Management of Hepatic Encephalopathy Associated with Advanced Liver Disease.

Hepatic encephalopathy (HE) is a very prevalent condition in patients with advanced liver disease and has a high recurrence rate. The pathophysiology has a multifactorial origin where hyperammonaemia and inflammation become particularly relevant. There are no HE-specific diagnostic tests, and diagnosis is usually made by taking into account the presence of suggestive and compatible clinical symptoms, the existence of a predisposing liver condition and ruling out other causes with similar clinical manifestations. Once the diagnosis of HE is established, it is essential to carry out an adequate classification based on the underlying liver disease, the intensity of clinical manifestations, the temporal course of the disease and the presence or absence of precipitating factors. Treatment should be aimed at decreasing the duration, intensity and consequences of episodes, preventing recurrence and limiting the impact of the disease in patients and their relatives.

From evaluation to action: Testing nudging strategies to prevent food waste in school canteens.

Food waste (FW) prevention is an essential measure to contribute to the achievement of the Sustainable Development Goal target 12.3, achieve more sustainable food systems and tackle the climate crisis. This paper aims at evaluating nudging strategies' impact on FW prevention in school canteens. To do so, it applies a four-stage methodology in 4 school canteens of the Metropolitan Region of Barcelona as case studies. This study has three main contributions. First, it provided real FW data by estimating a daily FW of 46 g per dinner. Secondly, it observed a 41% FW prevention impact when specific nudging strategies were applied. Dessert was the course with bigger reductions, especially when fruits were served. In addition, strategies involving canteen staff seemed to be more effective. Third, it proposed a methodological framework to co-design and evaluate the impact of FW prevention strategies by quantifying plate waste at school canteens. Thus, this study suggests nudging strategies as innovative interventions to improve food systems' sustainability by preventing FW in school canteens.

Primary gastric adenocarcinoma in a patient with Peutz-Jeghers syndrome.

We present the case of a 42-year-old female under study due to dyspepsia without response to empirical treatment, with perioral mucocutaneous pigmentation. A gastroscopy revealed a 5 cm gastric tumor in the antrum, as well as multiple sessile gastric and duodenal polyps smaller than 1 cm. Large-capacity forceps biopsies were obtained and a well-differentiated adenocarcinoma with gastric origin was diagnosed, with over expression of the HER2/neu without microsatellite instability in the context of a hamartomatous polyposis. The genomic study confirmed an alteration in the STK11 gene translated to a truncated protein product, compatible with a Peutz-Jeghers syndrome (PJS).

Long-term outcomes and clinical impact of anti-HLA donor-specific antibodies (DSA) after liver transplantation: a prospective study in a pilot cohort.

INTRODUCTION: the presence of donor-specific antibodies (DSA) is thought to affect survival of the allograft and patient after liver transplantation (LT). However, their significance is not well understood. PATIENTS AND METHODS: a prospective study was performed of 32 adult patients who underwent LT in 2011 to analyze the existence of DSA, associated risk factors and medium-term impact. Immunological determinations were performed immediately before LT and at three, six, 12 months and five years after LT. RESULTS: eight patients (24.2 %) presented pre-formed DSA. However, titers were negative in all patients five years after LT and there were no associated events. Eight out of 24 patients (33.3 %) developed de novo DSA. After five years, only two remained positive; both were class II with high mean fluorescence intensity (MFI) values at diagnosis (over 15,000). No association was found between the development of DSA and the risk of rejection, graft loss or death. However, an increase in liver stiffness values was observed in patients with persistent DSA, and focal sinusoidal deposition of C4d and moderate liver fibrosis were reported. CONCLUSION: the incidence of DSA is high after LT. In addition, the persistence of de novo DSA could be associated with silent liver fibrosis with a potential impact on graft outcomes.

Desmoid fibromatosis of the esophagogastric junction

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Desmoid fibromatosis of the esophagogastric junction.

Desmoid fibromatosis is a mesenchymal clonal proliferation, which lacks metastatic potential. Nevertheless, it has an infiltrative growth and thus implies a high morbidity1. Although the etiology remains unclear, mutations in the B-catenin or APC genes are involved. Some risk factors include pregnancy, hormonal exposure or surgery. Desmoid fibromatosis can be sporadic (80%) or FAP-associated2. In sporadic cases, it is caused by mutations in the B-catenin (CTNNB1) gene. Whether it is FAP-associated or not should be determined, as the treatment for each condition is different. A radiologic test is essential for diagnosis, although a biopsy is necessary for confirmation. With regard to treatment, there is a wide range of different alternatives such as observation only, medical treatment or even surgery3. However, a recurrence rate that ranges from 30% to 40% have been reported in the major published series4 and thus, conservative treatment is more common nowadays. We present the case of an 82-year-old male with constitutional syndrome. A computed tomography was performed, which identified a 69 x 52mm mass in the oesophago-gastric union. A computed tomography guided biopsy was performed and the histological analysis identified a fusocellular tumor compatible with desmoid fibromatosis. Treatment was started with indomethacin. However, a control computed tomography 3 months later showed that the mass had grown. Thus, indomethacin treatment was stopped and tamoxifen treatment was started. The patient has had an excellent performance status since symptom presentation. In conclusion, desmoid tumors are rare and most are sporadic. However, they may also be associated with familial adenomatous polyposis syndrome. It must be emphasized that our patient did not have any risk factors and the anatomical location in the oesophago-gastric union is not a common location. Desmoid fibromatosis supposes a clinical challenge for diagnosis and treatment and thus, management should be individualized.

Small bowel obstruction secondary to distal migration of the intestinal probe in a patient with an endoscopic gastrostomy for continuous carbidopa-levodopa infusion / Obstrucción de intestino delgado secundaria a migración distal de la sonda intestinal en una paciente con gastrostomía endoscópica para la infusión continua de carbidopa-levodopa

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Enteral stent for the treatment of a urinary fistula associated with a biological mesh following a Bricker-type procedure.

Postoperative fistula results in increased morbidity and a longer hospital stay. While surgery is the most common treatment, the endoscopic approach is an increasingly used alternative. A 57-year-old woman underwent surgery for colonic adenocarcinoma, which relapsed as peritoneal carcinomatosis and was managed with chemotherapy and surgery, a biological Permacol™ mesh was used for abdominal wall closure.

Tratamiento mediante prótesis enteral de una fístula urinaria asociada a malla biológica tras una cirugía tipo Bricker / Enteral stent for the treatment of a urinary fistula associated with a biological mesh following a Bricker-type procedure

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