Blunted blood pressure response to exercise and isolated muscle metaboreflex activation in patients with cirrhosis.

We sought to test the hypothesis that the cardiovascular responses to isolated muscle metaboreflex activation would be blunted in patients with cirrhosis. Eleven patients with cirrhosis and 15 healthy controls were evaluated. Blood pressure (BP; oscillometric method), contralateral forearm blood flow (FBF; venous occlusion plethysmography), and heart rate (HR; electrocardiogram) were measured during baseline, isometric handgrip at 30% of maximal voluntary contraction followed by postexercise ischemia (PEI). Forearm vascular conductance (FVC) was calculated as follows: (FBF / mean BP) × 100. Changes in HR during handgrip were similar between groups but tended to be different during PEI (controls: Δ 0.5 ± 1.1 bpm vs. cirrhotic patients: Δ 3.6 ± 1.0 bpm, P = 0.057). Mean BP response to handgrip (controls: Δ 20.9 ± 2.7 mm Hg vs. cirrhotic patients: Δ 10.6 ± 1.5 mm Hg, P = 0.006) and PEI was attenuated in cirrhotic patients (controls: Δ 16.1 ± 1.9 mm Hg vs. cirrhotic patients: Δ 7.2 ± 1.4 mm Hg, P = 0.001). In contrast, FBF and FVC increased during handgrip and decreased during PEI similarly between groups. These results indicate that an abnormal muscle metaboreflex activation explained, at least partially, the blunted pressor response to exercise exhibited by cirrhotic patients. Novelty: Patients with cirrhosis present abnormal muscle metaboreflex activation. BP response was blunted but forearm vascular response was preserved. HR response was slightly elevated.

Non-alcoholic Steatohepatitis: Comparison of Intestinal Microbiota between Different Metabolic Profiles. A Pilot Study.

BACKGROUND AND AIMS: Non-alcoholic steatohepatitis (NASH) has multifactorial etiopathogenesis, and intestinal microbiota is co-responsible in this process. The aim of this study was to evaluate the intestinal microbiota in NASH patients with different metabolic profiles. METHODS: Patients with biopsy-proven NASH were evaluated. Subjects were divided into two groups according to their metabolic profile, with or without metabolic syndrome (MS). Their characteristics in relation to liver disease and intestinal microbiota were analyzed. To evaluate the microbiota, breath tests to investigate small intestinal bacterial overgrowth (SIBO) and fecal microbiota analysis by fluorescence in situ hybridization (FISH) were performed. RESULTS: There was a high prevalence of SIBO in both groups, with no significant difference between them. Breathing tests were positive in 43.8% of patients with MS and 50% of those without MS. There was a significant difference regarding the quantification of Verrucomicrobiales, less abundant in patients with NASH without MS. Its lower concentration also correlated with higher serum ferritin levels and higher hepatocyte ballooning. This order of bacteria, through its representative in human microbiota, Akkermansia muciniphila, is associated with mucosal protection and metabolic processes with liver aggression. CONCLUSIONS: Our results suggested that lower Verrucomicrobiales concentration is associated with higher inflammatory activity in patients with NASH without MS, where the disease etiopathogenesis does not have its classic metabolic substrate.

Impact of superimposed Clostridium difficile infection in Crohn's or ulcerative colitis flares in the outpatient setting.

PURPOSE: The prospective assessment of Clostridium difficile infection (CDI) impact in inflammatory bowel disease (IBD) flare in outpatient setting has been poorly investigated. We aimed to evaluate the prevalence and the associated factors with CDI in IBD outpatients presenting colitis flares as well as the outcomes following treatment. METHODS: In this prospective cohort study, conducted from October, 2014, to July, 2016, 120 IBD patients (55% presenting colitis flare) and 40 non-IBD controls were assessed for CDI. Multivariate regression analysis was performed to identify predictors of CDI. Outcome analysis was estimated for recurrent CDI, hospitalization, colectomy, and CDI-associated mortality. RESULTS: The number of patients with CDI was significantly higher in IBD patients experiencing flares than in both inactive IBD and non-IBD groups (28.8 vs. 5.6 vs. 0%, respectively; p = 0.001). Females (OR = 1.39, 95% CI, 1.13-17.18), younger age (OR = 0.77, 95% CI, 0.65-0.92), steroid treatment (OR = 7.42, 95% CI, 5.17-40.20), and infliximab therapy (OR = 2.97, 95% CI, 1.99-24.63) were found to be independently associated with CDI. There was a dose-related increase in the risks of CDI on patients which had taken prednisone. Those treated with vancomycin had a satisfactory response to therapy, but 21% presented recurrent CDI and 16% were hospitalized. Neither necessity of colectomy nor mortality was noticed in any patient during the investigation. CONCLUSIONS: In IBD outpatients presenting colitis flares, CDI is highly prevalent. Females, younger age, infliximab, and notably steroid therapy were independently associated with CDI. Most patients with CDI experienced mild-to-moderate disease, and prompt treatment with vancomycin was highly effective, which seems to reduce the serious complication risks.

Variation rhythms of lymphocyte subsets during healthy aging.

Immunological alterations associated with aging (immunosenescence) do not represent a simple unidirectional decline in all functions but develop as a complex remodeling of the immune system, involving multiple reorganization and developmentally regulated changes. In general, most data available about aging were obtained at particular age intervals and most of them come from Caucasian individuals from either Europe or the United States. Here, we report the frequencies of major lymphocyte subsets in healthy Brazilian individuals from 2 distinct geographic regions (Southeast and South) at several age intervals spanning a lifetime period (0-86 years). Overall, we demonstrated that changes in the frequencies of cells related to both innate and adaptive immunity clearly occur with aging in these individuals. These changes were not progressive and equally steady for all cell populations tested but instead showed an oscillatory or rhythmic behavior that was distinctive of each population at different age intervals. We also observed that abrupt changes in the frequencies of immune cells may occur in healthy individuals over 75 years old, suggesting there is an impaired flexibility of the immune system at late stages of life to sustain homeostasis via immune mechanisms. We presented reference ranges for healthy Brazilian individuals at all ages. The knowledge of these parameters in further detail will allow interventions to optimize immune function in advanced age and to improve the quality of life in the elderly.

Hereditary hemochromatosis: population screening based on phenotype in Brazilian blood donors.

GOALS: A population of blood donors was screened for hereditary hemochromatosis (HH) based on the phenotype strategy in accordance with the European consensus. STUDY: Nonfasting serum samples were obtained from 1,050 donors. Transferrin saturation (TS) was measured using a threshold of 45%. Donors with a TS > or = 45% were retested in a fasting sample. If TS was elevated, the participants were tested for iron overload by ferritin measurement followed by genetic testing. All donors underwent clinical and laboratory workup for expression of the disease. RESULTS: A total of 775 (74.6%) of the donors were men, 749 (72.1%) white, and had a mean age of 30 years (range, 8-60 years). Mean +/- SD TS was 25.9% +/- 13.1% (range, 2.1%-85.8%), and there were 58 (5.6%) donors with a TS > or = 45%. Fifty-four subjects had a repeat TS in a fasting serum sample with a mean +/- SD TS of 32.1% +/-16.1% (range, 15.4%-63.0%), and 12 donors had a TS > or = 45%. Ten complied with genetic testing and ferritin measurement. The study found four donors with HH-related mutations (C282Y and/or H63D); therefore, a gene allele frequency of 0.4%. Only the C282Y homozygote had diagnostic criteria for HH, defining a disease frequency of 0.1%. None of the donors who were mutations carriers had clinical or laboratory manifestations of organic injury. CONCLUSION: We conclude that this is a feasible screening strategy that, by timely diagnosing HH, allows patients not only to benefit from effective treatment but also to have disease progression halted.

Pancreatite aguda / Acute pancreatitis

Pancreatite aguda é uma doença potencialmente fatal, com ampla variaçäo nos aspectos clínicos e na gravidade, abrangendo um aspectro de doença leve e autolimitada a uma rapidamente progressiva com insuficiência de múltiplos órgäos e óbito. Neste artigo, os autores revisam o tema, abordando principalmente os últimos avanços na patogênese no diagnóstico e no tratamento da pancreatite aguda (au)