Simultaneous Gastric and Colonic Metastasis of Breast Cancer.

Although breast cancer (BC) is the most common malignancy in women, metastasization to the gastrointestinal tract is rare. We present a 59-year-old woman with simultaneous gastric and colonic metastasis of invasive lobular breast carcinoma. She had been diagnosed with BC and underwent surgery and systemic therapy. Two years later, an increase in tumor markers motivated investigation, including upper and lower gastrointestinal endoscopy, which identified gastric ulcers and mucosal irregularity in the cecum. Histopathological analysis was compatible with gastric and colonic metastases from BC. We highlight the importance of biopsying every endoscopically visible lesion in patients with BC history.

Primary Diffuse Large B-Cell Lymphoma of the Rectum in a Non-Immunosuppressed Patient with Ulcerative Colitis.

Introduction: The incidence of primary colorectal lymphoma in the gastrointestinal tract is very low, the rectum being infrequently affected. The development of this entity in inflammatory bowel disease patients usually occurs in a context of immunosuppression-based therapy, with only a few case reports describing its development in patients presenting no known risk factors. Moreover, the clinical presentation of primary colorectal lymphomas may be difficult to distinguish from an acute flare of ulcerative colitis (UC). Case Presentation: We present a case of non-Hodgkin lymphoma of the rectum in a 42-year-old male with a 7-year history of UC and no previous exposure to immunomodulatory agents. He presented with a history of mucous diarrhoea, tenesmus, proctalgia and weight loss, refractory to optimized therapy. A lower gastrointestinal endoscopy was performed revealing a circumferential ulcerated lesion of the rectum, from which histopathological analysis established the diagnosis of a non-Hodgkin diffuse large B-cell lymphoma (DLBCL). Discussion/Conclusion: The present case suggests the existence of alternative mechanisms for the development of DLBCL in UC patients. The clinical presentation mimicking an acute flare of UC posed a diagnostic challenge, highlighting the complexity behind the management of UC patients.

Introdução: O linfoma não Hodgkin (LNH) difuso de grandes células B (DGCB) colorretal primário é uma entidade rara, estando a sua associação com a colite ulcerosa (CU) relacionada com a exposição a imunomoduladores. Apresentamos uma forma particularmente rara de LN-HDGCB primário, com atingimento do reto em doente com proctite ulcerosa sem história de imunossupressores, cuja apresentação simula agudização da CU. Descrição do caso clínico: Homem de 42 anos, com diagnóstico de proctite ulcerosa desde 2014, e sem história de terapêutica imunossupressora. Inicia quadro de diarreia com muco, proctalgia intensa, tenesmo e perda ponderal (10% em 2 meses), sem melhoria após otimização da terapêutica. Realiza colonoscopia que revela lesão ulcerada e circunferencial a nível do reto, condicionando estenose luminal, cujas biopsias revelaram LNHDGCB. Discussão/Conclusão: O presente caso sugere a existência de mecanismos fisiopatológicos alternativos à terapêutica imunossupressora para o desenvolvimento de LNH em doentes com CU. A apresentação clínica sugestiva de agudização da CU, constituiu um verdadeiro desafio diagnóstico, fazendo realçar a complexidade da abordagem destes doentes.

Task Force for a rapid response to an outbreak of severe acute hepatitis of unknown aetiology in children in Portugal in 2022.

On 5 April 2022, the United Kingdom reported an increase of cases of severe acute hepatitis of unknown aetiology in children, several needing hospitalisation and some required liver transplant or died. Thereafter, 35 countries reported probable cases, almost half of them in Europe. Facing the alert, on 28 April, Portugal created a multidisciplinary Task Force (TF) for rapid detection of probable cases and response. The experts of the TF came from various disciplines: clinicians, laboratory experts, epidemiologists, public health experts and national and international communication. Moreover, Portugal adopted the European Centre for Disease Prevention and Control (ECDC) and the World Health Organization (WHO) case definition and recommendations. By 31 December 2022, 28 probable cases of severe acute hepatitis of unknown aetiology were reported: 16 male and 17 aged under 2 years. Of these cases, 23 were hospitalised but none required liver transplant or died. Adenovirus was detected from nine of 26 tested cases. No association was observed between adenovirus infection and hospital admission after adjusting for age, sex and region in a binomial regression model. The TF in Portugal may have contributed to increase awareness among clinicians, enabling early detection and prompt management of the outbreak.

Translation, Cultural Adaptation and Validation of "PROMIS GI - Disrupted Swallowing" Scale for the Portuguese Language.

INTRODUCTION: Dysphagia is a prevalent condition (20%), and occurs more frequently in women and in older people. It negatively impacts innumerous aspects of patient's personal and professional lives. Patient-reported outcomes allow patients to directly quantify their experience regarding dysphagia and evaluate its true impact on quality of life. Among the scales available, Patient-Reported Outcomes Measurement Information System Gastrointestinal (PROMIS GI) Disrupted Swallowing stands out because it is a robust instrument that can be applied regardless of the type and etiology of dysphagia. The aim of this study was to translate, culturally adapt and validate PROMIS GI Disrupted Swallowing scale for the Portuguese-speaking population. MATERIAL AND METHODS: Firstly, the seven items of the scale were translated and transculturally reviewed following the systematic method proposed by the Functional Assessment of Chronic Illness Therapy (FACIT). Afterwards, the pre-test version of the questionnaire was administered to a convenience sample (n = 6) for semantic evaluation, with the aim of detection and subsequent correction of possible problems in the translation. The final translated and certified version of the scale was administered to 200 voluntary adult participants (n = 123 healthy; n = 77 dysphagia) in Portugal, for evaluation of reliability and validity. RESULTS: The Portuguese version of PROMIS GI Disrupted Swallowing presented acceptable internal consistency (coefficient of Cronbach's α of 0.919) and adequate test-retest reliability (intraclass correlation coefficient of 0.941). The translated version of the scale revealed a strong correlation with both Eckardt score (p < 0.001; ρ = 0.782) and the quality-of-life questionnaire EuroQol-5D (p < 0.001; ρ = -0.551), demonstrating evidence of convergent validity. CONCLUSION: The Portuguese version of PROMIS GI Disrupted Swallowing scale presented conceptual, semantic, cultural and measurement equivalence relatively to the original items. The results attained demonstrated that the translation of this scale to Portuguese is reliable and valid for use both in clinical practice and for research purposes.

Endoscopic sleeve gastroplasty: early results of a minimally invasive procedure in patients with obesity.

OBJECTIVES: We aimed to analyze the efficacy and safety of endoscopic sleeve gastroplasty at 3 months as well as to determine factors influencing post-procedural weight loss. METHODS: Seventy-three patients with obesity classes I, II and III (BMI 31.1-46.6 kg/m2) underwent ESG between September 2021 and April 2022 at a tertiary care hospital using Overstitch (Apollo Endosurgery, Austin, TX). ESG's efficacy and safety was evaluated at 1 and 3 months post-procedure with regard to excess weight loss (EWL) and total weight loss (TWL). Categorical variables were expressed as percentages and compared with chi-square test while continuous variables were expressed as mean ± standard deviation and compared with paired t test and analysis of variance (ANOVA) as applicable. Pearson's correlation was used to determine association between factors at baseline and weight loss. RESULTS: Mean age was 49.2 ± 9.7 years with 61 (83.6%) patients being female. Mean initial weight was 105.7 ± 15.7 kg, and mean BMI was 38.6 ± 3.5 kg/m2. Median hospitalization was 2.0 ± 1.8 days with 62 (84.9%) patients discharged after 24 h. One patient had accidental suturing of the stomach to the abdominal wall and diaphragm which was managed laparoscopically. Mean %EWL was 25.4 ± 7.1 and 36.3 ± 11.4, and %TBWL was 11.2 ± 2.6 and 15.8 ± 4.2 at 1 and 3 months, respectively. Significant excess weight loss at 3 months was only observed in patients with BMI < 40 kg/m2 (p = 0.001). CONCLUSIONS: ESG is safe and effective to manage obesity. Significant weight loss at 3 months was only observed in patients with obesity class I and class II.

Phylogeography of hepatitis B virus: The role of Portugal in the early dissemination of HBV worldwide.

In Portugal, the genetic diversity, origin of HBV and the Portuguese role in the dissemination of HBV worldwide were never investigated. In this work, we studied the epidemic history and transmission dynamics of HBV genotypes that are endemic in Portugal. HBV pol gene was sequenced from 130 patients followed in Lisbon. HBV genotype A was the most prevalent (n = 54, 41.5%), followed by D (n = 44, 33.8%), and E (n = 32, 24.6%). Spatio-temporal evolutionary dynamics was reconstructed in BEAST using a Bayesian Markov Chain Monte Carlo method, with a GTR nucleotide substitution model, an uncorrelated lognormal relaxed molecular clock model, a Bayesian skyline plot, and a continuous diffusion model. HBV subgenotype D4 was the first to be introduced in Portugal around 1857 (HPD 95% 1699-1931) followed by D3 and A2 a few decades later. HBV genotype E and subgenotype A1 were introduced in Portugal later, almost simultaneously. Our results indicate a very important role of Portugal in the exportation of subgenotypes D4 and A2 to Brazil and Cape Verde, respectively, in the beginning of the XX century. This work clarifies the epidemiological history of HBV in Portugal and provides new insights in the early and global epidemic history of this virus.

Hepatitis of unknown aetiology in children - epidemiological overview of cases reported in Europe, 1 January to 16 June 2022.

Following the report of an excess in paediatric cases of severe acute hepatitis of unknown aetiology by the United Kingdom (UK) on 5 April 2022, 427 cases were reported from 20 countries in the World Health Organization European Region to the European Surveillance System TESSy from 1 January 2022 to 16 June 2022. Here, we analysed demographic, epidemiological, clinical and microbiological data available in TESSy. Of the reported cases, 77.3% were 5 years or younger and 53.5% had a positive test for adenovirus, 10.4% had a positive RT-PCR for SARS-CoV-2 and 10.3% were coinfected with both pathogens. Cases with adenovirus infections were significantly more likely to be admitted to intensive care or high-dependency units (OR = 2.11; 95% CI: 1.18-3.74) and transplanted (OR = 3.36; 95% CI: 1.19-9.55) than cases with a negative test result for adenovirus, but this was no longer observed when looking at this association separately between the UK and other countries. Aetiological studies are needed to ascertain if adenovirus plays a role in this possible emergence of hepatitis cases in children and, if confirmed, the mechanisms that could be involved.

The role of stereotypical information on medical judgements for black and white patients.

THIS ARTICLE USES WORDS OR LANGUAGE THAT IS CONSIDERED PROFANE, VULGAR, OR OFFENSIVE BY SOME READERS. The new generation of direct-acting antivirals has improved dramatically the rates of cure for chronic hepatitis C. Yet, evidence shows that racial groups are deemed more often ineligible for hepatitis C treatment, despite no clinical evidence supporting differential treatment for Black and White patients. One possible explanation has to do with providers' racial biases. This investigation sought to explore medical students' racial stereotypes (Study 1, N = 171) and the role of stereotypical cues on perceptions of medical adherence of Black and White patients (Study 2, N = 208). In Study 1, we first sought to identify health-related aspects that are consistently associated with Blacks as part of a stereotype. In Study 2, we experimentally manipulated racial stereotypes identified in Study 1 by asking participants to read a clinical vignette depicting a patient (Black vs. White) and their medical history (cause of exposure to hepatitis C: unprotected sex vs. non-injectable drugs use). The results show that the impact of stereotypicality on patient perceived compliance varies as a function of medical students' racial prejudice. Implications for further applied health inequalities research and for medical training are discussed.

Strongyloides stercoralis Gastric Ulcer: A Rare Cause of Upper Gastrointestinal Bleeding.

Strongyloidiasis is an infection caused by Strongyloides stercoralis. Gastrointestinal manifestations typically include duodenitis, chronic enterocolitis, and malabsorption, while gastric involvement is very rare. In this case report, the -authors present a case of upper gastrointestinal bleeding caused by a gastric ulcer with a challenging etiological diagnosis. In Portugal, there have been reports in the past century of autochthonous cases of S. stercoralis infection suggesting endemic zones, but with the current sanitation infrastructure strongyloidiasis is thought to be rare. A 56-year-old Caucasian male smoker with a history of significant weight loss presented to the emergency department with hema-temesis and abdominal pain. Upper endoscopy revealed a giant gastric ulcer with a macroscopic appearance suggestive of malignancy. Further investigation with CT scan highlighted gastric wall thickness and a spiculated lung lesion in the upper right lobe without lymph node involvement or metastatic disease. Bronchoscopy with bronchial brushing was performed. Histological examination identified squamous cell carcinoma of the lung and the patient was referred to Oncological Pneumology. Gastric ulcer biopsies ruled out malignancy and identified fragments of nematodes with inflammatory infiltrates and fibrinogranulocytic exudate, suggestive of S. stercoralis. Accordingly, the diagnosis of strongyloidiasis was made and further confirmed with molecular methods and serology. The giant gastric ulcer was affirmed to be caused by S. stercoralis infection and the patient was treated with ivermectin with improvement of epigastric pain. On reevaluation 6 weeks later the patient was asymptomatic, had gained weight, parasitological stool examinations were negative, and upper endoscopy showed complete ulcer healing. Further tests were done targeting risk factors for strongyloidiasis, and in addition to the presence of malignancy, other underlying causes for immunosuppression were ruled out. In this case report strongyloidiasis was manifested by gastric involvement with upper gastrointestinal bleeding in a patient who was subsequently diagnosed with squamous cell carcinoma of the lung.

A estrongiloidíase é uma infecção causada por Strongyloides stercoralis. As manifestações gastrointestinais tipicamente incluem duodenite, enterocolite crónica e má absorção, sendo o envolvimento gástrico muito raro. Neste caso clínico, os autores apresentam um caso de hemorragia digestiva alta causada por uma úlcera gástrica com um diagnóstico etiológico desafiante. Em Portugal no século passado existiram casos autóctones de infecção a S. stercoralis sugerindo zonas endémicas, mas com a actual infraestrutura de saneamento a estrongiloidíase é rara. Homem de 56 anos de idade, caucasiano, fumador, com história de perda ponderal significativa, admitido no Serviço de Urgência por hematemeses e dor abdominal. A endoscopia digestiva alta realizada revelou uma úlcera gástrica gigante com aparência macroscópica sugestiva de malignidade. A investigação subsequente com tomografia computadorizada (TC) destacou a presença de espessamento gástrico e uma lesão pulmonar espiculada no lobo superior direito, sem envolvimento ganglionar ou doença metastática. Foi realizada broncofibroscopia com escovado brônquico tendo o exame histológico identificado carcinoma pavimento celular do pulmão, pelo que o doente foi referenciado para a Pneumologia Oncológica. As biópsias da úlcera gástrica descartaram malignidade e identificaram fragmentos de nemátodes com infiltrados inflamatórios e exsudado fibrino-granulocítico, sugestivo de Strongyloides stercoralis. Consequentemente, foi feito o diagnóstico de estrongiloidíase, confirmado com métodos moleculares e sorologia. Admitiu-se que a úlcera gástrica gigante terá sido causada pela infecção por Strongyloides stercoralis e o doente foi tratado com ivermectina com melhoria da dor epigástrica. Em reavaliação, seis semanas depois, o doente estava assintomático, com ganho ponderal, os exames parasitológicos das fezes estavam negativos e a endoscopia digestiva alta mostrou cicatrização completa da úlcera. Foram realizados exames adicionais para investigação de factores de risco para estrongiloidíase, tendo sido excluídas outras causas de imunossupressão subjacente para além da presença de malignidade. Neste caso clínico, a estrongiloidíase manifestou-se por envolvimento gástrico com hemorragia digestiva alta num doente que foi posteriormente diagnosticado com carcinoma pavimento celular do pulmão.

Proactive therapeutic drug monitoring is more effective than conventional management in inducing fecal calprotectin remission in inflammatory bowel disease.

BACKGROUND: Proactive therapeutic drug monitoring (pTDM) may improve treatment outcomes in inflammatory bowel disease. AIMS AND METHODS: We compared 135 patients following a prospective pTDM protocol aiming at an infliximab trough level (IFXTL) between 5 and 10 µg/ml with sequential measurements of Fc, with 108 patients from a retrospective group under conventional management. We evaluated the rates of Fc remission (<250 µg/g) and other clinical outcomes at 2-year of follow-up. RESULTS: pTDM associated with higher rates of Fc remission (69.6% vs. 50.0%; P = 0.002), and steroid-free clinical remission (78.4% vs. 55.2%, P = 0.028) with a trend for clinical remission (79.3% vs. 68.5%, P = 0.075). There was no difference in treatment discontinuation (P = 0.195), hospitalization (P = 0.156), and surgery (P = 0.110). Higher IFXTL associated with Fc remission at week 14 (6.59 vs. 2.96 µg/ml, P < 0.001), and at the end of follow-up (8.10 vs. 5.03 µg/ml, P = 0.001). In patients reaching Fc remission after week 14, IFXTL increased from week 14 to the end of follow-up (2.71 vs. 8.54 µg/ml, P < 0.001). Fc remission associated with higher rates of clinical (85.8% vs. 56.8% P < 0.001) and steroid-free clinical remission (86.9% vs. 50.0% P < 0.001), lower IFX discontinuation (8.8% vs. 36.8%, P < 0.001), and hospitalization (13.5% vs. 33.7%, P < 0.001), without significance for surgery (6.1% vs. 12.6%, P = 0.101). CONCLUSION: pTDM was more effective than conventional management in inducing Fc remission which was associated with improved outcomes.