Exactitud diagnóstica de la resonancia magnética preoperatoria en la determinación de la extensión y grado de actividad inflamatoria de la enfermedad de Crohn yeyuno-ileal

Introducción: La correcta identificación de la localización y cuantificación de la actividad inflamatoria de las lesiones de la enfermedad de Crohn es necesaria para establecer cuál es el manejo más adecuado para cada paciente Métodos: Se trata de un estudio prospectivo observacional consecutivo que abarca un periodo de estudio de 30 meses. El diagnóstico se realiza según los criterios de Lennard-Jones y la clasificación de Montreal. Se realizó una resonancia magnética mediante enterografía, con el mismo protocolo y secuencias, en los tres meses previos a la cirugía. Se determinaron las características radiológicas de las lesiones, se obtuvo el índice de actividad de la resonancia magnética (MaRIA) y se realizaron curvas de captación dinámicas de contraste. Durante la intervención quirúrgica se realizó en todos los casos una exploración minuciosa de todo el intestino delgado incluso con esferas de calibración. Se analizó histológicamente la pared completa de la lesión y se empleó la clasificación de Chiorean para determinar el grado de fibrosis o el grado de inflamación (incluida una modificación subclasificando las lesiones mixtas). Resultados: Se incluyen 38 pacientes con 83 lesiones. La probabilidad de que la enteroRM clasifique correctamente la localización de una lesión es del 90 %, con una sensibilidad del 75 % y una especificidad el 95.7 %. Aunque la especificidad se mantiene, la sensibilidad disminuye al estudiar lesiones localizadas en tramos superiores del intestino delgado. La calibración la luz del intestino delgado con esferas durante el acto quirúrgico es necesaria, ya que el 8,6% de las lesiones se detectaron solo con esferas, pasando desapercibidas macroscópicamente. La calprotectina fecal es un excelente marcador biológico de actividad inflamatoria en la EC de intestino delgado. Una cifra de 185 µg o superior implica que la lesión presentará inflamación histológica en más del 90 % de los casos. El resto de parámetros serológicos estudiados no obtuvieron correlación significativa con el grado de inflamación. La presencia de masa o flemón tiene una escasa correlación con los hallazgos de la RM. En cambio la presencia de fístulas o abscesos se correlaciona con una fiabilidad de 89,9 % y 98,6 % respectivamente. La clasificación de Chiorean modificada parece muy útil ya que las lesiones con bastante frecuencia son mixtas y no todas ellas tienen un comportamiento similar. La presencia de masa o flemón tiene una escasa correlación con los hallazgos de la RM. En cambio la presencia de fístulas o abscesos se correlaciona con una fiabilidad de 89,9 % y 98,6 % respectivamente. La descripción de una curva de inflamación indica que existe inflamación en la anatomía patológica (predominio inflamatorio o mixto) en el 100 % de los casos. A medida que aumenta el valor del índice MaRIA aumenta la probabilidad de que la inflamación encontrada en la lesión sea más grave (p intergrupos < 0.05). Conclusiones: Es necesaria la calibración con esferas durante el acto quirúrgico. La calprotectina fecal es un excelente marcador biológico de actividad inflamatoria. El índice MaRIA tiende a sobrestadiar la inflamación de las lesiones de intestino delgado (propuesta de MaRIA-small con punto de corte en 16 y 20 para inflamación moderada y grave respectivamente). La clasificación histológica de Chiorean debería modificarse subclasificando las lesiones mixtas en leves y graves ya que su actividad inflamatoria es muy diferente. Existe una elevada correlación de los estudios dinámicos de captación con el grado de actividad inflamatorio. La resonancia es una herramienta de gran utilidad para diferenciar lesiones inflamatorias vs. fibrosas y por lo tanto imprescindible para decidir el tratamiento más adecuado para cada paciente.  Introduction: The precise location and inflammatory activity assessment of Crohn’s Disease intestinal lesions is of paramount importance for the treatment approach proposed for individual patients. Methods: Prospective, observational and consecutive study. The Lennard-Jones criteria and the Montreal classification were used to diagnose and classify the patients. All patients underwent an MRI enterography exploration 3 months before surgery using the same imaging protocol and sequences. A thorough inspection and intraluminal sphere calibration of the entire small bowel was completed in each patient. Chiorean histological criteria were used to classify tissue samples. Results: 38 patients with 83 small bowel lesions were included. MRI was found to have a 90% accuracy rate for locating intestinal lesions (Sensitivity 75% Specificity 95.7%). A fecal calprotectin of 185 µg is the cut-off point between moderate or severe inflammation. 8.6% of the lesions were detected only by the intraluminal sphere calibration having been overlooked during the macroscopic inspection. Dynamic MRI intensity curves had an 80.9% correlation with the histological analysis. MaRIA scores were significantly higher with more severe degrees of inflammation (p < 0.05). Conclusions: Intraluminal calibration with spheres should always be done during the surgical act. The fecal calprotectin test is an excellent biological marker of inflammatory activity. The MaRIA score tends to overestimate inflammation in small bowel lesions (we propose the MaRIA-small with a cut-off point of 16 and 20 for moderate and severe inflammation respectively). Chiorean histological criteria should be reviewed, subclassifying mixed lesions in to mild and severe, due to their very different range of inflammatory activity. There is a high degree of correlation between the dynamic MRI intensity curves and the actual inflammatory activity in the tissue. The MRI is a helpful tool to distinguish inflammatory vs. fibrotic small bowel Crohn’s Disease lesions and hence essential in the therapeutic decision

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Next generation meshes for hernia repair: Polypropylene meshes coated with antimicrobial benzalkonium chloride induced proliferative activity of fibroblasts

Hernia repair is one of the most frequently performed world-wide surgical procedures in which hernia meshes are becoming increasingly used. Polypropylene (PP) mesh implants reduce the risk of recurrence and post-operative pain, although many other risks are associated with it, such as bacterial infection. In this study we developed PP meshes coated with the well-known antimicrobial compound, benzalkonium chloride (BAK) by dip-coating. Several dilutions (40, 20, 30, 10, 7.5, 5, 2.5, 1, 0.5, 0.1 and 0.05 % v/v) of commercial BAK solution (BAK diluted in 70 % ethyl alcohol at 0.1 % w/v) were used to produce antimicrobial meshes with different amounts of BAK. The dip-coating treatment with low concentrations of BAK (1, 0.5, 0.1 and 0.05 % v/v dilutions) was found to have biocompatible results in fibroblast. The use of 0.1 and 0.05 % v/v dilutions (PP meshes with up to ∼2 % w/w of BAK) showed proliferative activity on fibroblast cells, indicating that these novel antimicrobial meshes show great promise for hernia repair due to their ability to prevent infections while inducing fibroblast proliferation

Insertion of self-expanding metal stent for treatment of malignant obstruction in a pregnant woman

Colorectal cancer (CRC) is the second most frequent cancer both in incidence and mortality in women, especially in those over 60 years of age. Diagnosis in women at gestational age is rare, so its incidence during pregnancy is low. However, an increase in its diagnosis is expected during the next years because of the raise in the average age of pregnancy. In most cases, the diagnosis is delayed because symptoms related to CRC can be attributed to pregnancy itself. Up to 30 % of CRC cases may present as an intestinal obstruction. In this situation, the main objective is to solve the clinical emergency in the safest way for mother and fetus, together with performing an accurate diagnostic approach to offer the best possible therapeutic management knowing the limitations and difficulties related to pregnancy. The self-expanding metallic stent (SEMS) can be particularly useful in colon obstruction in a pregnant patient with CRC because it allows solving the acute condition providing time to perform a more accurate staging study and to prepare the patient for surgery, thus reducing both post-surgical morbidity and mortality. We report on the case of a patient who early in the second trimester of pregnancy presented with an acute colonic obstruction due to CRC which was successfully managed with the placement of a self-expanding metal stent