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Background Although esophagogastroduodenoscopy (EGD) is the standard procedure for the diagnosis of gastric cancer (GC), some GCs are missed. There are no published data on the missed rate of GC in Spain. Aims To determine the frequency and characteristics of missed GCs and assess the quality of the EGD in a specific population with GC. Methods Records of all patients diagnosed with gastric adenocarcinoma between 2012 and 2016 in a defined geographic area were reviewed. Missed GC was defined as a case with a prior negative EGD for cancer. Quality indicators from the prior EGDs were measured. Results From 212 cases of GC, 25 cases were excluded. Seventeen out of 187 patients had a prior EGD (9.1%). Twelve of those 17 missed GC had a prior EGD with some abnormal findings. In 6 of them, biopsies were taken. Survival was no different between patients with missed and non-missed GC. Quality indicators that failed to meet standards were recording time, image documentation, and a protocol of biopsies. Conclusions Missed GC in an EGD in a defined population in Spain is not uncommon (9.1%). The endoscopist is an important factor in missed GC due to lack of adequate detection and sampling error. Compliance with performance of quality indicators could reduce missed GC.

Background and Aim Accurate information on the epidemiology of hepatitis C and B infection is mandatory to establish a national/regional plan. We aim to update the prevalence of hepatitis C and B infection in Catalonia using point-of-care tests to analyze the risk factors related and to implement a linkage-to-care circuit. Methods This is a community-based study. A random list of adult individuals was retrieved from censuses of primary care centers. Point-of-care tests for anti-hepatitis C virus (HCV) and HBV surface antigen (HBsAg) and a questionnaire for risk factor assessment were performed. Positive results were validated and a circuit for linkage-to-care was established. Results A total of 3328 individuals were included. The anti-HCV and HBsAg overall prevalence were lower than expected [1.02%, 95% confidence interval (CI) 0.65-1.39; and 0.52%, 95% CI 0.26-0.77, respectively]. Anti-HCV positive subjects were mostly (88%) autochthonous. The prevalence increased with age; only 12% were under age 40. The associated risk factors were drug use, blood transfusion, relative with HCV, and diabetes. Notably, the prevalence of active infection was only 0.49% (95% CI 0.23-0.74), 40% less than previously reported, reflecting the impact of direct acting antiviral therapy. Differently, HBsAg positive subjects were mostly foreign migrants (53%) with no other risk factors. Despite the implementation of a linkage-to-care circuit, one third of HBsAg positive subjects were lost. Conclusions The prevalence of HCV infection was lower than previously reported, showing a strong impact of direct acting antiviral therapy in the last years. Because of hepatitis B universal vaccination, HBV infection in Catalonia is mainly associated with migrant population. Linkage-to-care in patients with hepatitis B was challenging and warrants additional efforts.

Resumen Objetivo Valorar los recursos disponibles en los hospitales comarcales catalanes para la asistencia urgente de la hemorragia digestiva alta. Metodo Se analiza una encuesta enviada a 32 hospitales, sobre la existencia, composicion y recursos del turno de guardia (TDG) de endoscopia, referida al ano 2009. Resultados Respondieron 24 centros, que cubrian la asistencia de 3.954.000 habitantes. Tenian TDG 12 hospitales. No disponian de TDG en su centro de referencia 1.483.000 habitantes. Los centros con TDG tenian mas camas y cubrian mas poblacion. Los TDG estaban formados por 4,5 endoscopistas (rango 2-11), que cubrian 82,1 (33,2-182,5) guardias/ano. Diecisiete centros reportaban 1.571 episodios (51 por centro, rango 3-280, 39,68/100.000 hab.). Los centros con TDG reportaban mas casos (76 vs. 43, p = 0,047). Los que no disponen de TDG derivaron mas pacientes (147 vs . 17, p= 0,001). Los pacientes en urgencias estaban a cargo de medicina interna en 4 centros, de cirugia en 14 y repartidos entre ambos servicios en 6. Si ingresaban, quedaron a cargo de Digestivo solo en 6 hospitales. Los recursos mas utilizados eran la ligadura en la hemorragia varicosa y las terapias de inyeccion en la no varicosa. Un 21% de centros no realizaban tratamiento combinado. Conclusiones Una proporcion significativa de la poblacion no dispone de endoscopista de guardia en su centro de referencia. La constitucion de TDG en hospitales comarcales supone importantes cargas asistenciales. La coordinacion entre profesionales y centros permitiria la aplicacion eficiente de los recursos terapeuticos y el establecimiento de TDG en centros que no tienen.

Fundamento y objetivo Valorar la aplicabilidad de una unidad de diagnostico rapido (UDR) dirigida al estudio ambulatorio de pacientes con sospecha de enfermedad grave Pacientes y metodo Se analiza de forma prospectiva a los pacientes atendidos en una UDR durante 5 anos (1997–2001) y se compara a los pacientes con cancer de pulmon y los de cancer de colon atendidos en la UDR y hospitalizados Resultados Los principales motivos de consulta fueron dolor abdominal, sintomas constitucionales y neurologicos, anemia y tumoraciones palpables. Las enfermedades digestivas y neoplasicas fueron las mas frecuentes. El intervalo medio (desviacion estandar) para la primera visita fue de 4,9 (3,4) dias y el de diagnostico, de 5,7 (6,5) dias. Un 95% de los pacientes mostro un elevado grado de satisfaccion con este modelo asistencial. En pacientes con cancer de colon estudiados en la UDR se observo una reduccion del intervalo diagnostico (p = 0,03) respecto a los hospitalizados. El coste economico del estudio diagnostico fue inferior en la UDR Conclusiones La UDR representa una forma asistencial aplicable en nuestro medio que consigue la misma eficacia y una mayor eficiencia que el ingreso hospitalario

Background/Aims: Silymarin has protective effects in different experimental conditions, but its efficacy in human liver cirrhosis has not been completely established. Therefore, this study was carried out to determine the effect of silymarin in alcoholics with liver cirrhosis with respect to survival and clinical and laboratory changes. Methods: From February 1986 to June 1989, we enrolled 200 alcoholics with histologically or laparoscopically proven liver cirrhosis in a randomized, double-blind multicenter trial comparing 450 mg of silymarin (150 mg/three times per day), with placebo. The primary outcome was time to death, and the secondary outcome was the progression of liver failure. Additional analyses were also performed in 75 patients in whom anti-hepatitis C virus antibodies were measured after completion of the trial. Results: One hundred and three patients were assigned to receive silymarin and 97 to receive placebo. The two groups were well matched for demographic and baseline clinical and laboratory features. A 2-year study period was completed in 125 patients (57 receiving silymarin and 68 receiving placebo). Twenty-nine patients (15 receiving silymarin, and 14 receiving placebo) died during the trial. Survival was similar in patients receiving silymarin or placebo. The effect of silymarin on survival was not influenced by sex, the persistence of alcohol intake, the severity of liver dysfunction or by the presence of alcoholic hepatitis in the liver biopsy. Silymarin did not have any significant effect on the course of the disease. No relevant side-effects were obaserved in any group. Conclusions: The results of this study indicate that silymarin has no effect on survival and the clinical course in alcoholics with liver cirrhosis.

To evaluate the resources available in Catalan regional hospitals for the emergency care of upper gastrointestinal hemorrhage.We analyzed a survey sent to 32 hospitals on the availability, composition and resources of a duty endoscopy service for the year 2009.Responses were obtained from 24 centers, covering 3,954,000 inhabitants. Duty endoscopists were available in 12 hospitals. A total of 1,483,000 inhabitants were unable to access a duty endoscopist in the referral center. Centers with duty endoscopists had more beds and had a larger catchment area. Duty services were composed of 4.5 endoscopists (range 2-11), covering 82.1 (33.2-182.5) duty shifts/year. Seventeen centers reported 1,571 episodes (51%, range: 3-280, 39.68/100,000 inhabitants). Centers with a duty service reported a greater number of cases (76 vs. 43, p=0.047). Centers without this service referred a greater number of patients (147 vs. 17, p=0.001). Patients in the emergency department were under the care of the internal medicine department in four centers, the surgery department in 14 centers and under the care of both departments in six. Admitted patients were under the care of the gastroenterology department in only six hospitals. The most widely used procedures were ligation of varicose bleeding and injection therapies in non-varicose bleeding. Twenty-one percent of centers did not perform combined treatment.A significant proportion of the population does not have access to a duty endoscopist in referral centers. Duty shifts represent significant workload in regional hospitals. Coordination among health professionals and centers would allow the efficient application of therapeutic resources and a duty endoscopy service to be established in centers lacking this resource.

Background & Aims Ten common low-penetrant genetic variants have been consistently associated with colorectal cancer (CRC) risk; little is known about the correlation between these variants and CRC phenotype. Characterization of such a correlation would improve CRC management and prevention programs. We assessed the association between these genetic variants and CRC phenotype in patients and modeled pairwise combinations to detect epistasis. Methods The validation population corresponded to a prospective, multicenter, population-based cohort (EPICOLON I) of 1096 patients with newly diagnosed CRC. The replication set was an independent, prospective, multicenter Spanish cohort (EPICOLON II) of 895 patients with newly diagnosed CRC. For individual single nucleotide polymorphism (SNP) association analyses, a multivariate method using logistic regression was applied in EPICOLON I and subsequently prospectively validated in EPICOLON II. Interactions between SNPs were assessed using the likelihood ratio test. Results Validated results confirmed that the C allele on 8q23.3 (rs16892766) was significantly associated with advanced-stage tumors (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.15–1.90; P value=4.9 × 10 −3 ). The G allele on 8q24.21 (rs6983267) was more common in patients with a familial history of CRC (OR, 2.02; 95% CI, 1.35–3.03; P value=3.9 × 10 −4 ). The combination of rs6983267 on 8q24.21 and rs9929218 on 16q22.2 was associated with a history of colorectal adenoma (carriers of GG and AA, respectively; OR, 2.28; 95% CI, 1.32–3.93; P = 5.0 × 10 −4 ). Conclusions CRC susceptibility variants at 8q23.3, 8q24.21, and 16q22.2 appear to be associated with cancer phenotype. These findings might be used to develop screening and surveillance strategies.

To analyze the applicability of an out-patient Quick and Early Diagnostic Unit (QEDU) to evaluate patients with a potential life-threatening disorder on an out-patient basis.We analyzed prospectively all patients attended in the unit for five years (1997-2001). We compared patients with lung cancer and colorectal cancer admitted to hospital for conventional study versus patients studied at the unit.We attended 2,748 patients in total Main reasons for consultation were abdominal pain, asthenia-anorexia, neurologic symptoms, anemia and palpable tumors. The most frequent diagnostic category corresponded to gastroenterological diseases and neoplastic diseases. The mean interval (standard error) for the first visit was 4.9 (3.4) days and for diagnosis it was 5.7 (6.5) days. Some 95% patients displayed a high degree of satisfaction by the questionnaire. In patients with cancer of the colon studied at the QEDU, we observed a reduction in the average interval for diagnosis which was highly significant (p = 0.03). The overall costs of final diagnosis were also lower for the QEDU model.The QEDU unit represents an alternative to in hospital admission for diagnostic workouts, which is fully feasible in our setting. It can result in the same efficacy and a higher efficiency than hospital admission.

Excerpt Sulindac treatment has been reported to induce marked reductions in the number and size of adenomatous polyps in the rectal segment after subtotal colectomy (1). These findings were not con...

The effects of pharmacological manipulation of the lower esophageal sphincter pressure on the esophageal circulation in patients with cirrhosis and portal hypertension were investigated in 33 patients by measuring the azygos venous blood flow, which is an index of blood flow through esophageal varices and periesophageal collaterals draining into the azygos venous system. Measurements were performed in baseline conditions and after the blind administration of metoclopramide (20 mg i.v.) (12 patients), domperidone (10 mg i.v.) (12 patients) and placebo (9 patients). Both metoclopramide and domperidone caused a significant reduction of azygos blood flow, that decreased by 11.5% (p less than 0.01) and 15.6% (p less than 0.02) respectively, while no change was observed in patients receiving placebo (+1.4%, not statistically significant). Reduction of azygos blood flow represents a selective effect of metoclopramide and domperidone on the esophageal circulation, since portal pressure, hepatic blood flow, cardiac output, heart rate and arterial blood pressure were unchanged by the administration of metoclopramide, domperidone or placebo. These results indicate that the administration of drugs that increase the lower esophageal sphincter pressure may reduce the inflow of blood into the esophageal varices in cirrhotic patients with portal hypertension.

Background Colorectal cancer (CRC) is the second leading cause of cancer death in developed countries. Familial aggregation in CRC is also important outside syndromic forms and, in this case, a polygenic model with several common low-penetrance alleles contributing to CRC genetic predisposition could be hypothesized. Mucins and GALNTs (N-acetylgalactosaminyltransferase) are interesting candidates for CRC genetic susceptibility and have not been previously evaluated. We present results for ten genetic variants linked to CRC risk in previous studies (previously identified category) and 18 selected variants from the mucin gene family in a case-control association study from the Spanish EPICOLON consortium. Methods CRC cases and matched controls were from EPICOLON, a prospective, multicenter, nationwide Spanish initiative, comprised of two independent stages. Stage 1 corresponded to 515 CRC cases and 515 controls, whereas stage 2 consisted of 901 CRC cases and 909 controls. Also, an independent cohort of 549 CRC cases and 599 controls outside EPICOLON was available for additional replication. Genotyping was performed for ten previously identified SNPs in ADH1C, APC, CCDN1, IL6, IL8, IRS1, MTHFR, PPARG, VDR and ARL11, and 18 selected variants in the mucin gene family. Results None of the 28 SNPs analyzed in our study was found to be associated with CRC risk. Although four SNPs were significant with a P-value < 0.05 in EPICOLON stage 1 [rs698 in ADH1C (OR = 1.63, 95% CI = 1.06-2.50, P-value = 0.02, recessive), rs1800795 in IL6 (OR = 1.62, 95% CI = 1.10-2.37, P-value = 0.01, recessive), rs3803185 in ARL11 (OR = 1.58, 95% CI = 1.17-2.15, P-value = 0.007, codominant), and rs2102302 in GALNTL2 (OR = 1.20, 95% CI = 1.00-1.44, P-value = 0.04, log-additive 0, 1, 2 alleles], only rs3803185 achieved statistical significance in EPICOLON stage 2 (OR = 1.34, 95% CI = 1.06-1.69, P-value = 0.01, recessive). In the joint analysis for both stages, results were only significant for rs3803185 (OR = 1.12, 95% CI = 1.00-1.25, P-value = 0.04, log-additive 0, 1, 2 alleles) and borderline significant for rs698 and rs2102302. The rs3803185 variant was not significantly associated with CRC risk in an external cohort (MCC-Spain), but it still showed some borderline significance in the pooled analysis of both cohorts (OR = 1.08, 95% CI = 0.98-1.18, P-value = 0.09, log-additive 0, 1, 2 alleles). Conclusions ARL11, ADH1C, GALNTL2 and IL6 genetic variants may have an effect on CRC risk. Further validation and meta-analyses should be undertaken in larger CRC studies.