Ulcerative colitis in remission symptoms: a response to anxiety or ongoing inflammation?

INTRODUCTION: Understand the cause of gastrointestinal symptoms compatible with irritable bowel syndrome (IBS) in patients with inflammatory bowel disease (IBD) in remission is challenging. Those patients are known to show more anxiety, that may influence the course of IBD. The aim of this study was to determine the prevalence of IBS-like symptoms and anxiety by a questionnaire, and his association with subclinical inflammation using calprotectin levels (FC), Mayo Endoscopic Score (MES) and Geboes score (GS) in patients with ulcerative colitis (UC) in clinical remission. METHODS: Recruitment occurred between January 2020 and December 2021 and included UC patients scheduled for colonoscopy. Clinical remission was defined by stool frequency, ulcerative colitis activity index and serum C-reactive protein. IBS diagnosis was evaluated by Roma IV criteria. RESULTS: We included 106 patients (51.9% women; mean age 51 years ±14.8). Rome IV criteria were fulfilled by 29 patients (27.4%). In the UC+IBS group more individuals had calprotectin >100mg/Kg (58.6% vs 23.4%, P=0.001), MES≥1 (37.9% vs 16.9%, P=0.023) and GS>2 (69.0% vs 29.9%, P=0.000). Thirty-three patients reported anxiety (31.3%). UC+IBS group also showed higher anxiety rates (51.7% vs 23.4, P=0.006). In multivariate logistic regression analyses: FC>100mg/Kg, histological activity, and higher anxiety were associated with IBS-like symptoms. CONCLUSION: IBS-like symptoms are common in UC patients considered in clinical remission and relates with anxiety and subclinical inflammation. Our findings underscore the necessity for a comprehensive strategy for these patients, targeting not only inflammation but also psychological conditions.

Quality Standards in Upper Gastrointestinal Endoscopy: Can Deep Sedation Influence It?

Introduction: According to the guideline published by ESGE/UEG, a high-quality esophagogastroduodenoscopy (EGD) implies the application of some criteria that enable better healthcare outcomes. Although intra-procedural performance measures are dependent on patient factors, there is no reference to sedation practices in the guideline mentioned above. Objective: This study aimed to evaluate whether deep sedation influences EGD performance measures established by ESGE/UEG. Methods: This was a cross-sectional study, with a prospective enrollment, that considered for inclusion consecutive patients referred for EGD. Two questionnaires were used to assess performance measures and patient satisfaction after EGD. Results: Sedation had a statistically significant impact on most quality indicators, including complete examination (77.2% without sedation vs. 97.8% with sedation), inspection time (6.17 ± 3.45 vs. 8.39 ± 2.67 min), photodocumentation (78% vs. 97.8%), biopsies (39.3% vs. 60.7%), and patient satisfaction (5.42 ± 2.93 vs. 9.1 ± 1.19). The main reason for an incomplete procedure was patient intolerance (82.6%). Discussion: Deep sedation of patients submitted to EGD proved to be a determinant in the applicability of the ESGE/UEG quality indicators. Patient intolerance was eliminated in the group with sedation, enhancing procedure completeness, adequate pathology identification, management, and consequently, the effectiveness of the exam. Conclusion: Sedation administration should be considered in patients undergoing EGD since it ensures a high-quality procedure.

Introdução: Uma endoscopia digestiva alta (EDA) de qualidade proporciona melhores resultados em termos de saúde e implica a aplicação dos critérios descritos pelas recomendações da ESGE/UEG. Embora os critérios perprocedimento sejam dependentes da colaboração e tolerância do doente, não está explicito o papel da anestesia. Objetivos: Este estudo pretende avaliar se o recurso a anestesia influencia o cumprimento dos critérios de qualidade para a EDA publicados pela ESGE/UEG. Materiais e métodos: Estudo transversal, com recrutamento prospetivo, que incluiu pacientes consecutivamente encaminhados para realização de EDA. Foram utilizados 2 questionários para avaliar medidas de desempenho e satisfação dos pacientes após realização de EDA. Resultados: A anestesia teve um impacto estatisticamente significativo na maioria dos indicadores de qualidade: exame completo (77,2% sem anestesia vs. 97,8% com anestesia); tempo de inspeção (6,17 ± 3,45 vs. 8,39 ± 2,67 minutos); fotodocumentação (78% vs. 97,8%); biópsias (39,3% vs. 60,7%); satisfação do paciente (5,42 ± 2,93 vs. 9,1 ± 1,19). O principal motivo para um procedimento incompleto foi a intolerância do paciente (82,6%). Discussão: A sedação profunda dos doentes submetidos a EDA provou ser determinante na aplicabilidade dos critérios de qualidade da ESGE/UEG. Eliminando por completo a intolerância por parte do doente, proporcionou a realização de exames completos, com correta identificação e gestão de patologias, potenciando assim a efetividade do exame. Conclusão: A administração de anestesia deve ser ponderada, sempre que possível, nos doentes submetidos a EDA, visto que permite garantir a alta qualidade do procedimento.

Auricular Vagal Neuromodulation and its Application in Patients with Heart Failure and Reduced Ejection Fraction. / Neuromodulação Vagal Auricular e sua Aplicabilidade em Pacientes com Insuficiência Cardíaca e Fração de Ejeção Reduzida.

BACKGROUND: The autonomic nervous system (ANS) imbalance in heart failure (HF) creates a vicious cycle, excess sympathetic activity, and decreased vagal activity contributing to the worsening of HF. Low-intensity transcutaneous electrical stimulation of the auricular branch of the vagus nerve (taVNS) is well tolerated and opens new therapeutic possibilities. OBJECTIVES: To hypothesize the applicability and benefit of taVNS in HF through intergroup comparison of echocardiography parameters, 6-minute walk test, Holter heart rate variability (SDNN and rMSSD), Minnesota quality of life questionnaire, and functional class by the New York Heart Association. In comparisons, p values <0.05 were considered significant. METHODS: Prospective, double-blind, randomized clinical study with sham methodology, unicentric. Forty-three patients were evaluated and divided into 2 groups: Group 1 received taVNS (frequencies 2/15 Hz), and Group 2 received sham. In comparisons, p values <0.05 were considered significant. RESULTS: In the post-intervention phase, it was observed that Group 1 had better rMSSD (31 x 21; p = 0.046) and achieved better SDNN (110 vs. 84, p = 0.033). When comparing intragroup parameters before and after the intervention, it was observed that all of them improved significantly in group 1, and there were no differences in group 2. CONCLUSION: taVNS is a safe to perform and easy intervention and suggests a probable benefit in HF by improving heart rate variability, which indicates better autonomic balance. New studies with more patients are needed to answer the questions raised by this study.

FUNDAMENTO: O desequilíbrio do sistema nervoso autônomo (SNA) na insuficiência cardíaca (IC) cria um ciclo vicioso, o excesso de atividade simpática e a diminuição da atividade vagal contribuindo para a piora da IC. A estimulação elétrica transcutânea de baixa intensidade do ramo auricular do nervo vago (taVNS) é bem tolerada e abre novas possibilidades terapêuticas. OBJETIVOS: Gerar hipótese da aplicabilidade e benefício da taVNS na IC através da comparação intergrupos de parâmetros ecocardiográficos, teste de caminhada de 6 min, variabilidade da frequência cardíaca pelo Holter (SDNN e rMSSD), questionário de qualidade de vida de Minnesota e classe funcional pela New York Heart Association. MÉTODOS: Estudo clínico prospectivo, duplo cego, randomizado com metodologia sham, unicêntrico. Avaliados 43 pacientes e alocados em 2 grupos: o Grupo 1 recebeu taVNS (frequências 2/15 Hz) e Grupo 2 recebeu sham. Nas comparações, valores de p<0,05 foram considerados significativos. RESULTADOS: Na fase pós-intervenção, observou-se que o Grupo 1 se manteve com melhor rMSSD (31 x 21; p = 0,046) e atingiu melhor SDNN (110 vs. 84, p = 0,033). Ao compararmos os parâmetros intragrupos, antes e após intervenção, observou-se que todos melhoraram significativamente no grupo 1 e não houve diferenças no grupo 2. CONCLUSÃO: A taVNS é uma intervenção segura, de fácil execução e que sugere provável benefício na IC pela melhora na variabilidade da frequência cardíaca, o que indica melhor equilíbrio autonômico. Novos estudos com maior número de pacientes são necessários para responder às questões levantadas por esse estudo.

Vagal Neuromodulation in Chronic Heart Failure With Reduced Ejection Fraction: A Systematic Review and Meta-Analysis.

Objectives: The aim of this study was to evaluate the effects of invasive vagal nerve stimulation (VNS) in patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF). Background: Heart failure is characterized by autonomic nervous system imbalance and electrical events that can lead to sudden death. The effects of parasympathetic (vagal) stimulation in patients with HF are not well-established. Methods: From May 1994 to July 2020, a systematic review was performed using PubMed, Embase, and Cochrane Library for clinical trials, comparing VNS with medical therapy for the management of chronic HFrEF (EF ≤ 40%). A meta-analysis of several outcomes and adverse effects was completed, and GRADE was used to assess the level of evidence. Results: Four randomized controlled trials (RCT) and three prospective studies, totalizing 1,263 patients were identified; 756 treated with VNS and 507 with medical therapy. RCT data were included in the meta-analysis (fixed-effect distribution). Adverse effects related to VNS were observed in only 11% of patients. VNS was associated with significant improvement (GRADE = High) in the New York Heart Association (NYHA) functional class (OR, 2.72, 95% CI: 2.07-3.57, p < 0.0001), quality of life (MD -14.18, 95% CI: -18.09 to -10.28, p < 0.0001), a 6-min walk test (MD, 55.46, 95% CI: 39.11-71.81, p < 0.0001) and NT-proBNP levels (MD -144.25, 95% CI: -238.31 to -50.18, p = 0.003). There was no difference in mortality (OR, 1.24; 95% CI: 0.82-1.89, p = 0.43). Conclusions: A high grade of evidence demonstrated that vagal nerve stimulation improves NYHA functional class, a 6-min walk test, quality of life, and NT-proBNP levels in patients with chronic HFrEF, with no differences in mortality.

Auriculotherapy for Chronic Cervical Pain.

Objective: Chronic cervical pain is a common and recurrent complaint. Auriculotherapy (AT) or ear acupuncture is an effective complementary method used for pain control, but only a few studies have evaluated this treatment for chronic cervical pain. Thus, the aim of this study was to analyze the effectiveness of AT to control chronic cervical pain and improve functional capacity. Materials and Methods: This study involved patients with at least 2 years of cervical pain and a neck disability index score (NDI) >5. AT was performed at detectable points once per week over 6 weeks. Patients were evaluated with the NDI and a visual analogue scale (VAS) for pain before and at 1 and 4 months after the final treatments. An analysis of variance test for repeated measures was used for comparisons. Results: During the study, 19 patients, with a mean (± SD) age of 44.5 ± 15.2 years, were enrolled. The majority of the patients were right-handed (89%) and female (79%). The median (interquartile range) disease duration was 48 months (range: 24-66 months ). An average of 4 ear points were used per session; the most frequent points used were: Shen men, Posterior Wall, Zero, and C1. Statistically significant decreases in NDI (15.58 ± 5.93) and VAS (4.76 ± 2.37) scores were observed at 1 and 4 months (8.84 ± 5.59; P < 0.0001 and 3.21 ± 2.12; P = 0.003, respectively) after AT treatment. Conclusions: AT can be used successfully as a complementary method to treat chronic cervical pain.

Leucomalácia periventricular e correlação com citocinas pro e antiinflamatórias / Periventricular leukomalacia and correlation with pro and anti-inflammatory cytokines

Introdução:Polimorfismos em genes de citocinas inflamatórias (TNF-α e IL-1ß) e antiinflamatórias (IL-10) intensificam a resposta inflamatória, após anóxia, aumentando as afecções decorrentes da síndrome hipóxico-isquêmica como a leucomalácia periventricular (LPV). Objetivos: Investigar a associação entre ambos os polimorfismos inflamatórios (-1031T/C no gene TNF-α e -511C/T no gene IL-1ß) e o antiinflamatório (-1082G/A no gene IL-10) e a etiopatogênese/risco da LPV em neonatos com esta afecção. Material e Métodos: Estudo prospectivo de casos-controle em 50 neonatos prematuros e a termo (Grupo Casos) e em 50 neonatos a termo (Grupo Controle), de ambos os sexos. DNA foi extraído de leucócitos de sangue periférico e a análise molecular realizada pela Reação em Cadeia da Polimerase/Análise de Restrição Enzimática (PCR/RFLP). Resultados: A idade gestacional média entre casos e controles foi, respectivamente, de 31,0 semanas e 39,4 semanas (p<0,0001). O peso médio, em gramas, foi de 1561,1 para os casos e 3509,9 para controles (p<0,0001). Foi encontrada associação entre o genótipo TC (produtor intermediário de citocina inflamatória) (OR: 2.495; IC95%: 1,10-5,63; p=0,043) assim como entre os genótipos TC+CC (produtores inflamatórios intermediário+alto) (OR: 2,471; IC95%: 1,10-5,55; p=0,044) no gene TNF-α e o risco de LPV. Estatisticamente significante associação foi encontrada entre os genótipos (CT+TT) (produtores inflamatórios intermediário+alto) (OR: 23,120; IC95%: 1,31-409,4; p=0,003) no gene IL-1ß e o risco de LPV. No gene IL-10, foi encontrada reduçãosignificativa do risco de LPV para o genótipo GG (alto produtor antiinflamatório) (OR: 0,07407; IC95%: 0,02-0,34; p<0,0001)assim como para o alelo G (OR: 0,5098; IC95%: 0,29-0,91; p=0,030). Conclusão: há associação entre os polimorfismosinflamatórios (-1031T/C no gene TNF-α e -511C/T no gene IL-1ß) e o risco de desenvolvimento de LPV e associação entre opolimorfismo antiinflamatório (-1082G/A no gene IL-10) na proteção ao desenvolvimento da LPV, na população estudada.