NSAIDs do not reduce severity among post-ERCP pancreatitis patients.

OBJECTIVE: Non-steroidal anti-inflammatory drugs (NSAIDs) are the most studied chemoprophylaxis for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). While previous systematic reviews have shown NSAIDs reduce PEP, their impact on moderate to severe PEP (MSPEP) is unclear. We conducted a systematic review and meta-analysis to understand the impact of NSAIDs on MSPEP among patients who developed PEP. We later surveyed physicians' understanding of that impact. DESIGN: A systematic search for randomized trials using NSAIDs for PEP prevention was conducted. Pooled-prevalence and Odds-ratio of PEP, MSPEP were compared between treated vs. control groups. Analysis was performed using R software. Random-effects model was used for all variables. Physicians were surveyed via email before and after reviewing our results. RESULTS: 7688 patients in 25 trials were included. PEP was significantly reduced to 0.598 (95%CI, 0.47-0.76) in the NSAIDs group. Overall burden of MSPEP was reduced among all patients undergoing ERCP: OR 0.59 (95%CI, 0.42-0.83). However, NSAIDs didn't affect the proportion of MSPEP among those who developed PEP (p = 0.658). Rectal Indomethacin and diclofenac reduced PEP but not MSPEP. Efficacy didn't vary by risk, timing of administration, or bias-risk. Survey revealed a change in the impression of the effect of NSAIDs on MSPEP after reviewing our results. CONCLUSIONS: Rectal diclofenac or indomethacin before or after ERCP reduce the overall burden of MSPEP by reducing the pool of PEP from which it can arise. However, the proportion of MSPEP among patients who developed PEP is unaffected. Therefore, NSAIDs prevent initiation of PEP, but do not affect severity among those that develop PEP. Alternative modalities are needed to reduce MSPEP among patients who develop PEP.

Transarterial Chemoembolization-Induced Ischemic Colitis: A Rare Complication Due to Nontarget Embolization.

Nontarget embolization is a rare complication that may occur after a patient undergoes transarterial chemoembolization as a localized treatment of hepatocellular carcinoma. This phenomenon can occur because of variations in arterial blood supply to the liver and ultimately can lead to ischemic complications in unintended locations. We describe a case of nontarget embolization during transarterial chemoembolization causing ischemic colitis because of anatomic variation in the origin of the right hepatic artery. This case highlights the importance of recognizing rare side effects associated with this procedure and the need for comprehensive imaging to assess for anatomical variation to avoid poor outcomes.

Risk of Metachronous Neoplasia with High-Risk Adenoma and Synchronous Sessile Serrated Adenoma: A Systematic Review and Meta-Analysis.

Background: Sessile serrated adenomas are important precursors to colorectal cancers and account for 30% of colorectal cancers. The United States Multi-Society Task Force recommends that patients with sessile serrated adenomas undergo surveillance similar to tubular adenomas. However, the risk of metachronous neoplasia when the high-risk adenoma co-exists with sessile serrated adenomas is poorly defined. Objective: To examine the risk of metachronous neoplasia in the presence of high-risk adenoma and synchronous sessile serrated adenomas compared with isolated high-risk adenoma. Data sources: PubMed, Embase, Scopus, Cochrane Library. Study selection: A literature search for studies evaluating the risk of metachronous neoplasia in patients with high-risk adenoma alone and those with synchronous high-risk adenoma and sessile serrated adenomas during surveillance colonoscopy was conducted on online databases. Main outcome measures: The primary outcome of interest was the presence of metachronous neoplasia. Results: Of the 1164 records reviewed, six (four retrospective and two prospective) studies met inclusion criteria with 2490 patients (1607 males, mean age 59.98 ± 3.23 years). Average follow-up was 47.5 ± 12.5 months. There were 2068 patients with high-risk adenoma on index colonoscopy and 422 patients with high-risk adenoma and synchronous sessile serrated adenomas. Pooled estimates showed a significantly elevated risk for metachronous neoplasia in patients with high-risk adenoma and synchronous sessile serrated adenomas (pooled odds ratio 2.21; 95% confidence intervals 1.65-2.96; p < 0.01). There was low heterogeneity (I2 = 11%) among the studies. Sensitivity analysis of the prospective studies alone also showed elevated risk of metachronous neoplasm (pooled odds ratio 2.56; 95%, confidence intervals 1.05-6.23; p = 0.04). Limitations: Inclusion of a small number of retrospective studies. Conclusions: The presence of high-risk adenomas and synchronous sessile serrated adenomas is associated with an increased risk of metachronous neoplasia. Therefore, shorter surveillance intervals may be considered in patients with high-risk adenoma and synchronous sessile serrated adenomas compared to those with high-risk adenoma alone.

Barrett's Esophagus: An Updated Review.

Barrett's esophagus (BE) is a change in the distal esophageal mucosal lining, whereby metaplastic columnar epithelium replaces squamous epithelium of the esophagus. This change represents a pre-malignant mucosal transformation which has a known association with the development of esophageal adenocarcinoma. Gastroesophageal reflux disease is a risk factor for BE, other risk factors include patients who are Caucasian, age > 50 years, central obesity, tobacco use, history of peptic stricture and erosive gastritis. Screening for BE remains selective based on risk factors, a screening program in the general population is not routinely recommended. Diagnosis of BE is established with a combination of endoscopic recognition, targeted biopsies, and histologic confirmation of columnar metaplasia. We aim to provide a comprehensive review of the epidemiology, pathogenesis, screening and advanced techniques of detecting and eradicating Barrett's esophagus.

Endoscopy versus early surgery for the management of chronic pancreatitis: a systematic review and meta-analysis.

BACKGROUND AND AIM: Endoscopic stone removal and stenting of pancreatic strictures are the initial treatment for treating chronic pancreatitis-related pain. Surgery is considered when endoscopic interventions fail to improve symptoms. In this meta-analysis, we have compared early surgery versus endoscopic interventions. METHODS: The study was performed as per the PRISMA statement. The literature search was conducted on online databases to identify studies that compared endoscopy and surgery for the management of chronic pancreatitis symptoms. Primary outcomes of interest were pain relief, complications, and exocrine/endocrine insufficiency. Secondary outcomes were mean length of stay and mean number of procedures. Pooled odds ratio (OR) was calculated using random-effects model with 95% confidence interval (CI). RESULTS: Of a total of 9880 articles that were screened, three randomized controlled trials and two retrospective studies with 602 patients (71.4% males) were found to be eligible. Endoscopic interventions were performed in 317 patients and 285 patients underwent early surgery. Early surgery provided significantly better pain relief compared to endoscopy (OR 0.46; 95%CI 0.27-0.80; p = 0.01; I2 = 17.65%) and required less number of procedures (Mean difference 1.66; 95%CI 0.9-2.43; p = 0.00; I2 = 96.46%). There was no significant difference in procedure-related complication (OR 0.91; 95%CI 0.51-1.61; p = 0.74; I2 = 38.8%), endocrine (OR 1.18; 95%CI 0.63-2.20; p = 0.61; I2 = 28.24%), or exocrine insufficiency (OR 1.78; 95%CI 0.66-4.79; p = 0.25; I2 = 30.97%) or the length of stay (Mean difference 1.21; 95%CI -7.12 to 4.70; p = 0.69). CONCLUSION: Compared to endoscopy, early surgery appears to be better in controlling chronic pancreatitis-related pain, with no significant difference in procedure-related complications. However, larger randomized controlled trials are needed to ascertain their efficacy.

Evidence showing lipotoxicity worsens outcomes in covid-19 patients and insights about the underlying mechanisms.

We compared three hospitalized patient cohorts and conducted mechanistic studies to determine if lipotoxicity worsens COVID-19. Cohort-1 (n = 30) compared COVID-19 patients dismissed home to those requiring intensive-care unit (ICU) transfer. Cohort-2 (n = 116) compared critically ill ICU patients with and without COVID-19. Cohort-3 (n = 3969) studied hypoalbuminemia and hypocalcemia's impact on COVID-19 mortality. Patients requiring ICU transfer had higher serum albumin unbound linoleic acid (LA). Unbound fatty acids and LA were elevated in ICU transfers, COVID-19 ICU patients and ICU non-survivors. COVID-19 ICU patients (cohort-2) had greater serum lipase, damage-associated molecular patterns (DAMPs), cytokines, hypocalcemia, hypoalbuminemia, organ failure and thrombotic events. Hypocalcemia and hypoalbuminemia independently associated with COVID-19 mortality in cohort-3. Experimentally, LA reacted with albumin, calcium and induced hypocalcemia, hypoalbuminemia in mice. Endothelial cells took up unbound LA, which depolarized their mitochondria. In mice, unbound LA increased DAMPs, cytokines, causing endothelial injury, organ failure and thrombosis. Therefore, excessive unbound LA in the circulation may worsen COVID-19 outcomes.

Current advances in the management of chronic pancreatitis.

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Endoscopic management of benign recalcitrant esophageal strictures.

Benign esophageal strictures are one of the common clinical conditions managed by endoscopists. Nearly 90% of the benign esophageal strictures respond to endoscopic dilation. However, a small percentage of patients progress to recalcitrant strictures. The benign recalcitrant esophageal strictures are difficult to manage both medically and endoscopically as they do not respond to conventional treatment with proton pump inhibitors and esophageal dilations. Patients with benign recalcitrant esophageal strictures are at a high risk of developing debilitating malnutrition and morbidity due to severe dysphagia. This condition is associated with psychological trauma to patients as treatments are usually prolonged with poor outcomes. Also, this can be a financial burden on the healthcare industry due to several sessions of treatment. In this article, we discuss the classification of benign esophageal strictures, evidence-based treatment strategies, endoscopic procedural techniques, and complications of endoscopic interventions. We aim to guide providers in managing benign esophageal strictures with a focus on endoscopic management of benign recalcitrant esophageal strictures.

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends.

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered "complex" based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

La pulsión en Freud ¿un concepto superado? / The drive in Freud, a concept surpassed?

Resumen El presente artículo expone un análisis crítico, intra y extratextual, del concepto de pulsión en la teoría psicoanalítica freudiana; primero, se destacan las características principales de la pulsión: la fuente, el esfuerzo (medida de trabajo), la meta y el objeto; segundo, se analiza si la pulsión es un concepto referido a una realidad biológica o a una psíquica; tercero, se estudian sus relaciones con la represión; cuarto, se interroga si es preferible hablar de tendencias (Logos, Eros, Thánatos y Ananké) y de pulsiones como aspectos de la vida psíquica sometidos a esas cuatro tendencias; y quinto, se analizan las estrechas relaciones de las pulsiones con la biología. En este recorrido, se examinan y señalan algunas contradicciones que surgen al comparar dos momentos en la conceptualización freudiana de la pulsión: primero, bajo la oposición entre pulsiones sexuales y pulsiones de autoconservación, y segundo, bajo la perspectiva de las pulsiones de vida y las pulsiones de muerte. Se concluye señalando la necesidad de un diálogo con la biología actual, así como con las investigaciones sobre las emociones en la psicología contemporánea.

Abstract The present article makes a critical analysis, intra and extratextual, of the concept of drive in the Freudian psychoanalytic theory; first, it highlights the main characteristics of the drive: the source, the effort (work measurement), the goal and the object; second, it analyzes whether the drive in a concept referred to a biological or a psychic reality; third, it studies its relations with repression; fourth, asks if it is preferable to talk about tendencies (Logos, Eros, Thánatos and Ananke) and of drives as aspects of psychic life subjected to these four tendencies; and fifth, it analyzes its close relations with biology. In this journey, we examine and point out some contradictions that arise when comparing two moments in their conceptualization: first, under the opposition between sexual and self-preservation drives, and second, under the perspective of the life and death drives. It concludes by pointing out the need for a dialogue with current biology, as well as with research on emotions in contemporary psychology.

Fitorremediación de aguas contaminadas con componentes de amalgama de la preclínica de odontología de la Universidad Antonio Nariño, Ibagué (Colombia) / Phytoremediation of contaminated water with amalgam components of the preclinical dentistry of the Universidad Antonio Nariño, Ibagué Colombia

Objetivo: remover componentes de amalgama de aguas contaminadas mediante fitorremediación. Métodos: se llevó a cabo un estudio descriptivo retrospectivo, en que fueron recolectados 12 litros de aguas de remoción de obturaciones de amalgama en 144 dientes artificiales en la preclínica de odontología. Se analizó agua sin fitorremediar (control), y se mantuvieron ocho litros para fitorremediación en el Laboratorio de Ciencias Básicas y un análisis semanal con dos especies de plantas acuáticas: Eichhornia crassipes y Pistia stratiotes. Mediante espectrofotometría de absorción atómica, se determinó la concentración de metales pesados en miligramos por litro. El análisis se llevó a cabo mediante estadística descriptiva, comparación con prueba t y ANOVA de una vía con el complemento de Excel XLSTAT. Resultados: tras el proceso, el porcentaje estimado de remoción de componentes de amalgama fue superior al 50%. No hubo diferencias estadísticamente significativas entre los tratamientos (α= 0.05; g l= 11; p= 0,4269). Conclusiones: se logró la remoción parcial de componentes de amalgama de aguas contaminadas a través del proceso de fitorremediación.

Objective: remove amalgam components from contaminated water by phytoremediation. Methods: a retrospective descriptive study was carried out, in which 12 liters of amalgam filling removal water were collected in 144 artificial teeth in the preclinical dentistry. Water was analyzed without phytoremediation (control), and eight liters were maintained for phytoremediation in the Laboratory of Basic Sciences and a weekly analysis with two species of aquatic plants: Eichhornia crassipes and Pistia stratiotes. The concentration of heavy metals in milligrams per liter was determined by atomic absorption spectrophotometry. The analysis was carried out using descriptive statistics, comparison with t-test and one-way ANOVA with the Excel XLSTAT add-in. Results: after the process, the estimated removal percentage of amalgam components was greater than 50%. There were no statistically significant differences between treatments (α = 0.05; g l = 11; p = 0.4269). Conclusions: the partial removal of amalgam components from contaminated water was achieved through the phytoremediation process.

Caracterización sociodemográfica y clínica de una población con falla cardíaca aguda: cohorte MED-ICA / Sociodemographic and clinical profile of a population with acute heart failure: MED-ICA cohort

Resumen Objetivo: Determinar las características epidemiológicas de adultos con insuficiencia cardiaca aguda admitidos en un hospital universitario. Métodos: Estudio de cohorte retrospectivo, descriptivo. Revisión de historias clínicas de mayores de 18 años hospitalizados entre julio y diciembre de 2015 en un hospital de Medellín, Colombia. Resultados: Se incluyeron 361 pacientes con insuficiencia cardíaca aguda. 193 (53,4%) fueron mujeres, cuya mediana de edad fue 76 años. 183 (50,6%) tenían fracción de eyección (FEVI) reducida, 19 (5,2%) FEVI intermedia y 148 (40,9%) FEVI preservada. El tratamiento farmacológico previo al ingreso incluía IECA/ARA2 en 253 (70%) pacientes, betabloqueador en 212 (58,7%) y espironolactona en 92 (25,4%). La principal causa de falla cardíaca aguda fue la presencia de taqui-bradiarritmias (17,5%), seguida de infección (17,2%) y exacerbación de neumopatía crónica (16,3%). La clasificación clínica de la descompensación fue Stevenson B en 335 (92,7%) pacientes, Stevenson C en 20 (5,5%) y Stevenson L en 6 (1,6%). La mediana de hospitalización fue 6 días (4-9 días). 30 pacientes (8,3%) fallecieron, 50% por infecciones asociadas a la descompensación cardiaca y 20% por síndrome coronario agudo. Conclusión: Se hallaron similitudes con estudios internacionales, pero mayor mortalidad vinculada principalmente a infección como factor precipitante de descompensación. Se caracterizaron factores desencadenantes y etiología, datos útiles en la práctica clínica. Hubo alta carga de comorbilidades, cuya descompensación impactó de manera significativa en la agudización de la falla cardiaca. El subgrupo con fracción de eyección intermedia presentó particularidades que ameritan mayor caracterización.

Abstract Objective: To determine the epidemiological characteristics of adults with acute heart failure admitted to a University Hospital. Method: A retrospective, descriptive cohort study conducted by reviewing the medical notes of patients over 18 years-old and admitted between July and December 2015 to a hospital in Medellin, Colombia. Results: The study included 361 patients with acute heart failure, with a mean age of 76 years, and of whom 193 (53.4%) were women. A reduced ejection fraction (LVEF) was observed in 183 (50.6%) patients, 19 (5.2%) with an intermediate LVEF, and 148 (40.9%) with normal LEVF. The pharmacological treatment prior to admission included angiotensin-converting-enzyme (ACE) inhibitors / angiotensin II receptor antagonists (ARA2) in 253 (70%) patients, a beta-blocker in 212 (58.7%), and spironolactone in 92 (25.4%). The main cause of acute heart failure was the presence of tachy-brady-arrhythmias (17.5%), followed by infection (17.2%), and exacerbation of chronic pulmonary disease (16.3%). The clinical classification of the decompensation was Stevenson B in 335 (92.7%) patients, Stevenson C in 20 (5.5%), and Stevenson L in 6 (1.6%). The mean admission time was 6 (4-9) days. There were 30 (8.3%) deaths, 50% due to infections associated with cardiac decompensation and 20% due to acute coronary syndrome. Conclusion: Similarities were found with international studies, but there was a higher mortality mainly linked to infection as a decompensation precipitating factor. The triggering factors and aetiology are presented, which are useful data in clinical practice. There was a high level of comorbidities, and their decompensation had a significant impact on the exacerbation of heart failure. The sub-group with the intermediate ejection fraction had features that require further characterisation.

Psychoanalitical Pshycotherapy / Psicoterapia psicoanalítica

Resumen El artículo tiene como objetivo analizar una de las prácticas más importantes de la orientación psicoanalítica: la psicoterapia, como posible respuesta, entre otras, a la pregunta por las relaciones entre la psicología y el psicoanálisis. Se presentan algunos antecedentes de la psicoterapia, se plantea una definición de la misma, se exponen dos clases generales para entender los propósitos psicoterapéuticos (ascéticos y sintomales) y se establecen algunas afinidades y divergencias a partir de tres categorías en las que se pueden ubicar diferentes modalidades psicoterapéuticas: a) el conocimiento psicológico y la transmisión de información al consultante; b) la relación terapéutica; y c) la transmisión de una actitud analítica al paciente. El presente manuscrito se propone desde una mirada pluralista e indogmática establecer tanto las afinidades (lo general) en las modalidades psicoterapéuticas como sus diferencias (lo específico). Muestra que la psicoterapia se remonta a la tradición filosófica del cuidado del alma (therapeuein heauton), tanto en un sentido específico (sintomal) como amplio (ascesis subjetiva). Considera que la focalización, más correspondiente con las psicoterapias sintomales, no se opone ni impide un trabajo de revisión exhaustiva de la vida del paciente. Privilegia, de los diversos modos de enfocar el trabajo psicoterapéutico, aquel que se basa en la transmisión de una actitud (analítica) como forma de abordar la existencia; en consecuencia, se distancia de la concepción de la psicología clínica como la aplicación del conocimiento psicológico al ámbito clínico.

Abstract This paper aims to analyze one of the most important practices of the psychoanalytic orientation: psychotherapy, as a possible answer, among others, to the question about the connections between psychology and psychoanalysis. A background of psychotherapy is presented, and it is set up a definition of its concept. In addition, two main categories are discussed (ascetical and symptomal), in order to understand better the psychotherapeutic purposes. Some similarities and differences are established departing from three categories in which psychotherapeutic approaches are located: 1) the psychological knowledge and the transfer of information to the consultant 2) the therapeutic relationship and 3) the transmission of an analytical attitude to the patient. This paper arose from a pluralistic and non-dogmatic point of view in order to establish both similarities (overall) and differences (particularities) in psychotherapeutic approaches. It is shown how psychotherapy dates back to the philosophical tradition of soul caring (therapeuein heauton), both in a specific sense (symptomal) and an overall sense (subjective ascesis).It is considered that the focus of the symptomal psychotherapies does not prevent an exhaustive revision of the patient's life. This article favors the different approaches for the psychotherapeutic work, that one based on the transmission of an (analytical) attitude as a way to face one's life; in consequence, it takes distance from the conception of clinical psychology as the application of psychological knowledge to the clinical domain.

Transcolonic Migration of Retained Epicardial Pacing Wires.

Temporary epicardial pacing wires are associated with rare complications. Most of these occur in the chest. Even rarer are complications that occur within the abdomen. We report a case of migrating epicardial pacing wires entering the abdomen and penetrating the transverse colon found incidentally on colonoscopy in an asymptomatic patient.

Psicología y Salud Psíquica / Psychology and Psychic Health

Es frecuente utilizar la expresión salud mental en lugar de salud psíquica. Partiendo de una definición del objeto de la psicología como cultura encarnada, en este escrito argumentaremos por qué es preferible utilizar la expresión salud psíquica. Consideramos que psyché es un concepto mucho más amplio que mente, y que abarca las diferentes facetas de la realidad humana. Basándonos en las elaboraciones de Canguilhem sobre lo normal y lo patológico, proponemos un concepto de salud que contempla el despliegue del ser humano, en tanto continuación de las pautas que la vida misma establece en su proceso de evolución (AU)

It is common to use the term "mental health" rather than "psychic health". Starting with a definition of the object of psychology as culture incarnate, in this paper we will argue why it is preferable to use the term psychic health. We believe that "psyche" is a much broader concept than mind, covering the different facets of human reality. Based on the working of Canguilhem on the normal and the pathological, we propose a concept of health that includes the deployment of human beings, like a continuation of the patterns that life itself states in its evolution process (AU)

Consistent safety and infectivity in sporozoite challenge model of Plasmodium vivax in malaria-naive human volunteers.

A safe and reproducible Plasmodium vivax infectious challenge method is required to evaluate the efficacy of malaria vaccine candidates. Seventeen healthy Duffy (+) and five Duffy (-) subjects were randomly allocated into three (A-C) groups and were exposed to the bites of 2-4 Anopheles albimanus mosquitoes infected with Plasmodium vivax derived from three donors. Duffy (-) subjects were included as controls for each group. Clinical manifestations of malaria and parasitemia were monitored beginning 7 days post-challenge. All Duffy (+) volunteers developed patent malaria infection within 16 days after challenge. Prepatent period determined by thick smear, was longer for Group A (median 14.5 d) than for Groups B and C (median 10 d/each). Infected volunteers recovered rapidly after treatment with no serious adverse events. The bite of as low as two P. vivax-infected mosquitoes provides safe and reliable infections in malaria-naive volunteers, suitable for assessing antimalarial and vaccine efficacy trials.