, colonoscopy with CO2, CT angiography, emergency angiography, risk factors.Introducción: La colitis isquémica es la forma más común de isquemia intestinal. Es más frecuente en pacientes mayores de 65 años y están reconocidos los factores de riesgo de la enfermedad.Objetivo: Considerar el diagnóstico precoz de la enfermedad, mediante la realización de estudios diagnósticos determinados, en un paciente en quien se identifican factores de riesgo para la enfermedad.Presentación del caso: Se presenta un paciente con rectorragia. Al interrogatorio y examen físico se recogen factores de riesgo para la colitis isquémica. El diagnóstico se confirma por colonoscopía y las pruebas radiológicas ayudan a establecer la causa y el lugar de la isquemia.Conclusiones: El reconocimiento de factores de riesgo para la colitis isquémica permitió la sospecha de la enfermedad. Las pruebas diagnósticas, realizadas en un período precoz confirmaron el diagnóstico y permitieron buena respuesta al tratamiento.Palabras claves: Colitis isquémica, colonoscopía de urgencia, colonoscopía con CO2, angio-TAC, angiografía de urgencia, factores de riesgo