Gastrointestinal symptoms in COVID-19 and its implications in inflammatory bowel disease

La pandemia por SARS-Cov-2, ha tomado gran relevancia por su impacto en los diversos sistemas de sa-lud en el mundo. Inicialmente solo se contemplaba la importancia de los síntomas respiratorios y la fiebre; sin embargo, a diario tenemos más reportes y publicaciones sobre la relevancia que está teniendo en el sistema digestivo, ya que algunos pacientes informan síntomas gastrointestinales como diarrea, vómito y dolor abdominal. Los estudios han identificado el ARN del SARS-CoV-2 en muestras de heces de pacientes infectados, en las que se encontró que su receptor que es el de la enzima convertidora de angiotensina 2 (ECA2) se expresaba altamente en las células epiteliales gastrointestinales. Esto sugiere que el SARS-CoV-2 puede infectar activamente y replicarse en el tracto gastrointestinal. Esto tiene implicaciones importantes para el tratamiento de la enfermedad, la transmisión y el control de infecciones. En pacientes con patologías crónicas como la enfermedad inflamatoria intestinal (EII), se han generado gran cantidad de preguntas e incertidumbres ante la presencia de COVID-19 junto con las implicaciones que pueden tener tanto en la severidad de los síntomas, como en la descompensación de la patología de base y en la continuidad del tratamiento inmunosupresor.The SARS-Cov-2 pandemic has taken great relevance due to its diverse impact in the worldwide health systems. Initially, only the importance or respiratory symptoms and fever was considered, however daily we have more reports and publications about the relevance that gastrointestinal symptoms, like diarrhea, vomit, and abdominal pain, are having in COVID-19. Several studies have identified SARS-CoV-2 RNA in stool samples of infected patients, and it was also found that the viral receptor, the angiotensin-converting enzyme 2 (ACE2) receptor is highly express in the gastrointestinal cells. These findings suggest that SARS-Cov-2 can actively infect and replicate in the gastrointestinal tract. All the above have relevant implications in the disease treatment, transmission, and infection control. In patients with chronic pathologies, such as inflammatory bowel disease (IBD), many questions and uncertainties, about symptoms severity, disease decompensation and use of immunosuppressive drugs, have been generated in the presence of COVID-19

Tuberculosis hepática aislada mimetizando un tumor hepático en un paciente en diálisis

Isolated tuberculosis (TB) of the liver is a rare form of extrapulmonary presentation of the disease, even in countries where tuberculosis in a public health concern. Given its low incidence, diagnosis is complex since the specificity of the clinical picture and microbiological studies have limited detection of the presence of Mycobacterium tuberculosis. Extrapulmonary forms of TB are clinical entities that may be precipitated by conditions linked to immunosuppression such as chronic kidney disease (CKD) particularly in the last stages.La tuberculosis (TB) hepática aislada es una forma rara de TB extrapulmonar, incluso en países donde la tuberculosis se comporta como un problema de salud pública. Su diagnóstico es complejo dada la baja especificidad del cuadro clínico y al limitado rendimiento diagnóstico de los estudios microbiológicos para establecer la presencia del Mycobacterium tuberculosis. Presentamos el caso de un varón de 65 años con enfermedad renal crónica grado 5 en terapia de reemplazo renal con hemodiálisis quien presentó cuadro clínico de 3 días de evolución asociado a dolor abdominal y anorexia. En la ecografía se evidenció lesiones hepáticas hipoecoicas, corroboradas por tomografía de ab domen con hallazgos sugestivos de neoplasia hepática secundaria sin establecerse un origen primario. La biopsia de hígado finalmente condujo al diagnóstico de tuberculosis hepática sin encontrarse compromiso pulmonar o extrapulmonar adicional. Concluimos que las formas extrapulmonares de TB son entidades clínicas que pueden estar precipitadas por condiciones ligadas a inmunosupresión como es la enfermedad renal crónica

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort

Objectives: This study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). Methods: Prospective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. Results: We included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. Conclusion: Our results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally