Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT).

BACKGROUND: There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types. METHODS: We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints. RESULTS: Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year. CONCLUSION: Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.

Ischemic stroke: Process perspective, clinical and profile characteristics, and external factors.

OBJECTIVE: To describe a method of analysis for understanding the health care process, enriched with information on the clinical and profile characteristics of the patients. To apply the proposed technique to analyze an ischemic stroke dataset. MATERIALS AND METHODS: We analyzed 4,830 electronic health records (EHRs) from patients with ischemic stroke (2010-2017), containing information about events realized during treatment and clinical and profile information of the patients. The proposed method combined process mining techniques with data analysis, grouping the data by primary care units (PCU - units responsible for the primary care of patients residing in a geographical area). RESULTS: A novel method, named process, data, and management (PDM) analysis method was used for ischemic stroke data and it provided the following outcomes: health care process for patients with ischemic stroke with time statistics; analysis of potential factors for slow hospital admission indicating an increase in the time to hospital admission of 3.4 h (mean value) for patients with an origin at the urgent care center (UCC) - 30% of patients; analysis of PCUs with distinct secondary stroke rates indicating that the social class of patients is the main difference between them; and the visualization of risk factors (before the stroke) by the PCU to inform the health manager about the potential of prevention. DISCUSSION: PDM analysis describes a step-by-step method for combining process analysis with data analysis considering a management focus. The results obtained on the stroke context can support the definition of more refined action plans by the health manager, improving the stroke health care process and preventing new events. CONCLUSION: When a patient is diagnosed with ischemic stroke, immediate treatment is needed. Moreover, it is possible to prevent new events to some degree by monitoring and treating risk factors. PDM analysis provides an overview of the health care process with time, combining elements that affect the treatment flow and factors, which can indicate a potential for preventing new events. We also can apply PDM analysis in different scenarios, when there is information about activities from treatment flow and other characteristics related to the treatment or the prevention of the analyzed disease. The management focus of the results aids in the formulation of service policies, action plans, and resource allocation.

Trends of Stroke Incidence from 1995 to 2013 in Joinville, Brazil.

BACKGROUND: Temporal trends on the incidence of stroke and its subtypes could help assess on-going public health policies and point to further targets for action among middle- and low-income countries, where the stroke burden is very high. This study aimed at evaluating longitudinal trends of stroke incidence in Joinville, Brazil. METHODS: We ascertained the incidence of all first-ever strokes occurred in 1995, 2005-2006 and 2012-2013, which were extracted from Joinville Stroke Registry, a prospective epidemiological data bank, launched in 1995. RESULTS: From 1995 to 2013, the age-adjusted incidence of all strokes decreased 37% (95% CI 32-42). From 2005 to 2013, the haemorrhagic stroke (HS) incidence decreased 60% (95% CI 13-86), ischemic stroke (IS) incidence decreased 15% (95% CI 1-28), and subarachnoid haemorrhage incidence remained stable. The proportion of IS and HS patients with regularly treated hypertension increased by 60% (p = 0.01) and 33% (p = 0.01), respectively. The proportion of IS and HS patients that quit smoking increased 8% (p = 0.03) and 17% (p = 0.03), respectively. CONCLUSIONS: Stroke incidence has been decreasing in Joinville over the last 18 years, more so for HS than IS. Better control of hypertension and tobacco use might explain these findings.

Transanal ileoproctostomy is feasible in human cadavers.

AIM: An ileorectal bypass performed entirely through a transanal route has recently been described in an animal model. The present study aimed to demonstrate its technical feasibility in four human cadavers. METHOD: A transanal endoscopic microsurgery (TEM) device and endoscopic instruments were used. The principal steps of the procedure included insertion of the TEM device, rectostomy above the peritoneal reflection, peritoneoscopy using a standard gastroscope and delivery of the small bowel through the proctostomy to perform an anastomosis. RESULTS: The procedure was successfully completed using transanal access in all cases. The mean procedure time was 90 min. The bypass was patent, and the anastomosis between the intraperitoneal rectum and the terminal ileum was leakproof. CONCLUSION: Transanal ileoproctostomy is technically feasible in human cadavers. The procedure may become an alternative to stoma formation in selected patients with colonic obstruction.

Transient ischemic attack incidence in joinville, Brazil, 2010: a population-based study.

BACKGROUND AND PURPOSE: There are scarce data on transient ischemic attack incidence in low- and middle-income countries. We aimed to measure transient ischemic attack incidence and the distribution of the ABCD2 risk score in Joinville, Brazil. METHODS: In 2009 to 2010, using a multiple overlapping sources, we ascertained all first ever probable and definite transient ischemic attacks. RESULTS: We recorded 74 definite and probable transient ischemic attacks. The crude incidence was 15 (12-18) per 100 000 population. Age adjusted to European population the incidence was 28 (22-35). One fourth was in the higher risk of stroke by the ABCD2 scale. CONCLUSIONS: The transient ischemic attack incidence in Joinville, Brazil, is lower than other well-designed studies. New studies could clarify whether the measured rates were due to underascertainment or reflect a truly low incidence.

The Brazilian Family Health Program and secondary stroke and myocardial infarction prevention: a 6-year cohort study.

OBJECTIVES: We compared the incidence of recurrent or fatal cardiovascular disease in patients using Brazil's government-run Family Health Program (FHP) with those using non-FHP models of care. METHODS: From 2005 to 2010, we followed outpatients discharged from city public hospitals after a first ever stroke for stroke recurrence and myocardial infarction, using data from all city hospitals, death certificates, and outpatient monitoring in state-run and private units. RESULTS: In the follow-up period, 103 patients in the FHP units and 138 in the non-FHP units had exclusively state-run care. Stroke or myocardial infarction occurred in 30.1% of patients in the FHP group and 36.2% of patients in non-FHP care (rate ratio [RR] = 0.85; 95% confidence interval [CI] = 0.61, 1.18; P = .39); 37.9% of patients in FHP care and 54.3% in non-FHP care (RR = 0.68; 95% CI = 0.50, 0.92; P = .01) died. FHP use was associated with lower hazard of death from all causes (hazard ratio [HR] = 0.58; P = .005) after adjusting for age and stroke severity. The absolute risk reduction for death by all causes was 16.4%. CONCLUSIONS: FHP care is more effective than is non-FHP care at preventing death from secondary stroke and myocardial infarction.

Age dependent impact of estimated glomerular filtration rate on long-term survival after ischaemic stroke.

AIMS: Low estimated glomerular filtration rate (eGFR) is associated with high mortality after stroke. However, ageing can influence eGFR directly and limit this burden impact. We investigated if low eGFR can be a predictor of death in different age groups after ischaemic stroke. METHODS: We evaluated and followed for 22 ± 14 months 871 unselected consecutive survivor patients more than 30 days after ischaemic stroke (55% men, mean age of 66 ± 13 years) recruited in a prospective Brazilian cohort study from March 2005 to December 2007. Traditional cardiovascular risk factors and eGFR by The Chronic Kidney Disease Epidemiology Collaboration formula were analyzed as predictors of mortality for the whole cohort population and stratified by age (younger or older than 65 years old) in a Cox proportional hazards regression model. RESULTS: There were 119 (14%) deaths during follow up. The mean eGFR was 74 ± 23 mL/min per 1.73 m(2). Three hundred and sixteen patients (36%) presented eGFR lower than 60 mL/min per 1.73 m(2). For the whole population, eGFR lower than 60 mL/min per 1.73 m(2) was independently associated with death after stroke in the multivariate analysis. When stratified by age groups, low eGFR was the single and independent predictor of death just for individuals younger than 65 years-old, as for older people just chronic atrial fibrillation, previous stroke and increase of age were associated with death. CONCLUSION: Low eGFR measured at the first day of hospital admission can be a simple and trustful predictor of death after ischaemic stroke in people younger than 65 years old.

Incidence, lethality, and post-stroke functional status in different Brazilian macro-regions: The SAMBA study (analysis of stroke in multiple Brazilian areas).

Background: Stroke is the second leading cause of death in Brazil. The social and financial burden of stroke is remarkable; however, the epidemiological profile remains poorly understood. Objective: The aim of this study was to report the incidence, lethality, and functional status at 30 and 90 days post-stroke in the cities of different Brazilian macro-regions. Methods: This is an observational, prospective, and population-based study, led in Canoas (South), Joinville (South, reference center), Sertãozinho (Southeast), and Sobral (Northeast) in Brazil. It was developed according to the three-step criteria recommended by the World Health Organization to conduct population-based studies on stroke. Using different sources, all hospitalized and ambulatory patients with stroke were identified and the same criteria were kept in all cities. All first events were included, regardless of sex, age, or type of stroke. Demographic and risk factor data were collected, followed by biochemical, electrocardiographic, and radiological test results. Functional status and lethality were obtained using the mRankin scale through telephonic interview (validated Brazilian version). Results: In 1 year, 932 stroke cases were registered (784 ischemic stroke, 105 hemorrhagic stroke, and 43 subarachnoid hemorrhage). The incidence rates per 100,000 inhabitants, adjusted for the world population, were 63 in Canoas, 106 in Joinville, 72 in Sertãozinho, and 96 in Sobral. The majority (70.8%) were followed for 90 days. Kaplan-Meier curves showed that 90-day survival was different among cities. Sobral, which has the lowest socioeconomic indexes, revealed the worst results in terms of lethality and functional status. Conclusion: This study expands the knowledge of stroke epidemiology in Brazil, a middle-income country with enormous socioeconomic and cultural diversity. The discrepancy observed regarding the impact of stroke in patients from Joinville and Sobral highlights the need to improve the strategic allocation of resources to meet the health priorities in each location.

Education level explains differences in stroke incidence among city districts in Joinville, Brazil: a three-year population-based study.

BACKGROUND: Current evidence suggests an inverse association between socioeconomic status and stroke incidence. Our aim was to measure the variation in incidence among different city districts (CD) and their association with socioeconomic variables. METHODS: We prospectively ascertained all possible stroke cases occurring in the city of Joinville during the period 2005-2007. We determined the incidence for each of the 38 CD, age-adjusted to the population of Joinville. By linear regression analysis, we correlated incidence data with mean years of education (MYE) and mean income per month (MIPM). RESULTS: Of the 1,734 stroke cases registered, 1,034 were first-ever strokes. In the study period, the crude incidence in Joinville was 69.5 per 100,000 (95% confidence interval, 65.3-73.9). The stroke incidence among CD ranged from 37.5 (22.2-64.6) to 151.0 per 100,000 (69.0-286.6). The stroke incidence was inversely correlated with years of education (r = -0.532; p < 0.001). MYE and MIPM were strongly related (R = 0.958), resulting in exclusion of MIPM by collinearity. CONCLUSIONS: Years of education can explain a wide incidence variation among CD. These results may be useful to guide the allocation of resources in primary prevention policies.

Report on a case of Rothmund-Thomson syndrome associated with esophageal stenosis.

Rothmund-Thomson syndrome (RTS) is a rare autosomal recessive genodermatosis. While its incidence is unknown, approximately 300 cases have been reported in the literature. The syndrome typically presents with a characteristic facial rash (poikiloderma), its diagnostic hallmark, and heterogeneous clinical features including congenital skeletal abnormalities, sparse hair distribution, juvenile cataracts, and a predisposition to osteosarcoma. Gastrointestinal symptoms, such as pyloric stenosis, anal atresia, annular pancreas, and rectovaginal fistula, have also been reported sporadically. This is a report describing a patient diagnosed with RTS referred to us because of dysphagia caused by esophageal stenosis. Long-term results of endoscopic dilation are also presented.

Prevalence of aphasia after stroke in a hospital population in southern Brazil: a retrospective cohort study.

Background: Aphasia negatively impacts quality of life. This is the first Brazilian study that investigates the prevalence of aphasia and its related factors, the results of which may underpin hospital and health service planning for this vulnerable population.Objective: To establish the prevalence of aphasia in patients after first-ever ischemic stroke (FEIS) and associated factors.Methods: This is a retrospective cohort study, based on a database held in Joinville, Brazil. All cases of FEIS admitted to one public hospital in Joinville in 2015 were selected. The diagnosis of aphasia was verified by neurologists through the language item of the National Institute of Health Stroke Scale (NIHSS).Results: Of the 350 patients with FEIS, 79 (22.6%) had aphasia. Patients with aphasia (PWA) were older, with a higher likelihood of dysarthria, more thrombolytic use, and greater stroke severity. PWA had higher mortality than patients without aphasia (24.1% versus 10.7%, p = .004) and longer hospitalization time (21.32 versus 17.46 days, p = .009). Higher NIHSS score was an independent predictor for the occurrence of aphasia on admission (OR 1.24, 95% CI 1.17-1.31, p < .001). Older age (OR 1.06, 95% CI 1.03-1.09, p < .001) and stroke severity by NIHSS (OR 1.19, 95% CI 1.12-1.25, p = <0.001) were independent predictors of death.Conclusions: PWA may need more health care during hospitalization, because of the severity of the stroke, and their frailty. Further studies are needed to assess the direct impact of aphasia on inpatients.

Improved Outcomes after Reperfusion Therapies for Ischemic Stroke: A "Real-world" Study in a Developing Country.

BACKGROUND: It is unknown if improvements in ischemic stroke (IS) outcomes reported after cerebral reperfusion therapies (CRT) in developed countries are also applicable to the "real world" scenario of low and middle-income countries. We aimed to measure the long-term outcomes of severe IS treated or not with CRT in Brazil. METHODS: Patients from a stroke center of a state-run hospital were included. We compared the survival probability and functional status at 3 and 12 months in patients with severe IS treated or not with CRT. From 2010 to 2011, we performed intravenous reperfusion when patients arrived within 4.5 h time-window (IVT group) and after 2011, mechanical thrombectomy (MT) combined or not with intravenous alteplase (IAT group). Those who arrived >4.5 h in 2010-2011 and >6 h in 2012-2017 did not undergo CRT (NCRT group). RESULTS: From 2010 to 2017, we registered 917 patients: 74% (677/917) in the NCRT group, 19% (178/917) in the IVT group and 7% (62/917) in the IAT group. Compared to the NCRT group, IVT patients had a 28% higher (HR: 0.72; 95% CI 0.53-0.96) 3-month adjusted probability of survival and risk of functional dependence was 19% lower (adjusted RR: 0.81; 95% CI 0.73-0.91). For those who underwent MT, the adjusted probability of survival was 59 % higher (HR: 0.41; 95% CI 0.21-0.77) and the risk of functional dependence was 21% lower (adjusted RR: 0.79; 95% CI 0.66-094). These outcomes remained significantly better throughout the first year. CONCLUSION: CRT led to better outcomes in patients with severe IS in Brazil.

Sex Differences in Disease Profiles, Management, and Outcomes Among People with Atrial Fibrillation After Ischemic Stroke: Aggregated and Individual Participant Data Meta-Analyses.

Objectives: To examine sex differences in disease profiles, management, and survival at 1 and 5 years after ischemic stroke (IS) among people with atrial fibrillation (AF). Methods: We performed a systematic literature search of reports of AF at IS onset according to sex. We undertook an individual participant data meta-analysis (IPDMA) of nine population-based stroke incidence studies conducted in Australasia, Europe, and South America (1993-2014). Poisson regression was used to estimate women:men mortality rate ratios (MRRs). Study-specific MRRs were combined using random effects meta-analysis. Results: In our meta-analysis based on aggregated data from 101 studies, the pooled AF prevalence was 23% (95% confidence interval [CI]: 22%-25%) in women and 17% (15%-18%) in men. Our IPDMA is of 1,862 IS-AF cases, with women (79.2 ± 9.1, years) being older than men (76.5 ± 9.5, years). Crude pooled mortality rate was greater for women than for men (1-year MRR 1.24; 1.01-1.51; 5-year 1.12; 1.03-1.22). However, the sex difference was greatly attenuated after accounting for age, prestroke function, and stroke severity (1-year 1.09; 0.97-1.22; 5-year 0.98; 0.84-1.16). Women were less likely to have anticoagulant prescription at discharge (odds ratio [OR] 0.94; 95% CI: 0.89-0.98) than men when pooling IPDMA and aggregated data. Conclusions: AF was more prevalent after IS among women than among men. Among IS-AF cases, women were less likely to receive anticoagulant agents at discharge; however, greater mortality rate in women was mostly attributable to prestroke factors. Further information needs to be collected in population-based studies to understand the reasons for lower treatment of AF in women.

Sex Differences in Severity of Stroke in the INSTRUCT Study: a Meta-Analysis of Individual Participant Data.

Background Women have worse outcomes after stroke than men, and this may be partly explained by stroke severity. We examined factors contributing to sex differences in severity of acute stroke assessed by the National Institutes of Health Stroke Scale. Methods and Results We pooled individual participant data with National Institutes of Health Stroke Scale assessment (N=6343) from 8 population-based stroke incidence studies (1996-2014), forming part of INSTRUCT (International Stroke Outcomes Study). Information on sociodemographics, stroke-related clinical factors, comorbidities, and pre-stroke function were obtained. Within each study, relative risk regression using log-binominal modeling was used to estimate the female:male relative risk ( RR ) of more severe stroke (National Institutes of Health Stroke Scale>7) stratified by stroke type (ischemic stroke and intracerebral hemorrhage). Study-specific unadjusted and adjusted RR s, controlling for confounding variables, were pooled using random-effects meta-analysis. National Institutes of Health Stroke Scale data were recorded in 5326 (96%) of 5570 cases with ischemic stroke and 773 (90%) of 855 participants with intracerebral hemorrhage. The pooled unadjusted female:male RR for severe ischemic stroke was 1.35 (95% CI 1.24-1.46). The sex difference in severity was attenuated after adjustment for age, pre-stroke dependency, and atrial fibrillation but remained statistically significant (pooled RR adjusted 1.20, 95% CI 1.10-1.30). There was no sex difference in severity for intracerebral hemorrhage ( RR crude 1.08, 95% CI 0.97-1.21; RR adjusted 1.08, 95% CI 0.96-1.20). Conclusions Although women presented with more severe ischemic stroke than men, much although not all of the difference was explained by pre-stroke factors. Sex differences could potentially be ameliorated by strategies to improve pre-stroke health in the elderly, the majority of whom are women. Further research on the potential biological origin of sex differences in stroke severity may also be warranted.

Gastrointestinal telangiectasia: a study by EGD, colonoscopy, and capsule endoscopy in 75 patients.

BACKGROUND: The distribution of lesions in the gastrointestinal tract in patients with sporadic telangiectasia is at present unknown. PATIENTS AND METHODS: 75 patients with sporadic telangiectasia underwent esophagogastroduodenoscopy (EGD), capsule endoscopy, and colonoscopy. Endoscopic diagnosis of telangiectasia and gastrointestinal bleeding were required for enrollment in the study. Hemorrhagic diathesis, co-morbidity, number of blood transfusions, and subsequent management were also noted. RESULTS: 35 of the patients presented with gastroduodenal vascular lesions, 51 with small-bowel lesions, and 28 with colonic lesions. 67 % of patients in whom EGD found telangiectasia also presented small-bowel vascular lesions at capsule endoscopy and 43 % colonic lesions at colonoscopy. 54 % percent of patients with positive colonoscopy also presented gastroduodenal lesions and 48 % small-bowel lesions. Patients with known duodenal lesions were more likely to have small-bowel lesions at capsule endoscopy (odds ratio [OR] 10.19, 95 % CI 2.1 - 49.33, P = 0.003). Patients with associated diseases, such as liver cirrhosis, chronic renal failure, or heart valvulopathy, presented more severe disease requiring blood transfusions (OR 6.37, 95 % CI 1.39 - 29.2, P = 0.015). The number of blood transfusions correlated with the number of sites affected ( R = 0.35, P = 0.002). The detection of new lesions at capsule endoscopy allowed new treatment in 46 % of patients. Mean follow-up was 18 months. CONCLUSIONS: Sporadic telangiectasia is a multifocal disease potentially involving the whole digestive tract. Patients with duodenal telangiectasia show a higher risk of jejunal or ileal lesions. Capsule endoscopy is a useful diagnostic tool for the detection of such small-bowel vascular lesions, indicating a more specific prognosis and treatment strategy.

Non-invasive optical method for real-time assessment of intracorneal riboflavin concentration and efficacy of corneal cross-linking.

Keratoconus is the primary cause of corneal transplantation in young adults worldwide. Riboflavin/UV-A corneal cross-linking may effectively halt the progression of keratoconus if an adequate amount of riboflavin enriches the corneal stroma and is photo-oxidated by UV-A light for generating additional cross-linking bonds between stromal proteins and strengthening the biomechanics of the weakened cornea. Here we reported an UV-A theranostic prototype device for performing corneal cross-linking with the ability to assess corneal intrastromal concentration of riboflavin and to estimate treatment efficacy in real time. Seventeen human donor corneas were treated according to the conventional riboflavin/UV-A corneal cross-linking protocol. Ten of these tissues were probed with atomic force microscopy in order to correlate the intrastromal riboflavin concentration recorded during treatment with the increase in elastic modulus of the anterior corneal stroma. The intrastromal riboflavin concentration and its consumption during UV-A irradiation of the cornea were highly significantly correlated (R = 0.79; P = .03) with the treatment-induced stromal stiffening effect. The present study showed an ophthalmic device that provided an innovative, non-invasive, real-time monitoring solution for estimating corneal cross-linking treatment efficacy on a personalized basis.

Five-year survival, disability, and recurrence after first-ever stroke in a middle-income country: A population-based study in Joinvile, Brazil.

Background Information about long-term outcomes after stroke in developing countries provided by population-based methodologies is scarce. Aim This study aimed to know outcomes five years after a first-ever stroke in Joinville, Brazil. Methods Data were extracted from the Joinville Stroke Registry about all patients who had strokes in Joinville in 2010 and were followed up to 2015. Stroke recurrence, Kaplan-Meier survival probabilities, functional outcomes, and causes of death were ascertained at 30 days, six months, one and five years. Results A total of 399 strokes were studied. The mean age was 64 (standard deviation 16) years. After five years, 52% (95% confidence interval: 47-57%) survived and 20% (95% confidence interval: 15-26%) of the survivors had modified Rankin scale scores >2. More than half of these patients were institutionalized in nursing or home care settings. The average risk of death per year was ≈7%. Survival rates were significantly lower for subarachnoid hemorrhage and primary intracerebral hemorrhage than for ischemic stroke. The five-year recurrence rate was 12% (95% confidence interval: 9-15%). The index stroke was the cause of death in three quarters of the patients. Conclusions The results showed that 68% of the patients with stroke were either dead or disabled five years after first-ever stroke. This percentage is similar to proportions of other recent cohorts from developed countries, despite the lower age of the patients in this study.

The Veneto Region's Barrett's Oesophagus Registry: aims, methods, preliminary results.

BACKGROUND: The natural history of Barrett's Oeosphagus is not completely clarified and Barrett's Oeosphagus Registries are considered useful tools to expand our knowledge on this disease. A Barrett's Oeosphagus Registry has been therefore established in the Veneto Region and neighbouring provinces. AIMS: The aims of the Registry are to assess the demographical, endoscopical and histological characteristics of Barrett's Oeosphagus patients; the prevalence of non-invasive neoplasia and Barrett's Adenocarcinoma and the timing and incidence of Barrett's Oeosphagus progression to malignancy. METHODS: An interdisciplinary committee of endoscopists, pathologists and information technology experts was established in 2004 to design a website-based Barrett's Oesophagus Registry for the Veneto Region and neighbouring north-eastern Italian provinces. Protocols for endoscopies and biopsies and standard reports were carefully defined. RESULTS: In the first 18 months, 397 patients with endoscopically visible and histologically proven Barrett's Oeosphagus were enrolled in the Registry; the median age of these patients was 66 years (male:female=3:1). Most patients (75%) had a Short Segment of Barrett's Oesophagus (3 cm). Long Segment of Barrett's Oesophagus patients were 5 years older than the Short Segment of Barrett's Oesophagus patients (p<0.05), suggesting a progression from Short Segment of Barrett's Oesophagus to Long Segment of Barrett's Oesophagus. Though no data are available on the incidence of non-invasive neoplasia or Barrett's Adenocarcinoma (i.e., progression to cancer at least 12 months after enrolment), the prevalence of neoplastic lesions (found within 12 months of enrolment) was 5% for Short Segment of Barrett's Oesophagus and 19% for Long Segment of Barrett's Oesophagus, indicating that a careful multiple-biopsy endoscopic protocol is needed, especially when Long Segment of Barrett's Oesophagus are suspected at endoscopy. The prevalence of Barrett's Adenocarcinoma among patients with non-invasive neoplasia was 1/17 cases of low-grade non-invasive neoplasia and 2/3 cases of high-grade non-invasive neoplasia, indicating that these patients require strict endoscopic and bioptic follow-up. CONCLUSION: A regional Barrett's Oeosphagus Registry is feasible at a relatively low cost and enables significant data to be collected in a relatively short time. The use of a standardised endoscopic nomenclature and report form, a strict biopsy protocol, a standard report for pathologists improves the quality of endoscopic and histological diagnoses.

Endoscopic treatment of bile duct complications after orthotopic liver transplantation.

AIM: To assess the indications and results of endoscopic retrograde cholangio-pancreatography (ERCP) in patients who have undergone ortotopic liver transplantation (OLT). METHODS: We reviewed data from 42 consecutive patients who underwent ERCP for biliary complications after OLT over an 8-year period, in particular recording indications and success of the treatment after a mean of 17 months follow-up. RESULTS: Cholangiograms performed in 33/42 patients (79%) displayed anastomotic strictures in 17 patients (52%), bile duct stones in 8 (24%), both bile duct stones and an anastomotic stricture in 2 (6%), papillary stenosis in 1 (3%), and anastomotic biliary leakage in 1 (3%). In contrast, the contrastogram was normal in four patients (12%). Stone extraction was completed in 9/10 patients (90%) with a mean of 1.2 sessions, while stricture dilation was achieved in 12/19 patients (63%) after a mean of 1.7 sessions, by stent positioning (n = 7), balloon dilation (n = 4), or Soehendra dilator (n = 1). Both biliary leakage and papillary stenosis were cured by ERCP. Only one procedure-related complication -- severe pancreatitis (2.4%) -- was observed and no mortality. CONCLUSION: ERCP is a safe and effective mode of management of bile duct complications after OLT. It should be attempted before a surgical approach. Better results are obtained for treatment of biliary stones than of anastomotic strictures.

[Levobupivacaine versus racemic bupivacaine for thoracic and upper lumbar epidural anesthesia-analgesia in children]. / Levobupivacaína versus bupivacaína racémica para anestesia/analgesia epidural toráicica y lumbar alta en niños.

OBJECTIVES: We compared levobupivacaine to bupivacaine for epidural analgesia for thoracic or upper abdominal surgery in children. Our working hypothesis was that at equivalent doses levobupivacaine and bupivacaine behave in the same way. MATERIAL AND METHODS: ASA 1-4 patients between the ages of 5 and 16 years were randomized to a levobupivacaine or a bupivacaine group. After general anesthesia was induced, we inserted a thoracic or upper lumbar epidural catheter and administered a dose of 0.25% bupivacaine or levobupivacaine (1 mgxkg(-1)) while maintaining general anesthesia. Analgesia was provided with an epidural infusion of 0.125% bupivacaine or levobupivacaine with fentanyl. Fentanyl was used as a perioperative rescue analgesic and metamizole magnesium as a postoperative rescue analgesic. The epidural infusion was reduced by 25% each day beginning on the second day. We analyzed hemodynamic and respiratory variables, rescue analgesia, time until extubation and discharge from the recovery unit, complications associated with the technique, adverse effects, and degree of comfort achieved. RESULTS: We studied 64 patients; 33 received levobupivacaine and 31 bupivacaine. Mean (SD) duration of recovery unit stay was significantly longer in the bupivacaine group (4.2 [0.99] days) than in the levobupivacaine group (35 [0.6] days; P<.05). Significantly more patients needed perioperative rescue analgesia in the levobupivacaine group (n=6 [18.18%]) than in the bupivacaine group (n=3 [9.67%]; P<.01). After 48 hours, the need for postoperative rescue analgesia was significantly lower with levobupivacaine (P<.01). Motor block was significantly greater with bupivacaine (P<05). Adverse effects and complications included 2 cases of persistent bradycardia and 1 case of dural puncture with no subsequent clinical manifestations. CONCLUSIONS: This experience with epidural anesthesia for thoracic and upper abdominal surgery showed levobupivacaine and racemic bupivacaine to have similar profiles. Levobupivacaine, which is less toxic, could be used to replace bupivacaine in children.