Respuesta al Señor Assiodoro, persona principal en el Dialogo Harmonico

Copia digital. Valladolid : Junta de Castilla y León. Consejería de Cultura y Turismo, 2009-2010Sign.: A

A case report: a very rarely occurring snakebite

Snake bite is one of the most neglected public health issues in poor rural communities living in the tropics. The venomous bites and stings during pregnancy are very rare and it cause significant adverse effects on fetus and mother. Multiple snake bites to two different individuals by a same snake at the same time are rarely reported in literatures. In present case report, husband and wife with two and half month of pregnancy were bitten with multiple bites by same snake at the same time. This unusual and interesting case occurred in a rural area of Ahmedabad, Gujarat. It is also believed that snake discharges maximum of venom on first bite, which may be fatal compared to subsequent bites. The uniqueness of this case lies in the fact that second bite was more serious than the first bite. Woman with two and half month of pregnancy who was bitten first and hade minor effect, and no negative effects on fetus. Man bitten latter with multiple bites and was affected seriously. Both the patients were successfully treated at our hospital.

La pesca, la sal y el comercio en el Círculo del Estrecho : Estado de la cuestión.

[email protected] travail analyse les sujets qui concernent le rôle de la pêche, ses produits dérivés et industries subordonnées —l’exploitation du sel et la production des amphores pour le transport— dans l’économie de la région du Détroit de Gibraltar, dès l’époque phénicienne et punique jusqu’à la romanisation. Les temples ou les villes et, enfin, l’État romain, ont contrôlé l’exploitation du sel et de la fabrication des récipients destinés au commerce des conserves de poisson, dont les bénéfices devaient être très importants

Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta-analysis with pre and post-test probability assessment

Background: Scoring systems for severe acute pancreatitis (SAP) prediction should be used in conjunction with pre-test probability to establish post-test probability of SAP, but data of this kind are lacking.Objective: To investigate the predictive value of commonly employed scoring systems and their usefulness in modifying the pre-test probability of SAP.Methods: Following PRISMA statement and MOOSE checklists after PROSPERO registration, PubMed was searched from inception until September 2022. Retrospective, prospective, cross-sectional studies or clinical trials on patients with acute pancreatitis defined as Revised Atlanta Criteria, reporting rate of SAP and using at least one score among Bedside Index for Severity in Acute Pancreatitis (BISAP), Acute Physiology and Chronic Health Examination (APACHE)-II, RANSON, and Systemic Inflammatory Response Syndrome (SIRS) with their sensitivity and specificity were included. Random effects model meta-analyses were performed. Pre-test probability and likelihood ratio (LR) were combined to estimate post-test probability on Fagan nomograms. Pooled severity rate was used as pre-test probability of SAP and pooled sensitivity and specificity to calculate LR and generate post-test probability. A priori hypotheses for heterogeneity were developed and sensitivity analyses planned.Results: 43 studies yielding 14,116 acute pancreatitis patients were included: 42 with BISAP, 30 with APACHE-II, 27 with Ranson, 8 with SIRS. Pooled pre-test probability of SAP ranged 16.6%-25.3%. The post-test probability of SAP with positive/negative score was 47%/6% for BISAP, 43%/5% for APACHE-II, 48%/5% for Ranson, 40%/12% for SIRS. In 18 studies comparing BISAP, APACHE-II, and Ranson in 6740 patients with pooled pre-test probability of SAP of 18.7%, post-test probability when scores were positive was 48% for BISAP, 46% for APACHE-II, 50% for Ranson. When scores were negative, post-test probability dropped to 7% for BISAP, 6% for Ranson, 5% for APACHE-II. Quality, design, and country of origin of the studies did not explain the observed high heterogeneity.Conclusions: The most commonly used scoring systems to predict SAP perform poorly and do not aid in decision-making

Avances en pancreatitis aguda: Clasificaciones e influencia de la dieta y las características basales de los pacientes en su evolución clínica

La pancreatitis aguda (PA) constituye la tercera causa de patología gastrointestinal que requiere un mayor número de hospitalizaciones. La PA es una enfermedad heterogénea en la que dos tercios de los pacientes tendrán un curso leve de la enfermedad, pero un tercio de ellos desarrollarán complicaciones locales y/o fallo orgánico (FO) con una morbilidad y mortalidad significativas. Por este motivo es necesaria una sólida clasificación de gravedad. La antigua clasificación de Atlanta tenía limitaciones y las nuevas clasificaciones, la revisión de la clasificación de Atlanta y la clasificación basada en determinantes, necesitan ser validadas. Además, es necesario conocer los principales determinantes de gravedad en PA. Por otra parte, pronosticar la gravedad de la evolución de la PA es importante para un mejor manejo de los pacientes. Dentro de los factores pronósticos, las características basales de los pacientes como la edad, la presencia de comorbilidad y la obesidad se postulan como posibles factores pronósticos. Por último, es conocido que los ácidos grasos insaturados son componentes del páncreas y tienen un efecto tóxico a nivel local y sistémico en la PA. Como las diferencias en la dieta pueden modificar la composición de la grasa pancreática, se podría hipotetizar que diferentes consumos de grasa en la dieta podrían condicionar diferente evolución de la PA.Objetivos1. Validar las nuevas clasificaciones de gravedad de PA.2. Investigar los determinantes de gravedad en PA.3. Estudiar la importancia de la edad, la comorbilidad y la obesidad en el pronóstico de la PA.4. Evaluar si las diferencias regionales de consumo de ácidos grasos se asocian a una diferente evolución clínica de la PA.MetodologíaSe realizó un estudio prospectivo y multicéntrico en el que participaron 23 hospitales españoles. Se incluyeron pacientes mayores de 18 años con diagnóstico de PA. Se excluyeron los pacientes con pancreatitis crónica. Las complicaciones locales se evaluaron con un TAC abdominal. A los pacientes con curso leve no se les realizó TAC y se asumió ausencia de complicaciones locales. En cuanto al análisis estadístico, para comparar las clasificaciones se empleó el área bajo la curva y para valorar la asociación de los determinantes de gravedad y las características basales de los pacientes con la evolución clínica de la PA se realizó un análisis univariante y posteriormente un análisis multivariante. Para el estudio del efecto de la dieta en el curso de la PA se llevó a cabo un análisis retrospectivo de la base prospectiva de PA combinado con los datos provenientes del estudio nutricional ANIBES.Resultados y discusiónLa base prospectiva incluyó 1655 pacientes con PA. Las nuevas clasificaciones son superiores a la antigua clasificación de Atlanta estratificando a los pacientes en grupos homogéneos. No hubo diferencias significativas entre las dos nuevas clasificaciones. El FO persistente es el determinante clave de morbilidad y mortalidad en PA. Todas las complicaciones locales se asociaron a una peor evolución de la PA. La infección de la necrosis pancreática se asoció con mayor morbilidad y mortalidad, pero si en el análisis multivariante se incluye el FO persistente pierde su asociación con mortalidad por lo que puede ser innecesaria la categoría crítica de la clasificación basada en determinantes. El fallo multiorgánico se asoció con mayor morbilidad y mortalidad que el FO único por lo que debería tenerse en cuenta en las clasificaciones. En cuanto a las características basales de los pacientes, la presencia de comorbilidad y la obesidad se asociaron a mayor mortalidad a los 30 días y mayor desarrollo de FO persistente por lo que deberían incluirse en los sistemas de puntuación pronóstica de PA. Por último, los pacientes con PA provenientes de regiones con mayor consumo de ácidos grasos insaturados y monoinsaturados presentaron peor evolución clínica de la PA, aunque estos resultados deberán ser confirmados en futuros estudios con datos nutricionales directos de los pacientes con PA recogidos de manera prospectiva.<br /

Pancreatic Cancer Malnutrition and Pancreatic Exocrine Insufficiency in the Course of Chemotherapy in Unresectable Pancreatic Cancer

Background: Malnutrition and cachexia are common in patients with advanced pancreatic ductal adenocarcinoma (PDAC) and have a significant influence on the tolerance and response to treatments. If timely identified, malnourished PDAC patients could be treated to increase their capacity to complete the planned treatments and, therefore, possibly, improve their efficacy. Aims: The aim of this study is to assess the impact of nutritional status, pancreatic exocrine insufficiency (PEI), and other clinical factors on patient outcomes in patients with advanced PDAC. Methods: PAncreatic Cancer MAlnutrition and Pancreatic Exocrine INsufficiency in the Course of Chemotherapy in Unresectable Pancreatic Cancer (PAC-MAIN) is an international multicenter prospective observational cohort study. The nutritional status will be determined by means of Mini-Nutritional Assessment score and laboratory blood tests. PEI will be defined by reduced fecal elastase levels. MAIN OUTCOME: adherence to planned chemotherapy in the first 12 weeks following the diagnosis, according to patients' baseline nutritional status and quantified and reported as "percent of standard chemotherapy dose delivered." SECONDARY OUTCOMES: rate of chemotherapy-related toxicity, progression-free survival, survival at 6 months, overall survival, quality of life, and the number of hospitalizations. ANALYSIS: chemotherapy dosing over the first 12 weeks of therapy (i.e., percent of chemotherapy received in the first 12 weeks, as defined above) will be compared between well-nourished and malnourished patients. SAMPLE SIZE: based on an expected percentage of chemotherapy delivered of 70% in well-nourished patients, with a type I error of 0.05 and a type II error of 0.20, a sample size of 93 patients per group will be required in case of a percentage difference of chemotherapy delivered of 20% between well-nourished and malnourished patients, 163 patients per group in case of a difference of 15% between the groups, and 356 patients per group in case of a 10% difference. Centers from Russia, Romania, Turkey, Spain, Serbia, and Italy will participate in the study upon Local Ethics Committee approval. Discussion: PAC-MAIN will provide insights into the role of malnutrition and PEI in the outcomes of PDAC. The study protocol was registered at clinicaltrials.gov as NCT04112836

Clinical usefulness of scoring systems to predict severe acute pancreatitis : A systematic review and meta-analysis with pre and post-test probability assessment

Scoring systems for severe acute pancreatitis (SAP) prediction should be used in conjunction with pre-test probability to establish post-test probability of SAP, but data of this kind are lacking.To investigate the predictive value of commonly employed scoring systems and their usefulness in modifying the pre-test probability of SAP.Following PRISMA statement and MOOSE checklists after PROSPERO registration, PubMed was searched from inception until September 2022. Retrospective, prospective, cross-sectional studies or clinical trials on patients with acute pancreatitis defined as Revised Atlanta Criteria, reporting rate of SAP and using at least one score among Bedside Index for Severity in Acute Pancreatitis (BISAP), Acute Physiology and Chronic Health Examination (APACHE)-II, RANSON, and Systemic Inflammatory Response Syndrome (SIRS) with their sensitivity and specificity were included. Random effects model meta-analyses were performed. Pre-test probability and likelihood ratio (LR) were combined to estimate post-test probability on Fagan nomograms. Pooled severity rate was used as pre-test probability of SAP and pooled sensitivity and specificity to calculate LR and generate post-test probability. A priori hypotheses for heterogeneity were developed and sensitivity analyses planned.43 studies yielding 14,116 acute pancreatitis patients were included: 42 with BISAP, 30 with APACHE-II, 27 with Ranson, 8 with SIRS. Pooled pre-test probability of SAP ranged 16.6%-25.3%. The post-test probability of SAP with positive/negative score was 47%/6% for BISAP, 43%/5% for APACHE-II, 48%/5% for Ranson, 40%/12% for SIRS. In 18 studies comparing BISAP, APACHE-II, and Ranson in 6740 patients with pooled pre-test probability of SAP of 18.7%, post-test probability when scores were positive was 48% for BISAP, 46% for APACHE-II, 50% for Ranson. When scores were negative, post-test probability dropped to 7% for BISAP, 6% for Ranson, 5% for APACHE-II. Quality, design, and country of origin of the studies did not explain the observed high heterogeneity.The most commonly used scoring systems to predict SAP perform poorly and do not aid in decision-making