39 research outputs found
Documento de consenso de la Sociedad Española de Patología Digestiva y de la Sociedad Española de Trombosis y Hemostasia sobre hemorragia digestiva masiva no varicosa y anticoagulantes orales de acción directa
Introducción: existe limitada experiencia y conocimiento
sobre la hemorragia digestiva masiva no varicosa durante
el tratamiento con anticoagulantes orales de acción directa.
Objetivos: aportar definiciones y recomendaciones basadas
en la evidencia.
Métodos: documento de consenso elaborado por la Sociedad
Española de Patología Digestiva y la Sociedad Española
de Trombosis y Hemostasia mediante una metodología Delphi
modificada. Se constituyó un panel con 24 gastroenterólogos
con experiencia en hemorragia digestiva y se evaluó la mejoría del acuerdo a lo largo de tres rondas. Las recomendaciones
finales se fundamentan en una revisión sistemática
de la literatura y la utilización del sistema GRADE.
Resultados: los panelistas estuvieron de acuerdo en el
91,53 % para el conjunto de los 30 ítems, porcentaje que
mejoró en las rondas 2 y 3 en aquellos ítems en los que existe
menor experiencia clínica. El desacuerdo explícito fue
solo del 1,25 %. Se ha podido establecer una definición de
hemorragia digestiva masiva no varicosa en los pacientes
tratados con anticoagulantes orales de acción directa,
y generar recomendaciones para optimizar el manejo de
esta patología.
Conclusión: la aproximación a este tipo de pacientes críticos
debe ser multidisciplinar y protocolizada, optimizando
las decisiones dirigidas a la identificación precoz del problema
y a la estabilización del paciente bajo el principio de la reanimación con control de daños. Por ello se debe
valorar la reversión inmediata del efecto anticoagulante,
preferentemente con los correspondientes antídotos (idarucizumab
para dabigatrán y andexanet alfa para los inhibidores
directos del factor Xa), la reanimación hemostática
y la identificación y tratamiento del punto de sangrado.Spanish Society of Digestives DiseasesAlexio
Uncovering Tumour Heterogeneity through PKR and nc886 Analysis in Metastatic Colon Cancer Patients Treated with 5-FU-Based Chemotherapy
Colorectal cancer treatment has advanced over the past decade. The drug 5-fluorouracil
is still used with a wide percentage of patients who do not respond. Therefore, a challenge is the
identification of predictive biomarkers. The protein kinase R (PKR also called EIF2AK2) and its
regulator, the non-coding pre-mir-nc886, have multiple e ects on cells in response to numerous types
of stress, including chemotherapy. In this work, we performed an ambispective study with 197
metastatic colon cancer patients with unresectable metastases to determine the relative expression
levels of both nc886 and PKR by qPCR, as well as the location of PKR by immunohistochemistry
in tumour samples and healthy tissues (plasma and colon epithelium). As primary end point, the
expression levels were related to the objective response to first-line chemotherapy following the
response evaluation criteria in solid tumours (RECIST) and, as the second end point, with survival
at 18 and 36 months. Hierarchical agglomerative clustering was performed to accommodate the
heterogeneity and complexity of oncological patients’ data. High expression levels of nc886 were
related to the response to treatment and allowed to identify clusters of patients. Although the PKR mRNA expression was not associated with chemotherapy response, the absence of PKR location
in the nucleolus was correlated with first-line chemotherapy response. Moreover, a relationship
between survival and the expression of both PKR and nc886 in healthy tissues was found. Therefore,
this work evaluated the best way to analyse the potential biomarkers PKR and nc886 in order to
establish clusters of patients depending on the cancer outcomes using algorithms for complex and
heterogeneous data.This research was funded by the Instituto de Salud Carlos III (DTS15/00174; PIE16-00045), by the
Consejería de Economía, Conocimiento, Empresas y Universidad de la Junta de Andalucía and European Regional
Development Fund (ERDF), references SOMM17/6109/UGR (UCE-PP2017-3) and (PI-0441-2014), and by the Chair
“Doctors Galera-Requena in cancer stem cell research” (CMC-CTS963). This research was also funded partially
by RTI2018-098983-B-I00
Percutaneous transhepatic or endoscopic ultrasound-guided biliary drainage in malignant distal bile duct obstruction using a self-expanding metal stent: Study protocol for a prospective European multicenter trial (PUMa trial)
Background Endoscopic ultrasound-guided biliary drainage (EUS-BD) was associated with better clinical success and a lower rate of adverse events (AEs) than fluoroscopy-guided percutaneous transhepatic biliary drainage (PTBD) in recent single center studies with mainly retrospective design and small case numbers (< 50). The aim of this prospective European multicenter study is to compare both drainage procedures using ultrasound-guidance and primary metal stent implantation in patients with malignant distal bile duct obstruction (PUMa Trial). Methods The study is designed as a non-randomized, controlled, parallel group, non-inferiority trial. Each of the 16 study centers performs the procedure with the best local expertise (PTBD or EUS-BD). In PTBD, bile duct access is performed by ultrasound guidance. EUS-BD is performed as an endoscopic ultrasound (EUS)-guided hepaticogastrostomy (EUS-HGS), EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade stenting (EUS-AGS). Insertion of a metal stent is intended in both procedures in the first session. Primary end point is technical success. Secondary end points are clinical success, duration pf procedure, AEs graded by severity, length of hospital stay, re-intervention rate and survival within 6 months. The target case number is 212 patients (12 calculated dropouts included). Discussion This study might help to clarify whether PTBD is non-inferior to EUS-BD concerning technical success, and whether one of both interventions is superior in terms of efficacy and safety in one or more secondary endpoints. Randomization is not provided as both procedures are rarely used after failed endoscopic biliary drainage and study centers usually prefer one of both procedures that they can perform best
Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions
[Background and Aims]: The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models.[Methods]: A multicenter cohort study was performed in patients with nonpedunculated lesions ≥20 mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies.[Results]: DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets.[Conclusions]: The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT 03050333.)Research support for this study was received from “La Caixa/Caja Navarra” Foundation (ID 100010434;project PR15/11100006)
Manual de simulación clínica en especialidades médicas
Manual sobre técnicas y modos de simulación clínica en diversas especialidades médicas.La enseñanza y formación en medicina necesita el uso de la simulación. Existen evidencias de su uso desde hace cientos de años, pero, en los últimos años se ha incrementado y diseminado.
La simulación clínica está validada científicamente en múltiples contextos médicos y de otras áreas profesionales de la salud. Y es considerada de gran importancia como proceso de entrenamiento y de mejora de las competencias y adquisición de habilidades médicas en campos que incluye desde la historia clínica, comunicación con el paciente, exploración, diagnóstico terapéutica médica-farmacológica y quirúrgica y seguridad al tratar al paciente.
Hoy en día, para muchas técnicas y situaciones clínicas es inaceptable llegar junto a los pacientes sin un dominio adquirido en simulación. La simulación puede ocurrir sin el uso de recursos adicionales, solo las personas, o utilizando pocos o muchos recursos de baja hasta alta tecnología y se puede adaptar a los recursos disponibles, abarcando todas las áreas de conocimiento, y dentro de ellas competencias técnicas o actitudes, solas o en conjunto.
El uso racional y basado en evidencia de la simulación es de la mayor importancia por la necesidad de una mayor efectividad y eficiencia en la transformación de los profesionales de la salud para que puedan mejorar su capacidad de atender a los pacientes.
La simulación es también una buena herramienta de evaluación de competencias y habilidades en Medicina y otras disciplinas de las Ciencias de la Salud
Este manual incluye técnicas y modos de simulación clínica en diversas especialidades médicas, útiles, para quien busque un manual práctico y actualizado.Cátedra de Mecenazgo de la Universidad de Málaga. Cátedra de Terapias Avanzadas en Patología Cardiovascular
Cátedra de Mecenazgo de la Universidad de Málaga. Cátedra de Investigación Biomédica Quirón Salu
Challenging Propofol Sedation in Gastrointestinal Endoscopy: High Risk Patients and High Risk Procedures
Sedation is increasingly becoming a must for most endoscopic procedures. Non-anesthesiologist administration of propofol is the standard of practice in many European countries. Nevertheless, despite anesthesiology societies concerns about sedation guided by endoscopist, practitioners find some limits to propofol administration, related to high risk patients or high risk and complex procedures, which can be long lasting and technically challenging.
The main patient related risk factors for sedation are elderly patients, obesity, ASA≥3 patients, individuals with craniofacial abnormalities or with pharyngolaringeal tumors, patients with an acute gastrointestinal bleeding, under pain medications, sedatives, antidepressants, or who consume significant amounts of alcohol or drugs. Procedure related risk factors have more to do with the duration and complexity of the procedure than with other factors, in which considering a general anesthesia allows the endoscopist to concentrate on a difficult task. Published papers addressing the most challenging sedation groups in endoscopy are exploring and even trespassing previously assumed frontiers, and new scenarios are opening to the endoscopist, increasing his/her autonomy, reducing costs and giving patients levels of comfort previously unknown. In this review we analyse each risk group determining the ones in which a sedation protocol could be widely applied, and other in which the published evidence does not guarantee a safe endoscopist guided propofol sedation
Role of wireless capsule endoscopy in inflammatory bowel disease
Capsule endoscopy (CE) offers state-of-the-art imaging of the small bowel. In Crohn’s disease its clinical role is still uncertain. This report analyses the usefulness of CE in patients with suspected Cronh’s disease, in patients with established Crohn’s disease (when assessing severity, occult gastrointestinal bleeding and/or as a guide to therapy), in patients with inflammatory bowel disease unclassified (IBDU), and in individuals with ulcerative colitis. The first item in this group is the most important although there is no strong evidence to establish the position of CE in the diagnostic workup. In patients with established Crohn’s disease, recently developed activity scores are promising tools for an accurate assessment of severity. As a guide to therapy, CE should be focused on patients with unexplained symptoms when other investigations are inconclusive. In postoperative Crohn’s Disease, international consensus recommended considering CE only if ileocolonoscopy is contraindicated or unsuccessful. In the case of IBDU, studies have shown a significant proportion of patients reclassified with Crohn’s disease. In this setting, CE could have a role determining small bowel involvement. The role of CE in ulcerative colitis is limited. Some authors advocate CE before colectomy for refractory cases in order to exclude Crohn’s disease. In summary, CE offers a new horizon in inflammatory bowel disease, and a better knowledge of mucosal abnormalities that could offer a paradigm shift: changing from symptom-based disease activity estimation to direct mucosal healing monitoring. Nevertheless, randomized controlled studies are still needed to provide stronger evidence in this setting
Role of wireless capsule endoscopy in inflammatory bowel
Journal Article;Capsule endoscopy (CE) offers state-of-the-art imaging of the small bowel. In Crohn's disease its clinical role is still uncertain. This report analyses the usefulness of CE in patients with suspected Cronh's disease, in patients with established Crohn's disease (when assessing severity, occult gastrointestinal bleeding and/or as a guide to therapy), in patients with inflammatory bowel disease unclassified (IBDU), and in individuals with ulcerative colitis. The first item in this group is the most important although there is no strong evidence to establish the position of CE in the diagnostic workup. In patients with established Crohn's disease, recently developed activity scores are promising tools for an accurate assessment of severity. As a guide to therapy, CE should be focused on patients with unexplained symptoms when other investigations are inconclusive. In postoperative Crohn's Disease, international consensus recommended considering CE only if ileocolonoscopy is contraindicated or unsuccessful. In the case of IBDU, studies have shown a significant proportion of patients reclassified with Crohn's disease. In this setting, CE could have a role determining small bowel involvement. The role of CE in ulcerative colitis is limited. Some authors advocate CE before colectomy for refractory cases in order to exclude Crohn's disease. In summary, CE offers a new horizon in inflammatory bowel disease, and a better knowledge of mucosal abnormalities that could offer a paradigm shift: changing from symptom-based disease activity estimation to direct mucosal healing monitoring. Nevertheless, randomized controlled studies are still needed to provide stronger evidence in this setting.Ye