Are Crohn's Disease Patients Limited in Sport Practise? An UltraEndurance Case-Control Study Response.

The aim of this study was to analyze the psychophysiological response of a Crohn's Disease patient in an ultra-endurance event. The psychophysiological responses of a Crohn's Disease and non-Crohn's Disease participant were analysed before during and after an 8 h ultra-endurance running event. Results showed how Crohn's patient presented a similar psychophysiological response than non-Crohn's participant in the ultra-endurance event, except for a higher pre- and post-event sympathetic modulation, lower event sympathetic tone, and lower event body temperature. This study could contribute to improving physical activity recommendations for persons with Crohn's Disease and open a new research line for an improved understanding of psychophysiological modifications of Crohn's Disease patients during exercise.

Quality indicators in enteroscopy. Enteroscopy procedure.

Within the project "Quality Indicators in Gastrointestinal Endoscopy," under the leadership of the Sociedad Española de Patología Digestiva (SEPD), our goal is to propose the procedures and the structure, process, and outcome indicators required for the application and assessment of quality in enteroscopy. To this end a search was performed for quality indicators in enteroscopy. Quality of evidence was measured by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, and classified as high, moderate, low, and very low. A total of 10 process indicators (one preprocedure, eight procedure, one postprocedure) were identified for enteroscopy, with appropriate indication and choice of most efficient route being most significant.

Sistema Integrado de Informações Mais Médicos: uma ferramenta de suporte à gestão baseada em evidências / More Doctors Integrated Information System: a tool to support evidence-based management / Sistema integrado de información de Más Médicos: una herramienta de apoyo a la gestión basada en la evidencia

O presente trabalho busca detalhar uma experiência pioneira de desenvolvimento de um sistema de informação em saúde voltado para subsidiar a gestão com base em evidências junto à atenção primária à saúde (APS). O processo de estruturação de programas e políticas públicas muitas vezes se dá sem acesso às melhores evidências científicas. Nesse contexto, o Sistema Integrado de Informações Mais Médicos (SIMM), aqui descrito, materializou um esforço para suprir a lacuna de informações para a gestão em saúde. Criado com objetivo de integrar os dados das principais fontes de informação relativas ao Projeto de Cooperação entre governo brasileiro e Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/ OMS) para provimento de médicos no Programa Mais Médicos (PMM), o SIMM buscou otimizar a geração e a consolidação de informações que possam subsidiar decisões, além de apoiar o controle administrativo e financeiro. A experiência ilustra o desenvolvimento de uma solução auxiliar que pode ser ampliada para monitorar parâmetros de recursos humanos em saúde não apenas no PMM, mas na APS como um todo. A expertise desenvolvida criou condições para que o sistema pudesse ser configurado como um bem público, para além do suporte à gestão de um projeto em específico. O sistema pode ser adaptado e replicado em outros países das Américas para melhorar a disponibilidade e a qualidade das informações utilizadas por tomadores de decisão.(AU)

The present work provides details about a novel experience involving the development of a health information system focused on supporting evidence-based management at the primary health care (PHC) level. The process of structuring public health programs and policies is often developed without access to the best available scientific evidence. In this context, the proposed system (Sistema Integrado de Informações Mais Médicos, SIMM) materializes the effort to bridge the information gap for health management. Created with the aim of integrating data from the main information sources associated with the Cooperation Project between the Brazilian federal government and the Pan American Health Organization/World Health Organization (PAHO/ WHO) for provision of physicians for the More Doctors Program, SIMM strove to optimize the generation and consolidation of information to support decision-making, in addition to providing support for administrative and financial control. The experience illustrates the development of an ancillary solution that can be expanded to monitor human resources for health parameters across the entire PHC setting, far beyond the More Doctors Program. The resulting expertise created conditions for the system to be configured as a public asset, rather than being restricted to providing managerial support for a specific project. SIMM may be adapted and replicated in other American countries to improve the availability and quality of the information used by decision makers.(AU)

En el presente trabajo se detalla una experiencia pionera de desarrollo de un sistema de información de salud centrado en apoyar la gestión basada en la evidencia en el nivel de la atención primaria de salud. Muchas veces, el proceso de estructuración de los programas y políticas públicas se realiza sin acceso a las mejor evidencia científica. En ese contexto, el sistema integrado de información de Mais Médicos (SIMM) que se describe aquí materializó un esfuerzo para suplir la carencia de información para la gestión en materia de salud. El SIMM, creado con el objetivo de integrar los datos de las principales fuentes de información relativas al proyecto de cooperación entre el Gobierno del Brasil y la Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS) para la provisión de médicos destinados al programa Más Médicos, se utilizó para optimizar la generación y consolidación de información a fin de sustentar las decisiones, además de servir de apoyo para el control administrativo y financiero. La experiencia ilustra el desarrollo de una solución complementaria que puede ampliarse para observar los parámetros de recursos humanos en salud no solo en el programa Más Médicos, sino en todo el ámbito de la atención primaria de salud. La pericia adquirida creó condiciones propicias para poder configurar el sistema como un bien público, con miras a ampliar su alcance más allá del apoyo a la gestión de un proyecto específico. Es posible adaptar y reproducir el sistema en otros países de la Región de las Américas para mejorar la disponibilidad y la calidad de la información utilizada por los responsables de tomar decisiones.(AU)

Quality indicators in gastroscopy. Gastroscopy procedure.

Within the project "Quality indicators in digestive endoscopy", pioneered by the Spanish Society for Digestive Diseases (SEPD), the objective of this research is to suggest the structure, process, and results procedures and indicators necessary to implement and assess quality in the gastroscopy setting. First, a chart was designed with the steps to be followed during a gastroscopy procedure. Secondly, a team of experts in care quality and/or endoscopy performed a qualitative review of the literature searching for quality indicators for endoscopic procedures, including gastroscopies. Finally, using a paired analysis approach, a selection of the literature obtained was undertaken. For gastroscopy, a total of nine process indicators were identified (one preprocedure, eight intraprocedure). Evidence quality was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification scale.

Programa Mais Médicos: como avaliar o impacto de uma abordagem inovadora para superação de iniquidades em recursos humanos / More Doctors recruitment program: a new approach to overcome inequalities in human resources / Programa Más Médicos: cómo evaluar el impacto de un enfoque innovador para superar las inequidades en recursos humanos

RESUMO Apesar de decorridos 40 anos da divulgação dos princípios de Alma-Ata, ainda persistem desafios para a consolidação da atenção primária à saúde (APS) como eixo norteador dos sistemas de saúde ao redor do globo. Dentre os desafios ainda presentes, merecem destaque as questões associadas à iniquidade na distribuição de recursos humanos em saúde. A experiência do Programa Mais Médicos (PMM) no Brasil é um exemplo de proposta voltada para a abordagem dessa agenda inconclusa de Alma-Ata. Ao modificar aspectos centrais da formação, provimento e alocação de profissionais médicos, o PMM mostrou-se uma saída viável para minimizar os desafios de escassez de profissionais. As avaliações do PMM, embora incipientes, produziram evidências positivas quanto a ampliação do acesso e melhoria da qualidade da APS no Brasil, um país de médio desenvolvimento econômico. Apesar disso, é premente a geração de evidências mais sólidas a respeito do impacto do PMM sobre indicadores de desempenho da APS. O debate apresentado ao longo deste trabalho discute a necessidade de se viabilizar estudos quase-experimentais capazes de mensurar o impacto do PMM junto à saúde da população. O artigo propõe, então, um conjunto de diretrizes que pode se configurar como um modelo aplicável para abordar desafios associados à escassez de profissionais em países de médio e baixo desenvolvimento econômico.

ABSTRACT Despite the 40 years elapsed since the Alma-Ata principles were first launched, a series of challenges still persists for the consolidation of primary health care (PHC) as the backbone of health care systems around the world. Among these challenges, especially noteworthy are the issues associated with the inequality in the allocation of human resources. The experience of the More Doctors Program (Programa Mais Médicos, PMM) in Brazil is an example of initiatives that tackle this inconclusive Alma-Ata agenda. By changing key aspects of physician training, provision, and allocation, PMM was shown to be a feasible alternative to minimize the challenge of physician shortage. Assessments of PMM, even though preliminary, have produced positive evidence showing increase in access and improvement of PHC quality in Brazil, a middle income country. Nevertheless, the generation of more robust evidence regarding the impact of PMM on PHC performance indicators is urgent. The discussion proposed in the present article emphasizes the need to prioritize quasi-experimental studies to measure the impact of PMM on population health. The article thus introduces a set of guidelines that may become a useful model to approach challenges associated with the shortage of health care professionals in low and middle income countries.

RESUMEN A pesar de que han transcurrido 40 años desde la proclamación de los principios de Alma-Ata, aún persisten desafíos para la consolidación de la atención primaria de salud (APS) como columna vertebral de los sistemas de atención de salud en todo el mundo. Entre estos desafíos, se destacan los problemas asociados con la desigualdad en la distribución de recursos humanos. La experiencia del Programa Más Médicos (PMM) en Brasil es un ejemplo de las iniciativas que abordan esta agenda inconclusa de Alma-Ata. Al cambiar aspectos clave de la capacitación, la provisión y la asignación de médicos, el PMM demostró ser una alternativa viable para minimizar el desafío de la escasez de profesionales. Las evaluaciones del PMM, aunque preliminares, han producido evidencias positivas que muestran un aumento en el acceso y mejora de la calidad de la APS en Brasil, un país de ingresos medios. Sin embargo, urge generar evidencia más sólida sobre el impacto del PMM en los indicadores de desempeño de la APS. La discusión propuesta en este trabajo enfatiza la necesidad de priorizar estudios cuasiexperimentales para medir el impacto del PMM en la salud de la población. El artículo propone un conjunto de directrices que pueden convertirse en un modelo útil para abordar los desafíos asociados con la escasez de profesionales de la salud en países de ingresos bajos y medios.

Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators.

The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification.

More Doctors Programme and the strengthening of Primary Health Care in Brazil: reflections from the monitoring and evaluation of the More Doctors Cooperation Project

Universal Health Coverage has been a challenge for the majority of the world’s health systems. Efforts to strengthen systems through universal coverage with the aim of improving living conditions and access to health services are optimized when this is based on quality Primary Health Care (PHC). A national policy has been being developed in Brazil since 2013 aimed at strengthening human resources for PHC. This policy is called the More Doctors Programme and is considered to be an important investment for PHC development in Brazil’s Unified Health System. The purpose of this article is to present the main results of the More Doctors Programme monitoring.

Monitoring and evaluation of the PAHO/WHO cooperation project, the Mais Médicos (More Doctors) Program: a mid-term assessment / Monitoramento e avaliação do Projeto de Cooperação da OPAS/OMS com o Programa Mais Médicos: reflexões a meio caminho

As relações de trabalho entre a Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS) e as instituições de saúde do Brasil têm uma longa história de cooperação com benefícios mútuos que, em muitos casos, foram compartilhados com outras nações sob diversos enfoques de cooperação entre os países para o desenvolvimento da saúde. Um marco nesta relação é a cooperação técnica prestada ao Programa Mais Médicos (PMM). Esta cooperação agrega valor estratégico na redução das lacunas em matéria de igualdade de saúde e capitaliza a natureza única da experiência de cooperação Sul-Sul entre Cuba e Brasil, triangulada através da OPAS/OMS. Este artigo discute o papel da OPAS/OMS na avaliação da sua cooperação técnica com o PMM. Foi desenvolvido um marco de monitoramento e avaliação, visando identificar progressivamente os avanços na cobertura e qualidade dos serviços de atenção básica proporcionados pelo Sistema Único de Saúde (SUS) por meio do PMM. Especial atenção foi dedicada à identificação das melhores práticas nos serviços de saúde, à análise dos resultados e impactos do PMM, e à gestão e divulgação dos conhecimentos produzidos pela sua implementação, através de plataforma de conhecimento. Alguns resultados relevantes do PMM são sinteticamente apresentados e discutidos.

Working relations between the Pan- American Health Organization/World Health Organization (PAHO/WHO) and Brazilian health institutions accumulated a long history of cooperation with mutual benefits, which in many cases were shared with other nations under various cooperation frameworks among countries for health development. A milestone in this relationship is the technical cooperation provided by PAHO/WHO to the More Doctors Program (Programa Mais Médicos - PMM). This cooperation has added both strategic value in reducing gaps in health equality and has capitalized on the unique nature of the Cuba-Brazil South-South cooperation experience, triangulated through PAHO/WHO. This paper discusses PAHO/WHO’s role in the evaluation of its technical cooperation within PMM. A Monitoring and Evaluation (M&E) Framework has been developed in order to progressively identify the advances in coverage and quality of primary health care provided by the Unified Health System (Sistema Único de Saúde - SUS) through the PMM. Special attention was given to identify best practices in health services, to analyze results and impacts of the PMM, and to manage and share knowledge that has been produced by its implementation, through a web-based knowledge platform. Some relevant results of PMM are briefly presented and discussed.

O Programa Mais Médicos e as redes de atenção à saúde no Brasil / Mais Médicos Program and Health Care Networks in Brazil

Este artigo procura discutir a colaboração entre a Organização Pan-Americana da Saúde e o Programa Mais Médicos (PMM), debruçando-se sobre os mandatos dos Estados- Membros da Organização para a cooperação técnica no desenvolvimento dos sistemas e serviços de saúde e a Cooperação Sul-Sul, ao mesmo tempo que o vincula aos elementos conceituais e da política nacional de desenvolvimento do Sistema Único de Saúde (SUS) do Brasil. Apresenta, ainda, a relevância do PMM na medida em que incrementou o número de médicos atuantes no SUS, especificamente na Atenção Básica, nos municípios mais vulneráveis e seu impacto na garantia do direito à saúde da população com a melhora da atenção primária e das redes integradas de serviços de saúde.

This paper aims on discussing the collaboration between the Pan-American Health Organization and Mais Médicos Program (PMM), analyzing the State-Members’ terms of office in the Organization for technical cooperation on the development of Health care systems and services and the South-South Cooperation, at the same time it links it to the conceptual elementsand to Brazilian national Unified Health System (SUS) development policy. It also presents PMM’s relevance, as it increased the number of active doctors on SUS, particularly on primarycare, in the most vulnerable cities and its impact on guaranteeing population’s right to health with improvement of primary care and integrated health services networks.

O papel da Organização Pan–Americana da Saúde no fortalecimento dos Sistemas Nacionais de Sangue: a cooperação técnica como instrumento para implementação da Política Nacional de Sangue, Componentes e Hemoderivados no Brasil / The contribution of the Pan American Health Organization in strengthening National Blood Systems: the technical cooperation as an instrument for the implementation of the National Blood Policy, Compounds and blood products in Brazil

Este trabalho de natureza descritiva buscou relatar o papel da OrganizaçãoPan–Americana da Saúde (OPAS) na cooperação técnica referente ao fortalecimento dos sistemas nacionais de sangue da região das Américas, com ênfase no Sistema Nacional de Sangue (SINASAN) brasileiro. Foram utilizados como fontes documentais as resoluções da Organização Mundial da Saúde e da OPAS e os termos de cooperação celebrados entre a OPAS, o Ministério da Saúde e a Empresa Brasileira de Biotecnologia e hemoderivados dentre os resultados, destaca–se o necessário papel articulador da OPAS para o desenvolvimento de parcerias estratégicas com as instituições brasileiras que compõem e apoiamo SINASAN, objetivando a realização de cooperação técnica para o fortalecimento dos sistemas de sangue dos países da região.

This descriptive work looks at presenting the technical cooperation provided by the Pan American Health Organization (PAHO) in contribution to strengthening National Blood Systems in the Americas, with special emphasis on the National Blood System in Brazil (SINASAN). Resolutions adopted by PAHO and WHO member states have been used as references, as well as the Agreement of Cooperation established between PAHO and Hemobras (Brazilian Public Company for biological and blood products). As a result, we stress the relevant rol of PAHO as a catalyzer in the development of strategic partnership among SINASAN players in Brazil, andtherefore the technical rol that the Organization (PAHO) plays in the Region as a broker.

Predictive value of MicroRNAs in the progression of barrett esophagus to adenocarcinoma in a long-term follow-up study.

OBJECTIVE: The aim of this study is to identify a set of microRNAs (miRNAs) as prognostic molecular biomarkers for the progression of Barrett esophagus (BE) to esophageal adenocarcinoma (EAC) to rationalize the surveillance programs in patients with BE. BACKGROUND: Histological dysplasia is currently used as the main biomarker to identify the BE patients at high risk for developing EAC. Although miRNA expression profiles in BE and EAC have been reported, it has not been established which set of miRNAs could constitute a robust diagnostic test to predict the progression of BE to EAC. METHODS: miRNAs associated with progression of BE to EAC were identified using miRNA sequencing analysis. Further validation by quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed in 2 groups of BE patients who either developed or did not develop adenocarcinoma after at least 5 years of follow-up. RESULTS: Twenty-three miRNAs were identified by miRNA sequencing analysis in the carcinogenesis process associated with BE. qRT-PCR analysis using independent tissue samples confirmed differential expression for 19 of them (miR-let-7c, 7, 146a, 149, 153, 192, 192*, 194, 194*, 196a, 196b, 200a, 203, 205, 215, 424, 625, 625*, and 944). However, only miR-192, 194, 196a, and 196b showed a significantly higher expression in BE samples from patients with progression to EAC compared with those who did not progress to EAC. CONCLUSIONS: These findings suggest that the expression pattern of a modest number of miRNAs in metaplasia biopsies could identify the BE patients at high risk for developing EAC. Therefore, it has potential use for the control and treatment of this malignancy.

Greenhouse gas emissions under conservation agriculture compared to traditional cultivation of maize in the central highlands of Mexico.

In 1991, the 'International Maize and Wheat Improvement Center' (CIMMYT) started a field experiment in the rain fed Mexican highlands to investigate conservation agriculture (CA) as a sustainable alternative for conventional maize production practices (CT). CT techniques, characterized by deep tillage, monoculture and crop residue removal, have deteriorated soil fertility and reduced yields. CA, which combines minimum tillage, crop rotations and residue retention, restores soil fertility and increases yields. Soil organic matter increases in CA compared to CT, but increases in greenhouse gas emissions (GHG) in CA might offset the gains obtained to mitigate global warming. Therefore, CO(2), CH(4) and N(2)O emissions, soil temperature, C and water content were monitored in CA and CT treatments in 2010-2011. The cumulative GHG emitted were similar for CA and CT in both years, but the C content in the 0-60 cm layer was higher in CA (117.7 Mg C ha(-1)) than in CT (69.7 Mg C ha(-1)). The net global warming potential (GWP) of CA (considering soil C sequestration, GHG emissions, fuel use, and fertilizer and seeds production) was -7729 kg CO(2) ha(-1) y(-1) in 2008-2009 and -7892 kg CO(2) ha(-1) y(-1) in 2010-2011, whereas that of CT was 1327 and 1156 kg CO(2) ha(-1) y(-1). It was found that the contribution of CA to GWP was small compared to that of CT.

Long-term follow-up of malignancy biomarkers in patients with Barrett's esophagus undergoing medical or surgical treatment.

OBJECTIVE: This study aims to compare some validated biomarkers of malignancy (Ki-67, p53, and apoptosis) between 2 groups of patients with Barrett's esophagus (BE) undergoing randomly medical or surgical treatment. BACKGROUND: The treatment of choice to prevent the malignant progression of BE remains controversial. Translational studies using biomarkers associated with the metaplasia-tumor pathway could be useful to provide some information in this regard. METHODS: The study group consisted of 45 patients: 20 under medical treatment with 40 mg/day of proton pump inhibitors (PPIs) and 25 after Nissen fundoplication (NFP). After a median follow-up of 8 years (range, 5-10 years), the values of Ki-67, p53, and apoptosis were analyzed in all patients before treatment (n = 45) and then 1 year (n = 45), 3 years (n = 45), 5 years (n = 45), and 10 years (n = 25) afterwards in both groups of treatment. These values were also analyzed in 2 subgroups of patients with successful medical and surgical treatment. RESULTS: Both Ki-67 and p53 remained stable after NFP, whereas they increased progressively in patients under PPIs with statistically significant differences between the 2 groups. Conversely, the apoptotic index increased progressively after NFP and decreased in the patients under PPIs with significant differences at 3, 5, and 10 years of follow-up. On comparing the subgroups of successful treatment the same differences were found. CONCLUSIONS: Barrett's epithelium remains more stable after a long-term follow-up in patients with BE treated surgically than in those under PPIs even in the absence of abnormal rates of acid reflux.

Effect of pest controlling neem and mata-raton leaf extracts on greenhouse gas emissions from urea-amended soil cultivated with beans: a greenhouse experiment.

In a previous laboratory experiment, extracts of neem (Azadirachta indica A. Juss.) and Gliricidia sepium Jacquin, locally known as mata-raton, used to control pests on crops, inhibited emissions of CO(2) from a urea-amended soil, but not nitrification and N(2)O emissions. We investigated if these extracts when applied to beans (Phaseolus vulgaris L.) affected their development, soil characteristics and emissions of carbon dioxide (CO(2)) and nitrous oxide (N(2)O) in a greenhouse environment. Untreated beans and beans planted with lambda-cyhalothrin, a commercial insecticide, served as controls. After 117days, shoots of plants cultivated in soil amended with urea or treated with lambda-cyhalothrin, or extracts of neem or G. sepium were significantly higher than when cultivated in the unamended soil, while the roots were significantly longer when plants were amended with urea or treated with leaf extracts of neem or G. sepium than when treated with lambda-cyhalothrin. The number of pods, fresh and dry pod weight and seed yield was significantly higher when bean plants were treated with leaf extracts of neem or G. sepium treatments than when left untreated and unfertilized. The number of seeds was similar for the different treatments. The number of nodules was lower in plants fertilized with urea, treated with leaf extracts of neem or G. sepium, or with lambda-cyhalothrin compared to the unfertilized plants. The concentrations of NH(4)(+), NO(2)(-) and NO(3)(-) decreased significantly over time with the lowest concentrations generally found at harvest. Treatment had no significant effect on the concentrations of NH(4)(+) and NO(2)(-), but the concentration of NO(3)(-) was significantly lower in the unfertilized soil compared to the other treatments. It was found that applying extracts of neem or G. sepium leaves to beans favored their development when compared to untreated plants, but had no significant effect on nitrification in soil.

[Severe lower gastrointestinal tract bleeding due to diverticulosis]. / Hemorragia digestiva baja grave de origen diverticular.

INTRODUCTION: Diverticulosis is the most frequent cause of lower gastrointestinal (GI) bleeding in adults in western countries. The aims of the present study were to analyze: 1) the diagnostic and therapeutic management of patients with severe lower GI bleeding due to diverticulosis; 2) associated morbidity and mortality; 3) the need for surgery, and 4) bleeding recurrence rates after hospital discharge. MATERIAL AND METHODS: Were retrospectively reviewed 42 patients with severe lower GI bleeding due to diverticulosis. Patients with rectorrhagia requiring transfusion of at least three packed red blood cell units and those with a decrease in hematocrit of 10 points or more were included. As a control group, we used 133 patients with severe lower GI hemorrhage due to causes other than colonic diverticular disease. RESULTS: All patients were stabilized with conservative measures except one who required emergency surgery. Colonoscopy was performed in 39 patients and the most frequent finding consisted of recent signs of bleeding independently of whether colonoscopy was performed early or was delayed. Endoscopic treatment with Argon laser electrocoagulation was performed in one patient. Bleeding recurrence after hospital discharge occurred in 13 patients (31%); of these, seven (16%) required hospital readmission. CONCLUSION: Severe lower GI bleeding due to diverticulosis can usually be resolved with conservative treatment although the percentage of bleeding recurrence is high. Early endoscopy is not as important as in the remaining causes of severe lower GI bleeding.

High risk of malignancy in familial Barrett's esophagus: presentation of one family.

Barrett's esophagus is an acquired condition fundamentally related to the presence of severe and prolonged pathologic acid and biliary gastro-esophageal reflux. However, genetic factors may also play a role in some cases. The aim of this study is to present 3 generations of a Spanish family with the largest number of members so far reported with Barrett's esophagus or esophageal adenocarcinoma. Of the 24 members of this family studied over 3 generations, 6 patients developed esophageal adenocarcinoma, 4 Barrett's esophagus, 6 clinical symptoms of gastro-esophageal reflux disease without Barrett's esophagus, and 8 were asymptomatic. In conclusion, patients with familial Barrett's esophagus get the disease more severely with a high rate of malignancy and, therefore, the endoscopic surveillance should be closer than in cases of nonfamilial Barrett's esophagus.

Very long-term objective evaluation of heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia.

OBJECTIVE: To present the objectively assessed very long-term results of a prospective study of 149 patients with achalasia of the cardia who underwent Heller myotomy and posterior partial fundoplication. SUMMARY BACKGROUND DATA: Very few studies evaluate objectively the very long-term results to analyze whether the effectiveness of Heller myotomy is maintained with the passing of time. METHODS: The study group consisted of 149 patients who underwent a Heller myotomy plus a posterior partial fundoplication through a laparotomy. The median follow-up was 6 years (range, 1-27 years). Follow-up period was over 10 years in 53 patients and over 15 in 36. Clinical, radiologic, endoscopic, manometric, and pHmetric evaluations were performed postoperatively. RESULTS: Satisfactory results were higher than 90% up to 5 years. From that time on results gradually decreased to a 75% rate after 15 years (P < 0.001) due to either heartburn or dysphagia. Both the esophageal diameter and the mean resting pressure of the lower esophageal sphincter decreased postoperatively with no significant changes during follow-up. Esophagitis appeared in 11% of the patients (47% of them being asymptomatic) and 24-hour pH monitoring showed pathologic rates of acid reflux in 14% of patients, 58% of them being asymptomatic. Both esophagitis and pathologic rates of reflux appeared in >40% of the patients late in the follow-up. CONCLUSION: Results after Heller myotomy plus posterior partial fundoplication deteriorate with time, although we achieved a 75% of satisfactory results after >15 years of follow-up. Our study highlights the importance of life long follow-up and the objective assessment of the results.

[Surgical treatment of high-grade dysplasia in Barrett's esophagus]. / Tratamiento quirúrgico de la displasia de alto grado en el esófago de Barrett.

INTRODUCTION: Barrett's esophagus undergoes malignant transformation in 0.5-1% of patients per year following the sequence of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. The aim of the present study was to present our experience in the surgical treatment of Barrett's esophagus with high-grade dysplasia. PATIENTS AND METHOD: Of a group of 128 patients with a diagnosis of Barrett's esophagus, 8 (6.2%) developed high-grade dysplasia during a median follow-up of 7 years (2-25). A further 5 patients with high-grade dysplaing out side the study were referred for evaluation and surgical treatment. Eight patients were under medical treatment with omeprazole (40 mg daily) while the remaining 5 patients had undergone open Nissen fundoplication, with a diagnosis of high-grade dysplasia at a median of 5 years (1-16) after treatment initiation. After confirmation of the diagnosis by a second pathologist and tumoral staging, transthoracic esophagectomy with anastomosis at the apex of the thorax was performed in all patients. RESULTS: Postoperative mortality was nil. Morbidity was 36% (5 patients). Definitive histological analysis of the surgical specimen revealed high-grade dysplasia in 7 patients (54%) and adenocarcinoma in 6 (46%). All patients remain alive after a median follow-up of 4.7 years (1-14). CONCLUSIONS: In patients with Barrett's esophagus with high-grade dysplasia, the best therapeutic option is surgical resection, which can be performed with nil mortality in experienced centers. In almost half of surgical patients, the surgical specimen shows adenocarcinoma. Five-year survival is higher than 90%.

Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality.

BACKGROUND: Many factors can cause morbidity and mortality in patients with severe acute lower gastrointestinal bleeding (LGIB). The objectives of this study are to analyze three aspects related to severe acute LGIB: (1) indications and prognostic factors for urgent surgery, (2) risk factors for morbidity and mortality, and (3) relapse rates. PATIENTS AND METHODS: A retrospective cohort was collected between 1985 and 2002 in a tertiary referral center. One hundred seventy-one patients with severe acute LGIB were reviewed (LGIB is defined as frank rectal bleeding either with a hematocrit decrease >/=10 points or when a transfusion of at least three units of concentrated red blood cells is needed). The main outcome measures are: (1) indications for urgent surgery and results, (2) morbidity and mortality, and (3) relapse. RESULTS: There were 158 (92%) stable patients, and in 61% of these, the bleeding was identified via colonoscopy. Bleeding was identified using urgent colonoscopy in a higher percentage of patients compared to delayed colonoscopy (68% versus 14%; p < 0.001). Urgent surgery was indicated in 24 (14%) patients, and the approach was peri-anal in 5 (21%) patients and abdominal in the rest. Local intestinal resection was performed on the 15 patients in which bleeding was identified, whereas a subtotal colectomy was performed on the remaining 4 patients. The presence of hypotension (p = 0.001; 35 versus 10%) and etiology of LGIB (p < 0.001) are prognostic factors of urgent surgery. Morbidity was 6.4%, and mortality was 4.7%. The only morbidity or mortality risk factors detected were the presence of associated comorbidities (p = 0.008) and the need for urgent surgery (p = 0.002). The most frequent etiology was diverticulosis (25%). After a mean follow-up of 132 +/- 75 months, bleeding relapsed in 30% of patients. CONCLUSIONS: It is difficult to predict which patients are going to need urgent surgery in severe acute LGIB; only the presence of hypotension on arrival at the emergency ward would lead us to suspect a negative outcome for the hemorrhage. In severe acute LGIB, morbidity and mortality is high, and this is mainly due to the high level of associated comorbidity and the need for urgent surgery. It is necessary for strict hemodynamic monitoring of the patients at risk if we want to improve outcomes. The bleeding relapse rate is high in LGIB, although generally, it is not severe.