[Contribution to the study of dental caries in 0-30-month-old infants]. / Contribuição ao estudo da cárie dentária em crianças de 0-30 meses.

This study evaluated the oral health conditions of 340 children, aged 0-30 months (21.3 +/- 5.6)--54.4% of girls and 45.6% of boys--from 20 public day nurseries of Salvador (Brazil), as to the presence of incipient carious lesions. The exam was carried out by a single examiner, who utilized a mirror, a probe and a penlight. The teeth were wiped with gauzes in order to remove the dental plaque. A questionnaire was answered by the children's parents or caretakers in order to assess information regarding knowledge on caries, caries risk factors, socioeconomic status of the family and utilization of fluoride. Two hundred and twenty-nine answered questionnaires (67.35%) were obtained. The observed lesions were classified in five stages, according to their severity (C0-C4; active/inactive). The data were analyzed using the Epi-info 6.02. The prevalence of caries was 55.3% when all stages were registered: 25% for subjects aged 0-12 months, 51.18% for subjects aged 13-24 months and 71.03% for those aged 25-30 months (chi 2 = 25.31, p < 0.01). When only active white spots were considered, 49.7% of the children were affected; 17.6% of the children presented with cavitated lesions. Among the affected children, 90.96% had lesions only on anterior teeth: 80% of the lesions were white spots and 20%, cavities. No significant difference was observed between genders. The increased amount of biofilm was positively associated with dental decay in toddlers (chi 2 = 67.61, p < 0.01), and the number of affected children increased when the sleep-time nursing habit was present (chi 2 = 0.24, p = 0.62). The prevalence of lesions increased with age and with the number of erupted teeth (chi 2 = 25.31, p < 0.01; chi 2 = 122.95, p < 0.01). Early oral health attention, diagnosis of incipient lesions, as well as educative and preventive programs to change oral hygiene and dietary habits are suggested.

[Esophageal manometry: equipment cleaning and disinfection with glutaraldehyde]. / Manometria esofágica: limpeza e desinfecção do equipamento com glutaraldeído. Protocolo do Hospital de Clínicas de Porto Alegre, RS.

BACKGROUND: Many publications have emphasized the need of proper cleaning, disinfection and sterilization process for reused materials intended to prevent cross infections. As the endoscope the esophageal manometry catheters are considered as semicritical materials and must be free of microrganisms. AIM: To standardize the esophageal manometry materials cleaning and disinfection process to guarantee the safety of patients when reusing semicritical materials. It was based on international protocols and according to recommendations of the Hospital Infection Control Commission of the "Hospital de Clinicas de Porto Alegre", Porto Alegre, RS, Brazil. MATERIALS AND METHODS: Enzymatic detergent was used for catheter cleaning, followed by immersion with 2% glutaraldehyde solution during 20 minutes for high-level disinfection. The water reservatory was kept clean and dry to prevent microorganisms proliferation. CONCLUSIONS: The high level disinfection with 2% glutaraldehyde, preceded by enzymatic detergent cleaning, is a safe and simple technique that avoids cross infection in the esophageal manometry equipment. This care must be taken after each manometric procedure. The transducers must be resterilized in ethylene oxide. The professionals of this area must work in concordance with the Hospital Infection Control Commission, being acquainted with the country laws and regulations and keeping sterilizing process and materials updated.

[Contribution of hepatic immunoglobulin A deposits to the diagnosis of alcoholic hepatopathy]. / Contribuição dos depósitos hepáticos de imunoglobulina a no diagnóstico da hepatopatia alcoólica.

BACKGROUND: Alcoholic hepatic disease is a severe and frequent disease and its diagnosis is not always an easy task. AIM: To assess the contribution of immunoglobulin A (IgA) in the hepatic sinusoids for diagnosis of alcoholic hepatopathy. PATIENTS AND METHODS: The presence of IgA was studied through direct immunofluorescence in 59 patients submitted to hepatic needle biopsy, indicated by clinical or in vitro changes suggestive of chronic hepatopathy. RESULTS: A significant deposition of IgA was found in alcoholic patients as compared to non-alcoholic patients, with 76% sensitivity (95% CI: 54.5-89.8) and 73.5% specificity (95% CI: 55.3-86.5). In individuals who present only alcohol as the etiological agent of hepatopathy, compared with the subgroup of B or C virus carriers, the results were even more significant, with 85.7% sensitivity (95% CI: 56.2-97.5) and 89.5% specificity (95% CI: 65.5-98.2). CONCLUSION: The deposition of IgA in the hepatic sinusoids present sensitivity and specificity for the diagnosis of an alcohol-induced hepatic lesion. This resource can be particularly useful when conventional histology can not be define a specific cause for the change found.

[Experience in patients with suspected chronic liver disease and contraindication for percutaneous biopsy using modified Ross needle]. / Experiência em pacientes com suspeita de hepatopatia crônica e contra-indicação para biópsia hepática percutânea utilizando a agulha de Ross modificada.

PURPOSE: This work aimed at introducing the transjugular liver biopsy technique oriented by radiologic methods in our hospitals. This technique is indicated for obtaining histopathologic diagnosis in patients clinically and laboratory suspected of having chronic liver disease with contraindications to percutaneous liver biopsy. METHODS: Liver biopsy was obtained with a modified Ross needle through the right jugular vein and right hepatic vein under fluoroscopic control. RESULTS: Transjugular liver biopsy was attempted for 39 patients, liver tissue obtained en 32 and histopathologic diagnosis in 25 (64.1%). In 11 patients (28.2%) there was agreement between the diagnoses established before and after biopsy, however, in 14 patients (35.9%), there was disagreement. The yield of diagnosis was low when patients were suspected for cirrhosis. The procedure was well tolerated by the majority of patients. Nonetheless, 1 presented intra-abdominal bleeding and required immediate surgery to control retroperitoneal hemorrhage. CONCLUSIONS: Transjugular liver biopsy is useful for the histopathologic diagnosis of patients with chronic liver diseases whenever the percutaneous route is contraindicated. In this series we obtained histopathologic diagnosis for 64.1% of the subjects studied. Patients suspected of having cirrhosis had a low yield of histopathologic diagnosis (50%) when compared to subjects without clinical evidence for cirrhosis (78.9%). The technique is rather complex, and can cause serious complications. This, it should be performed in reference centers in radiology and hepatology.

[High temperature "matè" infusion drinking in a population at risk for squamous cell carcinoma of the esophagus]. / Mate (chimarrão) é consumido em alta temperatura por população sob risco para o carcinoma epidermóide de esôfago.

UNLABELLED: "Matè", a popular hot infusion of a herb (Ilex paraguayensis) drunk in large volumes, is a known risk factor for squamous cell carcinoma of the esophagus and there is a suspicion that high temperature of boiled water used for the infusion may contribute for carcinogenesis. METHODS: We measured the temperature of "matè" infusion drunk by a sample of the population at risk for this carcinoma in Taquara, southern Brazil. We interviewed inhabitants for drinking habits and the temperature of the infusion was measured with high precision thermometers. Temperature of the infusion was asked to consumers and their estimate compared to our measurements. We considered 60 degrees C or higher as "hot". RESULTS: In 36 residencies, 107 individuals were drinking "matè". Most individuals drank it daily (97.2%), and the medium daily volume was 1,265 ml (SD +/- 1,132 mL) ranging from 250 to 6,000 mL. The measured temperature was 60 degrees C or higher in 72% of residencies with medium of 63.4 degrees C (51-78 degrees C) and median 64.4 degrees C. CONCLUSION: In this study, "matè" was consumed in large volumes at high temperature and individuals did not estimate correctly the temperature of infusion. High temperatures of "matè" may contribute to carcinogenesis in this population.

[Prevalence of adenocarcinoma of the esophagus and esophagogastric junction in a 10 year period at a cancer referral center in southern Brazil]. / Prevalência de adenocarcinoma do esôfago e da junção esofagogástrica durante 10 anos num centro de referência para câncer no sul do Brasil.

UNLABELLED: There is increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction in the USA and Europe, however, data in Brazil are scanty. OBJECTIVE AND METHODS: We reviewed all histology confirmed esophageal and esophagogastric junction cancer reports during a 10-year period (1987-1996) obtained by upper digestive endoscopy biopsies at a cancer referral center in Southern Brazil. Cancer cases were classified in three categories: adenocarcinoma, squamous cell carcinoma, and others. RESULTS: Among 349 cases, adenocarcinoma was found in 53 (15.2%), squamous cell carcinoma in 283 (81.1%) and others in 13 (3.7%). CONCLUSIONS: In this study, the prevalence of adenocarcinoma was 15%.

Occult dysplasia is disclosed by Lugol chromoendoscopy in alcoholics at high risk for squamous cell carcinoma of the esophagus.

BACKGROUND AND STUDY AIMS: Squamous cell carcinoma of the esophagus (SCCE) becomes symptomatic at a late stage when the disease is already advanced, and this contributes to its poor prognosis. Esophagoscopy of asymptomatic individuals exposed to known risk factors associated with the development of this cancer may facilitate the diagnosis of early cancerous or precancerous lesions; however, conventional esophagoscopy is not accurate enough. The aim of this study was to measure the value of Lugol chromoendoscopy of the esophagus (LCE) as an endoscopic technique to detect dysplasia in patients at risk. PATIENTS AND METHODS: We studied 190 male patients older than 35 attending an outpatient unit for alcoholics who consumed more than 80g of alcohol, more than 10 cigarettes and more than 500 ml 'maté' (a hot infusion of herbs) per day over 10 years. All underwent conventional upper gastrointestinal endoscopy followed by LCE, a spraying of Lugol 3% on the entire esophagus. All patients denied dysphagia. Biopsies were obtained from any unstained areas larger than 5mm and also from stained areas in all individuals. Biopsies were analyzed independently by two pathologists unaware of the biopsy sites. All conventional esophagoscopies showed normal mucosa, except for two suspicious small elevated lesions, confirmed histologically to be SCCE. These two cases were excluded from the statistical analysis. RESULTS: The LCE found unstained areas in 23 patients and a uniformly stained esophageal mucosa in the remaining 165. Biopsies taken from these 23 unstained areas showed dysplasia in six (two high grade and four low grade), and the ones from the 165 stained areas taken at the middle esophagus showed low-grade dysplasia in seven. There was a high prevalence (6.9%) of dysplastic lesions in these individuals and occult dysplasia was significantly more frequent in unstained than stained areas (p = 0.0017). LCE showed a sensitivity of 46%, a specificity of 90%, a positive predictive value of 26% and a negative predicitve value of 96% when unstained areas were compared to stained ones. Agreement between two independent pathologists was high, with a kappa coefficient of 0.64. CONCLUSION: We concluded that individuals who abuse alcohol, smoke and consume 'maté' have a high prevalence of dysplastic lesions that can be better detected by LCE. Esophagi with unstained areas had an eight-fold higher chance of revealing dysplasia than the uniformly stained ones. LCE is an easy and inexpensive method. It improves the detection of dysplasia and should be added to conventional upper GI endoscopy in patients at risk for SCCE.

[Perception on and registration of alcohol abuse and alcohol-related diseases at a university general hospital]. / Percepção e registro de abuso de álcool e de doenças relacionadas num hospital geral universitário.

BACKGROUND: The high frequency of alcohol related problems highlights the importance of its approach. The association of both the alcohol-abuse and alcohol related diseases has been pointed in the literature and are often the main reason for hospitalization. Physicians use different tools to detect abusive drinkers, and one of them is the CAGE-test, validated by Mayfield et al. in 1974. OBJECTIVES: To study the association between the result of the CAGE-test and the perception and registration of alcohol abuse by the medical staff and the nurses in charge of inpatients of Hospital de Clínicas de Porto Alegre, southern Brazil. MATERIAL AND METHOD: The design involved three phases. First, the application of the CAGE-test to the 385 eligible patients. Second, review of all 51 CAGE-positive patients' records as well the controlled evaluation of 51 randomized CAGE-negative patients, to seek alcoholic habits and alcohol-related diseases. Third, interview with the medical staff to find out their perception about these subjects. RESULTS: We found 51 patients CAGE-positive (prevalence = 13%). When evaluated through the registration and through a standardized interview, medical staff and nurses were not aware of more than half of CAGE-positive patients. No significant differences were found between medical staff registration and perception; the prevalence of alcohol related diseases was the same for both: 26 and 27% (p = .861). The prevalence of alcohol related diseases was higher among CAGE-positive patients (p = .0003). CONCLUSIONS: In spite of the high prevalence among our patients, alcohol abuse is not pursued by our health teams as it should be. As for the future, there is reason to envision a continuing alcoholism rapprochement.

Esophageal dysplasia and chronic esophagitis: detection at upper gastrointestinal tract endoscopy.

UNLABELLED: Cancer of the esophagus becomes symptomatic at an advanced phase with a late diagnosis, when the tumor is already incurable. Early diagnosis has been shown to improve the survival rates. Conventional esophagoscopy is largely available but its sensitivity to detect early cancer or precancerous lesions remains controversial. In this study we tested the sensitivity of conventional esophagoscopy to identify suspicious areas and compared to histopathology of endoscopic biopsies to detect dysplasia and chronic esophagitis in a population at risk for cancer in southern Brazil. Adult males scheduled to have outpatient endoscopy were examined by two experienced endoscopists and any small (< 5 mm) plaque, nodule, erosion, hyperemia and or friable areas of the mucosa were biopsied and looked for the presence of early cancer or precancerous lesions. Normal appearing mucosa at the middle third of the esophagus was also biopsied and results compared for sensitivity, specificity, positive and negative predictive value. Of the 89 individuals with satisfactory biopsies, 3 had dysplasias, 29 moderate or severe chronic esophagitis and 57 normal findings at the histopathological study. We found no early cancer. We found two large, vegetating lesions confirmed to be advanced squamous cell carcinoma but they were excluded from analysis. To detect dysplasia or moderate/severe chronic esophagitis conventional esophagoscopy had a sensitivity of 40.6%, specificity of 78.9%, positive predictive value of 52% and negative predictive value of 70.3. CONCLUSIONS: In this study, conventional esophagoscopy had a low sensitivity to detect dysplasias and/or chronic esophagitis and techniques to improve endoscopic identification of these lesions in individuals at risk for cancer are much needed.

[Resection of a laterally spreading tumor by strip biopsy]. / Ressecção de "laterally spreading tumor" por "strip biopsy".

A male white patient 58 years-old was submitted to colonoscopy for follow-up of surgical resection of an advanced colorectal carcinoma 33 months ago. Small polyps were observed in the colons and histopathological examination proved to be tubular adenomas with moderate dysplasia. At the hepatic flexure of the transverse colon a large flat-elevated laterally spreading tumor measuring 2.5 cm in diameter was observed. After spraying of methilene-blue 0.1% the margins of the lesion were demarcated and following saline injection under the lesion it was completely resected in one single procedure. Histologically, the lesion was diagnosed as intramucosal adenocarcinoma.

Evaluation of postprandial serum bile acid response as a test of hepatic function.

Commercial assays for serum bile acids (SBA) have made this measurement practical. The purpose of this study was to examine the utility of SBA measured every 30 min after a standardized meal in controls and in patients with acute viral hepatitis, cholestasis, and anicteric cirrhosis. In five controls, repeated examination of the area under the bile acid curve (AUC) was not statistically different, whereas the fasting and 2-hr postprandial levels were significantly different. In the group of patients with anicteric cirrhosis, AUC identified disease in 18/20 using total serum bile acids (TSBAs) and in 15/20 using cholylglycine (CG). AUC can be calculated from three samples obtained at 0, 60, and 120 min without losing the sensitivity achieved with seven serial samples. SGOT, alkaline phosphatase, and serum albumin were compared for sensitivity to the total SBA response curve in 20 patients with anicteric cirrhosis. SGOT and alkaline phosphatase identified only 50% and 55% as abnormal and serum albumin was less sensitive. Using total SBA, combining the fasting level and AUC identified 100% as abnormal; using CG, 85% of these patients were detected. As a stepwise cost-effective approach, the fasting level of SBAs can identify most patients with anicteric liver disease. In cases with normal fasting levels where liver disease is suspected, the three-point AUC determination may identify additional patients.

Response of total and individual serum bile acids to endogenous and exogenous bile acid input to the enterohepatic circulation.

The response of total nonsulfated serum bile acids, cholylglycine, and chenodeoxycholyl species was examined every 20 min for 3 h in 6 subjects. Noncaloric feeding led to a progressive decline or no change in bile acids, while there was a progressive rise in response to a standard liquid meal. After reaching a peak at 60 min, total bile acids declined progressively but cholylglycine and chenodeoxycholyl species remained elevated. Continuous infusion of cholecystokinin led to significantly greater levels most probably due to more rapid enterohepatic recirculation. Oral administration of 250 mg of chenodeoxycholic acid with water resulted in a rise in total bile acids and chenodeoxycholyl species, but not cholylglycine, indicating the rise was due to the administered bile acid and not gallbladder contraction. Administration of a meal and chenodeoxycholic acid simultaneously caused no greater rise of total serum bile acids or cholylglycine than either stimulus alone. Peak response and area under the curve were compared for each patient. The increase for chenodeoxycholyl species was additive for the two stimuli, suggesting that free chenodeoxycholic acid, when administered with a meal, decreased the absorption of endogenous conjugated bile acids. This study is compatible with the thesis that serum bile acids accurately reflect enterohepatic cycling and that administration of chenodeoxycholic acid with a meal may decrease its efficacy because exogenous chenodeoxycholic acid may compete with endogenous bile acids for absorption.