Targeted intervention to achieve waste reduction in gastrointestinal endoscopy.

OBJECTIVE: Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role. DESIGN: In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO2e) and 1 kg of RMW to 3kgCO2e was assumed. Paired samples t-tests for comparisons. RESULTS: From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO2e by 31.6% (138.8kgCO2e) was found (mean kgCO2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel. CONCLUSION: In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

Autoimmune hepatitis as a complication of common variable immunodeficiency.

In common variable immunodeficiency (CVID) there is a deregulation of the immune system, which frequently leads to an increased risk of infections, but also to autoimmunity phenomena. Autoimmune hepatitis may develop at any time of CVID's evolution, but it is difficult to diagnose due to the frequent absence of autoantibodies and low levels of IgG. Early diagnosis is important because targeted treatment may allow disease improvement. We present a case of autoimmune hepatitis in a patient with CVID.

Comparison of the prognostic value of Chronic Liver Failure Consortium scores and traditional models for predicting mortality in patients with cirrhosis.

BACKGROUND AND AIM: Recently, the European Association for the Study of the Liver - Chronic Liver Failure (CLIF) Consortium defined two new prognostic scores, according to the presence or absence of acute-on-chronic liver failure (ACLF): the CLIF Consortium ACLF score (CLIF-C ACLFs) and the CLIF-C Acute Decompensation score (CLIF-C ADs). We sought to compare their accuracy in predicting 30- and 90-day mortality with some of the existing models: Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD), MELD-Na, integrated MELD (iMELD), MELD to serum sodium ratio index (MESO), Refit MELD and Refit MELD-Na. METHODS: Retrospective cohort study that evaluated all admissions due to decompensated cirrhosis in 2 centers between 2011 and 2014. At admission each score was assessed, and the discrimination ability was compared by measuring the area under the ROC curve (AUROC). RESULTS: A total of 779 hospitalizations were evaluated. Two hundred and twenty-two patients met criteria for ACLF (25.9%). The 30- and 90-day mortality were respectively 17.7 and 37.3%. CLIF-C ACLFs presented an AUROC for predicting 30- and 90-day mortality of 0.684 (95% CI: 0.599-0.770) and 0.666 (95% CI: 0.588-0.744) respectively. No statistically significant differences were found when compared to traditional models. For patients without ACLF, CLIF-C ADs had an AUROC for predicting 30- and 90-day mortality of 0.689 (95% CI: 0.614-0.763) and 0.672 (95% CI: 0.624-0.720) respectively. When compared to other scores, it was only statistically superior to MELD for predicting 30-day mortality (p=0.0296). CONCLUSIONS: The new CLIF-C scores were not statistically superior to the traditional models, with the exception of CLIF-C ADs for predicting 30-day mortality.

Curative criteria for endoscopic treatment of gastric cancer.

Endoscopic treatment, particularly endoscopic submucosal dissection, has become the primary treatment for early gastric cancer. A comprehensive optical assessment, including white light endoscopy, image-enhanced endoscopy, and magnification, are the cornerstones for clinical staging and determining the resectability of lesions. This paper discusses factors that influence the indication for endoscopic resection and the likelihood of achieving a curative resection. Our review stresses the critical need for interpreting the histopathological report in accordance with clinical guidelines and the imperative of tailoring decisions based on the patients' and lesions' characteristics and preferences. Moreover, we offer guidance on managing complex scenarios, such as those involving non-curative resection. Finally, we identify future research avenues, including the role of artificial intelligence in estimating the depth of invasion and the urgent need to refine predictive scores for lymph node metastasis and metachronous lesions.

Pain and Swelling after Percutaneous Endoscopic Gastrostomy Removal: An Unexpected Evolution.

Gastrostomy site metastization is considered an uncommon complication of percutaneous endoscopic gastrostomy (PEG) placement in patients with head and neck tumours, but it is important to consider this possibility when evaluating gastrostomy-related symptoms. The authors present the case of a 40-year-old male with excessive alcohol consumption and active smoking, diagnosed with a stage IV oropharyngeal squamous cell carcinoma. The patient developed a paraneoplastic demyelinating motor polyneuropathy that, associated with tumour mass effect, caused dysphagia with need for nasogastric tube feeding. Treatment with radiotherapy and then chemoradiotherapy was administered and a PEG was placed with the pull method. Cancer remission and resolution of polyneuropathy was achieved, so PEG was removed. Two weeks later, the patient presented with pain and swelling at the gastrostomy site suggesting a local abscess, with improvement after drainage and antibiotic therapy. After 1 month, there was a tumour mass at the gastrostomy site and an oropharyngeal cancer metastasis was diagnosed. The patient underwent surgical excision of abdominal wall metastasis and abdominal disease was controlled. Nevertheless, there was subsequent oropharyngeal neoplasia recurrence and the patient died 6 months later. This case raises the discussion about gastrostomy placement methods that could avoid gastrostomy site metastization, the possible differential diagnosis, and diagnostic workout. Surgical resection may allow metastatic disease control, but by primary disease evolution greatly affects prognosis.

A metastização do local de gastrostomia é considerada uma complicação incomum da colocação de gastrostomia endoscópica percutânea (PEG) em pacientes com tumores da cabeça e pescoço, no entanto é importante considerar essa possibilidade ao avaliar sintomas relacionados com a gastrostomia. Os autores apresentam o caso de um homem de 40 anos com consumo excessivo de álcool e tabagismo ativo, diagnosticado com carcinoma espinocelular orofaríngeo no estádio IV. O paciente desenvolveu uma polineuropatia motora desmielinizante paraneoplásica que, associada ao efeito de massa tumoral, causou disfagia com necessidade de alimentação por sonda nasogástrica. Foi administrado tratamento com radioterapia, seguido de quimioradioterapia e foi colocada PEG com o método de pull. Foi obtida remissão tumoral e resolução da polineuropatia, sendo removida a PEG. Duas semanas depois, o paciente apresentou dor e edema no local da gastrostomia, sugerindo um abscesso local, com melhoria após drenagem e antibioterapia. Um mês depois o local da gastrostomia apresentava uma massa tumoral e foi diagnosticada uma metástase do cancro orofaríngeo. O paciente foi submetido a excisão cirúrgica da metástase da parede abdominal, com controlo da doença abdominal. Contudo, houve recorrência neoplásica orofaríngea subsequente e o paciente faleceu 6 meses depois. Este caso levanta a discussão sobre os métodos de realização de gastrostomia que poderiam evitar a metastização do local de gastrostomia, possíveis diagnósticos diferenciais e marcha diagnóstica. A ressecção cirúrgica pode permitir o controle da doença metastática, no entanto o prognóstico é muito afetado pela evolução da doença primária.

Hepatitis autoinmune como complicación de inmunodeficiencia común variable / Autoimmune hepatitis as a complication of common variable immunodeficiency

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Comparison of the prognostic value of Chronic Liver Failure Consortium scores and traditional models for predicting mortality in patients with cirrhosis / Comparación del valor pronóstico de los modelos del Chronic Liver Failure Consortium y modelos tradicionales para predecir la mortalidad en pacientes con cirrosis

BACKGROUND AND AIM: Recently, the European Association for the Study of the Liver - Chronic Liver Failure (CLIF) Consortium defined two new prognostic scores, according to the presence or absence of acute-on-chronic liver failure (ACLF): the CLIF Consortium ACLF score (CLIF-C ACLFs) and the CLIF-C Acute Decompensation score (CLIF-C ADs). We sought to compare their accuracy in predicting 30- and 90-day mortality with some of the existing models: Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD), MELD-Na, integrated MELD (iMELD), MELD to serum sodium ratio index (MESO), Refit MELD and Refit MELD-Na. METHODS: Retrospective cohort study that evaluated all admissions due to decompensated cirrhosis in 2 centers between 2011 and 2014. At admission each score was assessed, and the discrimination ability was compared by measuring the area under the ROC curve (AUROC). RESULTS: A total of 779 hospitalizations were evaluated. Two hundred and twenty-two patients met criteria for ACLF (25.9%). The 30- and 90-day mortality were respectively 17.7 and 37.3%. CLIF-C ACLFs presented an AUROC for predicting 30- and 90-day mortality of 0.684 (95% CI: 0.599-0.770) and 0.666 (95% CI: 0.588-0.744) respectively. No statistically significant differences were found when compared to traditional models. For patients without ACLF, CLIF-C ADs had an AUROC for predicting 30- and 90-day mortality of 0.689 (95% CI: 0.614-0.763) and 0.672 (95% CI: 0.624-0.720) respectively. When compared to other scores, it was only statistically superior to MELD for predicting 30-day mortality (p = 0.0296). CONCLUSIONS: The new CLIF-C scores were not statistically superior to the traditional models, with the exception of CLIF-C ADs for predicting 30-day mortality

ANTECEDENTES Y OBJETIVOS: Recientemente The European Association for the Study of the Liver-Chronic Liver Failure Consortium estableció 2 nuevos sistemas pronósticos considerando la existencia o no de Acute-on-chronic liver failure (ACLF): el score CLIF Consortium ACLF (CLIF-C ACLF) y el CLIF-C Acute Descompensation score (CLIF-C ADs). Pretendimos comparar su fiabilidad para predecir la mortalidad a los 30 y 90 días con la de algunos de los sistemas de puntuación existentes: Child-Turcotte-Pugh, Model for End-Stage Liver Disease (MELD), MELD-Na, integrated MELD, MELD to serum sodium ratio index, Refit MELD y Refit MELD-Na. MÉTODOS: Estudio retrospectivo de cohortes incluyendo todos los pacientes con cirrosis ingresados en 2 centros entre 2011 y 2014 por descompensación de su enfermedad. En el momento de la admisión cada puntación fue calculada y fueron comparadas las áreas bajo la curva ROC (AUROC) para evaluar su capacidad de discriminación respecto a la mortalidad a los 30 y 90 días. RESULTADOS: Fueron analizadas un total de 779 hospitalizaciones. Doscientos y veintidós pacientes cumplían criterios para ACLF (25,9%). La mortalidad a los 30 y 90 días fue de 17,7% y 37,3% respectivamente. En los pacientes con ACLF el AUROC del CLIF-C ACLF para predecir la mortalidad a los 30 y 90 días fue 0,684 (IC 95%: 0,599-0,770) y 0,666 (IC 95%: 0,588-0,744) respectivamente. No se encontraron diferencias significativas con los modelos tradicionales. En los pacientes sin ACLF, el AUROC del CLIF-C ADs para predecir la mortalidad a los 30 y 90 días fue 0,689 (IC 95%: 0,614-0,763) y 0,672 (IC 95%: 0,624-0,720) respectivamente. Únicamente fue estadísticamente superior al MELD para predecir la mortalidad a los 30 días (p = 0,0296). CONCLUSIONES: Los nuevos modelos CLIF-C no fueron superiores estadísticamente a los modelos tradicionales, con la excepción del CLIF-C ADs en la predicción de la mortalidad a los 30 días

Enamel microabrasion as treatment of dental fluorosis in child - case report / Microabrasão do esmalte como tratamento da fluorose dentária em criança – relato de caso

Enamel microabrasion is an efficient method for treating fluorosis since it is a controlled non-invasive technique to remove surface stains promoting a minimum wear of the tooth structure. This paper aimed to report a case of stains removal on the upper incisors using the microabrasion technique. After detailed history taking, clinical examination and confirmation of the diagnosis of dental fluorosis, it was used a paste at 1:1 proportion of 37% phosphoric acid and pumice stone on the surface of the affected teeth. This technique can be used to re¬cover aesthetics of permanent teeth in children presenting opaque patches suggestive of fluorosis, being well accepted by the patient for being a conservative technique, easy to perform and fast, while presenting immediate aesthetic result that motivates the patient immediately.

Para o tratamento da fluorose dentária, a microabrasão do esmalte é um eficiente método para remover manchas superficiais, por consistir em uma técnica controlada e não invasiva promovendo uma quantidade mínima de desgaste da estrutura dentária. Este trabalho tem como objetivo relatar um caso clínico de remoção dessas manchas nos incisivos permanentes superiores utilizando a técnica de microabrasão. Após anamnese e exame clínico minucioso e confirmação do diagnóstico de fluorose dentária, foi empregada uma pasta de ácido fosfórico a 37% e pedra pomes numa proporção de 1:1 com ponta abrasiva na superfície dos dentes afetados. Esta técnica de microabrasão pode ser utilizada para a recuperação estética de dentes permanentes em crianças que apresentam manchas opacas sugestivas de fluorose, sendo bem aceita pelo paciente infantil por ser uma técnica conservadora, de fácil execução e rápida, além de apresentar um resultado estético imediato que motiva o paciente.