Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis.

Background and aim Guidelines recommend use of ligation and vasoactive drugs as first-line therapy and as grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB in patients with cirrhosis. Trials that included patients with hepatocellular carcinoma, use of portocaval shunts or esophageal resection, balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded. Results A total of 8382 publications were searched, of which 36 RCTs with 3593 patients were included. Ligation was associated with a significant improvement in bleeding control (relative risk [RR] 1.08; 95 % confidence interval [CI] 1.02 - 1.15) when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone (RR 1.17; 95 % CI 1.10 - 1.25). The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding (RR 2.21; 95 %CI 0.55 - 8.92) and in-hospital mortality (RR 1.97; 95 %CI 0.78 - 4.97). Other treatments did not generate meta-analysis. Conclusions This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend combined use of ligation with vasoactive drugs in treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.

Large Colorectal Lesions: Evaluation and Management.

In the last years, a distinctive interest has been raised on large polypoid and non-polypoid colorectal tumors, and specially on flat neoplastic lesions ≥20 mm tending to grow laterally, the so called laterally spreading tumors (LST). Real or virtual chromoendoscopy, endoscopic ultrasound or magnetic resonance should be considered for the estimation of submucosal invasion of these neoplasms. Lesions suitable for endoscopic resection are those confined to the mucosa or selected cases with submucosal invasion ≤1000 µm. Polypectomy or endoscopic mucosal resection remain a first-line therapy for large colorectal neoplasms, whereas endoscopic submucosal dissection in high-volume centers or surgery should be considered for large LSTs for which en bloc resection is mandatory.

Nos últimos anos houve um crescente interesse pelas lesões colorretais polipoides e não polipoides de grande tamanho, especialmente pelas lesões planas neoplásicas ≥20 mm que tendem a crescer lateralmente - as chamadas lesões de espraiamento lateral (LST). Para avaliar o acometimento submucoso dessas lesões, pode-se utilizar a cromoendoscopia real ou virtual, a ecoendoscopia e a ressonância magnética. A ressecção endoscópica está indicada em lesões restritas à mucosa ou em casos selecionados com invasão da submucosa ≤ 1000 µm. A polipectomia e a ressecção endoscópica de mucosa permanecem um tratamento de primeira escolha para lesões colorretais grandes, enquanto que as LSTs cuja ressecção em bloco é mandatória devem ser submetidas à dissecção submucosa endoscópica em centros com grande experiência na técnica ou à ressecção cirúrgica.

Aprendizagem Baseada em Problemas na Graduação Médica – Uma Revisão da Literatura Atual / Problem-Based Learning Undergraduate Courses in Medicine – A Review of the Current Literature

RESUMO A aprendizagem baseada em problemas (ABP) é uma técnica em que a transmissão do conhecimento se dá a partir de casos elaborados com base em casos reais, tendo como principal objetivo a busca da aprendizagem pelo próprio estudante. Este trabalho tem por finalidade revisar os artigos originais publicados nos últimos dois anos sobre o tema, na graduação médica. A maioria dos trabalhos revisados demonstrou bons resultados quando utilizada a ABP, principalmente no que diz respeito a pensamento crítico e habilidades técnicas. O uso concomitante de mais de uma técnica, porém, traz maiores benefícios na formação médica.

ABSTRACT Problem-based learning (PBL) is a technique whereby knowledge is transmitted through cases based on real life situations, aimed at self-motivated learning by the student. This study aims to review original articles published in the last two years on the subject in relation to medical education. It was observed that most of the studies reviewed showed good results when PBL was used, especially with regard to critical thinking and technical skills. The concomitant use of more than one method, however, brings benefits to medical training.