Non-alcoholic Steatohepatitis: Comparison of Intestinal Microbiota between Different Metabolic Profiles. A Pilot Study.

BACKGROUND AND AIMS: Non-alcoholic steatohepatitis (NASH) has multifactorial etiopathogenesis, and intestinal microbiota is co-responsible in this process. The aim of this study was to evaluate the intestinal microbiota in NASH patients with different metabolic profiles. METHODS: Patients with biopsy-proven NASH were evaluated. Subjects were divided into two groups according to their metabolic profile, with or without metabolic syndrome (MS). Their characteristics in relation to liver disease and intestinal microbiota were analyzed. To evaluate the microbiota, breath tests to investigate small intestinal bacterial overgrowth (SIBO) and fecal microbiota analysis by fluorescence in situ hybridization (FISH) were performed. RESULTS: There was a high prevalence of SIBO in both groups, with no significant difference between them. Breathing tests were positive in 43.8% of patients with MS and 50% of those without MS. There was a significant difference regarding the quantification of Verrucomicrobiales, less abundant in patients with NASH without MS. Its lower concentration also correlated with higher serum ferritin levels and higher hepatocyte ballooning. This order of bacteria, through its representative in human microbiota, Akkermansia muciniphila, is associated with mucosal protection and metabolic processes with liver aggression. CONCLUSIONS: Our results suggested that lower Verrucomicrobiales concentration is associated with higher inflammatory activity in patients with NASH without MS, where the disease etiopathogenesis does not have its classic metabolic substrate.

Health-related quality of life and fatigue in patients with chronic hepatitis C with therapy with direct-acting antivirals agents interferon-free.

INTRODUCTION: Interferon (IFN)-free regimens for the treatment of chronic hepatitis C have shown high rates of sustained virological response (SVR) and improved patient-reported outcomes (PROs). The aim of this study was to evaluate the health-related quality of life (HRQoL) and fatigue of patients with chronic hepatitis C (HCV) treated with IFN-free direct-acting antiviral (DAA) agents that achieved SVR following treatment and identify the predictive factors related to HRQoL. METHODS: Prospective cohort study that included patients with HCV treated with DAA who obtained an SVR. The patients answered three self-reported questionnaires (PROs): Short Form 36 (SF-36), the Chronic Liver Diseases Questionnaire (CLDQ), and the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire at baseline, weeks 6 and 12 of treatment, and at 12 weeks after therapy. Patients were treated with DAA with or without ribavirin (RBV). The PRO scores were compared using analysis of variance (ANOVA). A comparison of PROs and serum hemoglobin levels was performed between the group that used ribavirin and the one that did not use ribavirin using the t student test. Predictive factors were calculated using a multiple linear regression model. RESULTS: Among the 113 patients selected, 105 presented an SVR and were included in the study, in which, 54% men, 80% genotype 1, 44% cirrhosis and 46% with RBV. At 12 weeks after the end of treatment, there was a significant improvement in the scores of the patient self-reports (PROs) when compared with baseline for the CLDQ (+10.52%, p<0.001), SF-36-Physical Summary (+19%, p<0.001), and FACIT (+17.34%, p<0.001). Patients who used RBV had worse PROs and serum hemoglobin levels compared to the group that did not use RBV (p<0,05). As predictors of worsening of the PROs we had the presence of diabetes mellitus, liver cirrhosis and HIV co-infected. CONCLUSION: Patients treated with IFN free regimens presents significant improvement in PROs. The presence of diabetes mellitus, cirrhosis, and HIV co-infected has a negative effect on HRQoL before, during and after treatment of hepatitis C. The addition of ribavirin to the antiviral regimens used compromises the HRQoL indexes during antiviral therapy.

Effects of Dietary Intervention on Gut Microbiota and Metabolic-Nutritional Profile of Outpatients with Non-Alcoholic Steatohepatitis: a Randomized Clinical Trial.

BACKGROUND AND AIMS: Modulation of the gut microbiota emerges as a therapeutic possibility to improve health. Our objective was to compare the impact of three months of intervention with diet plus nutritional orientation versus only nutritional orientation on the gut microbiota and metabolic-nutritional profile of outpatients with non-alcoholic steatohepatitis. METHODS: It was a randomized clinical trial with 40 outpatients (49.48 ± 10.3 years), allocated in two groups: DIET group (n=20), who received diet (1.651.34 ± 263.25 kcal; 47% carbohydrates, 28% lipids, 25% proteins, 30 g fibers) and nutritional orientation, and control group (n = 20), which received only nutritional orientation. RESULTS: The DIET group, in relation to baseline, presented a reduction in body weight (p<0.001), BMI (p<0.001), waist circumference (p=0.001), percentage of fat (p=0.002), serum aspartate aminotransferase (p<0.001), alanine aminotransferase (p<0.001), γ-glutamyltransferase (p=0.001), glycemia (p=0.003), homeostasis model assessment of insulin resistance (p=0.017), total cholesterol (p=0.014), and triacylglycerols (p=0.008), whereas the control group did not present changes. After intervention, the small intestinal bacterial overgrowth frequency was 30% in the DIET group and 45% in the control group (p=0.327). In the DIET group, an increase in the density of total microorganisms (3.76 ± 7.17 x 10 8 cells g -1 ; p=0.048) was detected, while in the control group reduced Bacteroidetes (-0.77 ± 2.01 x 10 8 cells g -1 , p=0.044) and Verrucomicrobiales (-0.46 ± 0.75 x 10 8 cells g -1 ; p=0.022) were observed. CONCLUSIONS: The results suggest that exclusively dietary modifications contribute to health promotion in non-alcoholic steatohepatitis and should be the basis of nutritional treatment for this condition.

THE USE OF THE FORCEPS BIOPSY AS AN AUXILIARY TECHNIQUE FOR THE VISUALIZATION OF THE MAJOR DUODENAL PAPILLA USING THE FOWARD-VIEWING UPPER ENDOSCOPY.

BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A), partially visualized (position B) or not visualized (position C). If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8%) with mean age of 49 years. Of the 671 patients, 324 (48.3%) major duodenal papilla was identified in position A, 112 (16.7%) in position B and 235 (35%) in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%), position B in 51 (14.7%) and position C in 110 (31.7%). Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%), position B in 14 (8.7%) and position C in 53 (32.9%). The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90%) of the patients (P<0.01) and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.

O uso da pinça de biópsia como técnica auxiliar na visualização da papila duodenal maior utilizando-se o esofagogastroduodenoscópio de visão frontal / The use of the forceps biopsy as an auxiliary technique for the visualization of the major duodenal papilla using the foward-viewing upper endoscopy

ABSTRACT BACKGROUND: - Conventional esophagogastroduodenoscopy is the best method for evaluation of the upper gastrointestinal tract, but it has limitations for the identification of the major duodenal papilla, even after the use of the straightening maneuver. Side-viewing duodenoscope is recommended for optimal examination of major duodenal papilla in patients at high risk for lesions in this region. OBJECTIVE: To evaluate the use of the biopsy forceps during conventional esophagogastroduodenoscopy as an additional tool to the straightening maneuver, in the evaluation of the major duodenal papilla. METHODS: A total of 671 patients were studied between 2013 and 2015, with active major duodenal papilla search in three endoscope steps: not straightened, straightened and use of the biopsy forceps after straightening. In all of them it was recorded whether: major duodenal papilla was fully visualized (position A), partially visualized (position B) or not visualized (position C). If major duodenal papilla was not fully visualized, patients continued to the next step. RESULTS: A total of 341 were female (50.8%) with mean age of 49 years. Of the 671 patients, 324 (48.3%) major duodenal papilla was identified in position A, 112 (16.7%) in position B and 235 (35%) in position C. In the 347 patients who underwent the straightening maneuver, position A was found in 186 (53.6%), position B in 51 (14.7%) and position C in 110 (31.7%). Of the 161 remaining patients and after biopsy forceps use, position A was seen in 94 (58.4%), position B in 14 (8.7%) and position C in 53 (32.9%). The overall rate of complete visualization of major duodenal papilla was 90%. CONCLUSION: The use of the biopsy forceps significantly increased the total major duodenal papilla visualization rate by 14%, reaching 604/671 (90%) of the patients (P<0.01) and it can be easily incorporated into the routine endoscopic examination of the upper gastrointestinal tract.

RESUMO CONTEXTO: Esofagogastroduodenoscopia convencional é o melhor método para avaliação do trato gastrointestinal superior, mas apresenta limitações para identificação da papila duodenal maior, mesmo após emprego da manobra de retificação. Exame completo da papila duodenal maior está indicado para pacientes de alto risco para adenocarcinoma da papila duodenal maior. OBJETIVO: Avaliar a utilização da pinça de biópsia durante esofagogastroduodenoscopia convencional como ferramenta adicional à manobra de retificação na avaliação da papila duodenal maior. MÉTODOS: Foram estudados 671 pacientes entre 2013-2015 com busca ativa da papila duodenal maior em três etapas: endoscópio não retificado, endoscópio retificado e uso da pinça de biópsia após retificação. Em todas se registrou: se a papila duodenal maior foi totalmente visualizada (posição A), se parcialmente visualizada (posição B) ou se não visualizada (posição C). Caso a papila duodenal maior não tenha sido completamente visualizada, o paciente foi direcionado para a etapa seguinte. RESULTADOS: Um total de 341 era do sexo feminino (50,8%) com idade média de 49 anos. Dos 671 pacientes, em 324 (48,3%) a papila duodenal maior foi identificada na posição A, 112 (16,7%) em posição B e, 235 (35%) em posição C. Dos 347 pacientes submetidos à manobra de retificação, posição A foi encontrada em 186 (53,6%), posição B em 51 (14,7%) e posição C em 110 (31,7%). Dos 161 pacientes restantes que utilizaram a pinça de biópsia, posição A foi vista em 94 (58,4%), posição B em 14 (8,7%) e posição C em 53 (32,9%). A taxa acumulativa de visualização completa da papila duodenal maior foi de 90%. CONCLUSÃO: O uso da pinça de biópsia aumentou a taxa de visualização completa da papila duodenal maior em 14%, alcançando 604/671 (90%) dos pacientes (P<0,01) avaliados e pode ser facilmente incorporada aos exames endoscópicos de rotina do trato gastrointestinal superior.

DEPRESSIVE EPISODE INCIDENCE IN PATIENTS WITH CHRONIC HEPATITIS C TREATED WITH PEGYLATED INTERFERON AND RIBAVIRIN.

BACKGROUND: The effectiveness of antiviral therapy with pegylated interferon and ribavirin for chronic hepatitis C is far from ideal and presents several adverse events. Among such events, there is the depressive episode that can even lead to treatment discontinuity. OBJECTIVE: Analyze the incidence of depressive episodes in patients with chronic hepatitis C treated with pegylated interferon (IFN-PEG) and ribavirin, as well as the possible factors associated with its occurrence and its impact on patients' sustained virological response. METHODS: People with chronic hepatitis C undergoing antiviral therapy were interviewed at the baseline, at the 4th, 12th, 24th and 48th treatment weeks and 4 weeks after the end of it, using the HADS scale for tracking the depressive episode. Patients with HADS ≥9 were subjected to Beck Depression Inventory (BDI-II) to grade the episode. Clinical, sociodemographic, laboratorial and histological variables were obtained to identify factors related to the onset of depression. The sustained virological response rate (negative HCV-RNA 6 months after end of therapy) was compared among patients with and without depressive symptoms. RESULTS: The study comprised 32 patients, most men (59%) with mean age of 54±11.13 years old. Genotype non-1 was prevalent (56%) and 81% of the patients were non-cirrhotic. The depressive episode was diagnosed in 25% of the patients and the peak incidence was found in the 12th treatment week. The depressive episode was moderate in 87% of the patients and only one patient abandoned the treatment. None of the analyzed factors was associated with depressive episode onset. A trend was observed in female patients ( P =0.08). The sustained virological response rate was of 75% and 67% in patients with and without depressive episode, respectively ( P =0.66). CONCLUSION: The incidence of depressive episodes in patients with chronic hepatitis C undergoing antiviral therapy was of 25% and the 12th treatment week was the most critical one. The presence of depressive episode did not affect the sustained virological response rate.

Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam / Sedação para colonoscopia: ensaio clínico comparando propofol e fentanil associado ou não ao midazolam

ABSTRACT Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic 5 min before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.

RESUMO A colonoscopia é um dos procedimentos mais feitos. Sedação e analgesia diminuem a ansiedade e o desconforto e minimizam riscos. Em razão disso, os pacientes preferem que o exame seja feito sob anestesia, embora não tenha sido determinada a melhor combinação de fármacos. A associação de benzodiazepínicos com opioides é usada para aliviar a dor e o desconforto do paciente. Mais recentemente, o propofol assumiu posição de destaque. Este estudo, prospectivo e randomizado, é único na literatura médica e especificamente comparou o uso do propofol e fentanil associado ou não ao midazolam na sedação para colonoscopia feita por anestesiologistas. Os objetivos do estudo foram avaliar os efeitos colaterais da sedação, as condições de alta, a qualidade da sedação e o consumo de propofol durante a colonoscopia, com ou sem o midazolam como pré-anestésico. Envolveu 140 pacientes submetidos à colonoscopia, no Hospital Universitário da Universidade Federal de Juiz de Fora. Os pacientes foram divididos em dois grupos. O Grupo I recebeu, por via endovenosa, midazolam como pré-anestésico, cinco minutos antes da sedação, seguido do fentanil e propofol. O Grupo II recebeu, por via endovenosa, anestesia com fentanil e propofol. Os pacientes do Grupo II apresentaram maior incidência de reação (motora ou verbal) à introdução do colonoscópio, bradicardia, hipotensão arterial e maior consumo de propofol. A satisfação dos pacientes foi maior no Grupo I. De acordo com a metodologia empregada, a associação de midazolam ao propofol e fentanil para sedação em colonoscopia reduz o consumo de propofol e cursa com maior satisfação do paciente.

Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam.

Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic 5min before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.

Depressive episode incidence in patients with chronic hepatitis c treated with pegylated interferon and ribavirin

ABSTRACT Background The effectiveness of antiviral therapy with pegylated interferon and ribavirin for chronic hepatitis C is far from ideal and presents several adverse events. Among such events, there is the depressive episode that can even lead to treatment discontinuity Objective Analyze the incidence of depressive episodes in patients with chronic hepatitis C treated with pegylated interferon (IFN-PEG) and ribavirin, as well as the possible factors associated with its occurrence and its impact on patients' sustained virological response. Methods People with chronic hepatitis C undergoing antiviral therapy were interviewed at the baseline, at the 4th, 12th, 24th and 48th treatment weeks and 4 weeks after the end of it, using the HADS scale for tracking the depressive episode. Patients with HADS ≥9 were subjected to Beck Depression Inventory (BDI-II) to grade the episode. Clinical, sociodemographic, laboratorial and histological variables were obtained to identify factors related to the onset of depression. The sustained virological response rate (negative HCV-RNA 6 months after end of therapy) was compared among patients with and without depressive symptoms. Results The study comprised 32 patients, most men (59%) with mean age of 54±11.13 years old. Genotype non-1 was prevalent (56%) and 81% of the patients were non-cirrhotic. The depressive episode was diagnosed in 25% of the patients and the peak incidence was found in the 12th treatment week. The depressive episode was moderate in 87% of the patients and only one patient abandoned the treatment. None of the analyzed factors was associated with depressive episode onset. A trend was observed in female patients ( P=0.08). The sustained virological response rate was of 75% and 67% in patients with and without depressive episode, respectively (P =0.66). Conclusion The incidence of depressive episodes in patients with chronic hepatitis C undergoing antiviral therapy was of 25% and the 12th treatment week was the most critical one. The presence of depressive episode did not affect the sustained virological response rate.

RESUMO Contexto A terapia antiviral para a hepatite C crônica com interferon peguilado e ribavirina tem eficácia longe do ideal e é repleta de eventos adversos. Entre estes, destaca-se o transtorno depressivo que pode inclusive levar a interrupção do tratamento. Objetivos Em pacientes com hepatite C crônica tratados com interferon peguilado (IFN-PEG) e ribavirina, verificar a incidência de episódio depressivo, os possíveis fatores associados ao seu surgimento e o impacto deste sobre a resposta virológica sustentada. Métodos Portadores de hepatite C crônica submetidos à terapia antiviral foram entrevistados no Baseline, nas semanas 4, 12, 24, 48 de tratamento e quatro semanas após o término do mesmo utilizando a escala HADS para rastreamento do episódio depressivo e naqueles com HADS ≥9 o Inventário de Depressão de Beck (BDI-II) para graduação do episódio. Variáveis clínicas, sociodemográficas, laboratoriais e histológicas foram obtidas com o objetivo de identificar os fatores relacionados ao surgimento da depressão. A taxa de resposta virológica sustentada (HCV-RNA negativo seis meses após a interrupção da terapia) foi comparada entre os pacientes com e sem sintomas depressivos. Resultados Foram incluídos 32 pacientes, a maioria do sexo masculino (59%) e com média de idade de 54±11,13 anos. Prevaleceu o genótipo não 1 (56%) e 81% dos pacientes foram não cirróticos. Episódio depressivo foi diagnosticado em 25% dos pacientes sendo o pico de incidência observado na semana 12 de tratamento. O episódio depressivo foi moderado em 87% dos pacientes e motivou a interrupção em somente 1 deles. Nenhum dos fatores analisados foi associado ao surgimento de episódio depressivo observando-se uma tendência com relação ao sexo feminino ( P =0,08). A taxa de resposta virológica sustentada foi 75% e 67% nos pacientes com e sem episódio depressivo, respectivamente ( P =0,66). Conclusão A incidência de episódio depressivo em pacientes com hepatite C crônica submetidos à terapia antiviral foi de 25% e a semana 12 é a mais crítica. A presença de episódio depressivo não interferiu na taxa de resposta virológica sustentada.

[Colonoscopy sedation: clinical trial comparing propofol and fentanyl with or without midazolam]. / Sedação para colonoscopia: ensaio clínico comparando propofol e fentanil associado ou não ao midazolam.

Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic five minutes before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction.

Health-Related Quality of Life in patients with hepatitis C in double and triple therapy / Calidad de vida relacionada con la salud en pacientes con hepatitis c en terapia doble y triple / Qualidade de vida relacionada à saúde em pacientes com hepatite C em terapia dupla e tripla

Abstract OBJECTIVE Comparing Health-Related Quality of Life (HRQoL) scores in patients with chronic hepatitis C undergoing double and triple antiviral therapy and analyzing possible factors related to HRQoL. METHOD HRQoL was assessed using the Short Form 36 and Chronic Liver Disease Questionnaire, which were applied at baseline and at weeks 4, 12 and 16 of treatment to 32 patients divided into two groups: double therapy with pegylated interferon (IFN-PEG) and ribavirin, and triple therapy with PEG-IFN, ribavirin and telaprevir. RESULTS The reduction of HRQoL was greater in patients receiving triple therapy compared to those treated with two drugs, the most critical time is at 12 weeks in both groups. After removal of telaprevir, the triple therapy group significantly improved their HRQoL scores. Anxiety and depression before treatment, employment status and race are significantly related to diminished HRQoL. CONCLUSION Patients undergoing double and triple therapy have diminished HRQoL indexes, but the addition of telaprevir chooses a more significant decrease.

Resumen OBJETIVO Comparar los puntajes de Calidad de Vida Relacionada con la Salud (CVRS) en pacientes con hepatitis C crónica sometidos a la terapia antiviral doble y triple y analizar los posibles factores relacionados con la CVRS. MÉTODO La CVRS fue evaluada utilizando el Short Form 36 y elChronic Liver Disease Questionnaire , que fueron aplicados antes y en las semanas 4, 12 y 16 de tratamiento, en 32 pacientes divididos en 2 grupos: terapia doble con interferón pegilado (IFN-PEG) y ribavirina, y triple con IFN-PEG, ribavirina y telaprevir. RESULTADOS La reducción de la CVRS fue mayor en pacientes en terapia triple cuando comparados con los tratados con dos drogas, siendo el momento más crítico la 12ª semana en ambos grupos. Después de la retirada del telaprevir, el grupo de terapia triple mejoró de modo significativo los puntajes de CVRS. Ansiedad y depresión en el pre tratamiento, situación de empleo y raza se mostraron relacionados con la reducción de la CVRS. CONCLUSIÓN Pacientes sometidos a la terapia doble y triple presentan reducción de los índices de CVRS, pero la adición del telaprevir les proporciona una caída más expresiva.

Resumo OBJETIVO Comparar os escores de Qualidade de Vida Relacionada à Saúde (QVRS) em pacientes com hepatite crônica C submetidos à terapia antiviral dupla e tripla e analisar os possíveis fatores relacionados à QVRS. MÉTODO A QVRS foi avaliada utilizando o Short Form 36 e oChronic Liver Disease Questionnaire , que foram aplicados antes e nas semanas 4, 12 e 16 de tratamento, em 32 pacientes divididos em 2 grupos: terapia dupla com interferon peguilado (IFN-PEG) e ribavirina e tripla com IFN-PEG, ribavirina e telaprevir. RESULTADOS A redução da QVRS foi maior em pacientes em terapia tripla quando comparados àqueles tratados com duas drogas, sendo o momento mais crítico a 12ª semana em ambos os grupos. Após a retirada do telaprevir, o grupo terapia tripla melhorou de modo significativo os escores de QVRS. Ansiedade e depressão no pré-tratamento, status empregatício e raça se mostraram relacionados à redução da QVRS. CONCLUSÃO Pacientes submetidos à terapia dupla e tripla apresentam redução dos índices de QVRS, mas a adição do telaprevir confere uma queda mais expressiva.

[Health-Related Quality of Life in patients with hepatitis C treated with dual and triple therapy]. / Qualidade de vida relacionada à saúde em pacientes com hepatite C em terapia dupla e tripla.

OBJECTIVE: Comparing Health-Related Quality of Life (HRQoL) scores in patients with chronic hepatitis C undergoing double and triple antiviral therapy and analyzing possible factors related to HRQoL. METHOD: HRQoL was assessed using the Short Form 36 and Chronic Liver Disease Questionnaire, which were applied at baseline and at weeks 4, 12 and 16 of treatment to 32 patients divided into two groups: double therapy with pegylated interferon (IFN-PEG) and ribavirin, and triple therapy with PEG-IFN, ribavirin and telaprevir. RESULTS: The reduction of HRQoL was greater in patients receiving triple therapy compared to those treated with two drugs, the most critical time is at 12 weeks in both groups. After removal of telaprevir, the triple therapy group significantly improved their HRQoL scores. Anxiety and depression before treatment, employment status and race are significantly related to diminished HRQoL. CONCLUSION: Patients undergoing double and triple therapy have diminished HRQoL indexes, but the addition of telaprevir chooses a more significant decrease.

Acupuncture effectiveness as a complementary therapy in functional dyspepsia patients.

CONTEXT: Functional dyspepsia represents a frequent gastrointestinal disorder in clinical practice. According to the Roma III criteria, functional dyspepsia can be classified into two types as the predominant symptom: epigastric pain and postprandial discomfort. Even though the pathophysiology is still uncertain, the functional dyspepsia seems to be related to multiple mechanisms, among them visceral hypersensitivity, changes in the gastroduodenal motility and gastric accommodation and psychological factors. OBJECTIVE: Evaluate the effectiveness of acupuncture as a complementary to conventional treatment in functional dyspepsia patients. METHODS: Randomized clinical trial in which were enrolled patients with functional dyspepsia patients in according with Rome III criteria. One group was submitted to drug therapy and specific acupuncture (GI) and the other to drug therapy and non-specific acupuncture (GII). The gastrointestinal symptoms, presence of psychiatric disorders and quality of life were evaluated, at the end and three months after treatment. RESULTS: After 4 weeks of treatment there was improvement of gastrointestinal symptoms in Group I (55 ± 12 vs 29 ± 8.8; P = 0.001) and Group II (50.5 ± 10.2 vs 46 ± 10.5; P = 0.001). Quality of life was significantly better in Group I than group II (93.4 ± 7.3 vs 102.4 ± 5.1; P = 0.001). Anxiety (93.3% vs 0%; P = 0.001) and depression (46.7% vs 0%; P = 0.004) were significantly lower in Group I than group II. When comparing the two groups after 4 weeks of treatment, gastrointestinal symptoms (29 ± 8.8 vs 46 ± 10.5; P<0.001) and quality of life (102.4 ± 5.1 vs 96 ± 6.1; P = 0.021) were significantly better in Group I than group II. Three months after the treatment, gastrointestinal symptoms remained better only in Group I, when compared to the pre-treatment values (38 ± 11.3 vs 55 ± 12; P = 0.001). CONCLUSION: In patients with functional dyspepsia the complementary acupuncture treatment is superior to conventional treatment. Further studies with more patients are needed to confirm these findings.

Acupuncture effcctiveness as a complementary therapy in functional dyspepsia patients / Eficacia da acupuntura como terapia complementar em pacientes com dispepsia funcional

Context Functional dyspepsia represents a frequent gastrointestinal disorder in clinical practice. According to the Roma III criteria, functional dyspepsia can be classified into two types as the predominant sympton: epigastric pain and postprandial discomfort. Even though the pathophysiology is still uncertain, the functional dyspepsia seems to be related to multiple mechanisms, among them visceral hypersensitivity, changes in the gastroduodenal motility and gastric accommodation and psychological factors. Objective Evaluate the effectiveness of acupuncture as a complementary to conventional treatment in functional dyspepsia patients. Methods Randomized clinical trial in which were enrolled patients with functional dyspepsia patients in according with Rome III criteria. One group was submitted to drug therapy and specific acupuncture (GI) and the other to drug therapy and non-specific acupuncture (GII). The gastrointestinal symptoms, presence of psychiatric disorders and quality of life were evaluated, at the end and three months after treatment. Results After 4 weeks of treatment there was improvement of gastrointestinal symptoms in Group I (55 ± 12 vs 29 ± 8.8; P = 0.001) and Group II (50.5 ± 10.2 vs 46 ± 10.5; P = 0.001). Quality of life was significantly better in Group I than group II (93.4 ± 7.3 vs 102.4 ± 5.1; P = 0.001). Anxiety (93.3% vs 0%; P = 0.001) and depression (46.7% vs 0%; P = 0.004) were significantly lower in Group I than group II. When comparing the two groups after 4 weeks of treatment, gastrointestinal symptoms (29 ± 8.8 vs 46 ± 10.5; P<0.001) and quality of life (102.4 ± 5.1 vs 96 ± 6.1; P = 0.021) were significantly better in Group I than group II. Three months after the treatment, gastrointestinal symptoms remained better only in Group I, when compared to the pre-treatment values (38 ± ...

Contexto A dispepsia funcional representa uma frequente desordem gástrica da prática clínica. Segundo os critérios de Roma III, pode ser subdividida em dois tipos: do tipo dor epigástrica e tipo desconforto pós prandial, de acordo com o sintoma predominante. Embora de fisiopatologia incerta, a dispepsia funcional parece estar relacionada a múltiplos mecanismos, entre eles: a hipersensibilidade visceral, alterações da motilidade gastroduodenal e acomodação gástrica e participação de fatores psíquicos. Objetivos Avaliar a eficácia da acupuntura como forma complementar ao tratamento medicamentoso em pacientes com dispepsia funcional. Método Ensaio clínico randomizado, com portadores de dispepsia funcional, segundo os critérios de Roma III. Dois grupos foram formados: Grupo I (terapia medicamentosa e acupuntura específica) e; II (terapia medicamentosa e acupuntura não específica). Foram avaliados o índice de sintomas gastrointestinais, a presença de transtornos psíquicos e a qualidade de vida no início, no fim e 3 meses após o tratamento. Resultados Após 4 semanas de tratamento houve melhora dos sintomas gastrointestinais no Grupo I (55 ± 12 vs 29 ± 8,8; P = 0,001) e no Grupo II (50 ± 10 vs 46 ± 10,5; P = 0,001). Na comparação intergrupos, os sintomas gastrintestinais (29 ± 8,8 vs 46 ± 10,5; P<0,001) e os sintomas de ansiedade (0% vs 41,7%; P = 0,003) foram significativamente menores no Grupo I e a qualidade de vida (102,4 ± 5,1 vs 96,4 ± 6,1; P = 0,021) também foi significativamente melhor neste grupo. Três meses após o tratamento, os sintomas gastrointestinais permaneceram melhores no Grupo I, quando comparados aos valores pré-tratamento (38 ± 11,3 vs 55 ...

Insulin resistance in non-diabetic patients with chronic hepatitis C: what does it mean?

OBJECTIVES: To determine the prevalence of insulin resistance (IR) in non-diabetic patients with chronic hepatitis C, and to assess the association between IR, laboratory parameters and histological findings. SUBJECTS AND METHODS: Eighty-two patients had their serum analyzed for glucose, lipid profile, C-reactive protein (CRP), ferritin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), HOMA-IR, viral load and HCV genotype. Patients with HOMA-IR levels > 2.5 were considered as carriers of insulin resistance. RESULTS: IR was observed in 27% of patients and was associated with age, waist circumference and body mass index. IR patients were more likely to have more advanced hepatic fibrosis and necroinflammatory activity, higher levels of aminotransferases and liver steatosis than patients without IR. CONCLUSIONS: Insulin resistance is often present in patients with chronic hepatitis C, and this parameter is associated with more advanced HCV-related hepatic fibrosis.

Insulin resistance in non-diabetic patients with chronic hepatitis C: what does it mean? / Resistência insulínica em portadores de hepatite crônica C não diabéticos: qual o significado?

OBJECTIVES: To determine the prevalence of insulin resistance (IR) in non-diabetic patients with chronic hepatitis C, and to assess the association between IR, laboratory parameters and histological findings. SUBJECTS AND METHODS: Eighty-two patients had their serum analyzed for glucose, lipid profile, C-reactive protein (CRP), ferritin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), HOMA-IR, viral load and HCV genotype. Patients with HOMA-IR levels > 2.5 were considered as carriers of insulin resistance. RESULTS: IR was observed in 27 percent of patients and was associated with age, waist circumference and body mass index. IR patients were more likely to have more advanced hepatic fibrosis and necroinflammatory activity, higher levels of aminotransferases and liver steatosis than patients without IR. CONCLUSIONS: Insulin resistance is often present in patients with chronic hepatitis C, and this parameter is associated with more advanced HCV-related hepatic fibrosis.

OBJETIVOS: Em portadores de hepatite crônica C não diabéticos, verificar a prevalência de resistência insulínica (RI) e analisar a associação desta com os parâmetros laboratoriais e histológicos. SUJEITOS E MÉTODOS: Foram incluídos no estudo 82 pacientes, e amostras de sangue foram coletadas para determinação de glicose, perfil lipídico, alanina aminotransferase (ALT), aspartato aminotransferase (AST), ferritina, HOMA-IR, carga viral e genótipo do VHC. HOMA-IR superior a 2,5 foi considerado resistência insulínica. RESULTADOS: RI foi observada em 27 por cento dos pacientes e foi associada a idade, circunferência abdominal e índice de massa corpórea. Quando comparado a pacientes sem RI, aqueles com HOMA-IR superior a 2,5 apresentaram graus mais acentuados de fibrose hepática e atividade necroinflamatória, maiores níveis de aminotransferases e esteatose hepática mais frequente. CONCLUSÕES: É comum a presença de RI em portadores de hepatite crônica C e esta se associa com graus mais avançados de fibrose hepática induzida pelo vírus da hepatite C.

Utilização de endopróteses auto-expansíveis em tumores concomitantes de esôfago e região pré-pilórica: relato de caso / Self-expanding endoprostheses in concomitant esophageal and pre-pyloric malignancies: case report

Endopróteses auto-expansíveis são dispositivos utilizados com objetivo de restituir a patência da luz do Trato Gastrointestinal, sendo consideradas ferramentas bem estabelecidas e minimamente invasivas. Antes de seu desenvolvimento, o único meio para a restituição da continuidade do trânsito era através de cirurgia paliativa, que, embora ainda considerada padrão-ouro, não é isenta de riscos, podendo acarretar aumento nas taxas de morbidade e mortalidade. A utilização de múltiplas próteses na abordagem de tumores localizados em pontos distintos é rara, sendo poucos os casos relatados na literatura. Relatamos o caso de uma paciente de 92 anos com quadro de anemia de etiologia desconhecida e disfagia progressiva. Ao exame endoscópico, observou-se lesão infiltrante de esôfago e lesões vegetantes ulceradas em corpo e antro. Procedeu-se ao controle endoscópico da hemorragia gástrica. A família autorizou a introdução de endoprótese auto-expansível somente no esôfago inicialmente. Contudo, após nova reavaliação e explicação da possibilidade de obstrução gástrica, procedeu-se, um mês após, à colocação de endoprótese também na região pré-pilórica. Durante os últimos nove meses de sobrevida depois da introdução da segunda prótese, observou-se melhora importante da qualidade de vida da paciente.

Self-expanding endoprostheses are well established and minimally invasive devices used to re-establish patency of the gastrointestinal tract. Before their development, patency could only be re-established through palliative surgery, a procedure that though still the gold standard, carries a significant risk and increases morbidity and mortality rates. Management of localized tumors with multiple prostheses is still rarely reported in the literature. We report a 92-year-old women with anemia of unknown origin and progressive dysphagia. Endoscopy revealed an infiltrative lesion of the esophagus along with ulcerated vegetative lesions of gastric body and antrum. Gastric hemorrhage was endoscopically controlled. The family initially agreed with the introduction of a self-expanding prosthesis in the esophagus alone. On re-evaluation one month later the possibility of gastric obstruction was discussed and the introduction of a prepyloric endoprosthesis was agreed upon. Significant improvement in life quality was observed in the last nine months of survival following introduction of the second prosthesis.

Hemorragia digestiva alta / Upper gastrointestinal bleeding

Hemorragia digestiva alta é uma condição grave e potencialmente fatal associada com muitas doenças sistêmicas e gastrointestinais. Embora a mortalidade varia de acordo com a etiologia do sangramento, em geral, é cerca de 10%. Metade desses pacientes têm mais de 60 anos de idade, e neste grupo etário de mortalidade é ainda maior. que podem ser provenientes de várias fontes, principalmente: úlcera péptica, hypertesion portal, anomalias vasculares e neoplasias. Avaliação inicial inclui a estabilização do quadro hemodinâmico e de reposição de sangue sempre que necessário. Endoscopia desempenha um papel importante no diagnóstico e tratamento da maioria das condições de sangramento. O tratamento farmacológico inclui agentes anti-secretores octreotide, e vasopressina. A cirurgia é eventualmente necessário.

Upper gastrointestinal bleeding is a serious and potentially life threatening condition associated with many systemic and gastrointestinal diseases. Although mortality varies according to the etiology of the bleeding, in general, it is around 10%.Half of these patients are over 60 years of age, and in this age group mortality is even higher. it may originate from a number of sources, mainly: peptic ulcer disease, portal hypertesion, vascular anomalies and neoplasms. Initial evaluation includes stabilization of the hemodynamic status and blood replacement whenever necessary. Endoscopy plays an important role in diagnosis and treatment of most bleeding conditions. Pharmacological treatment includes anti-secretory agents, octreotide and vasopressin. Surgery is eventually necessary.

Hemorragia digestiva baixa em criança / Lower digestive hemorrhage in childhood

A hemorragia digestiva baixa em crianças está relacionada a uma série de diagnósticos que variam de acordo com a faixa etária do paciente pediátrico. Os dados da história clínica, assim como a idade do paciente, tipo de sangramento e história dietética, são fundamentais para um diagnóstico correto. Os achados de exame físico e os exames complementares realizados de acordo com a suspeita clínica, geralmente levam à resolução do problema. Os autores propõem, através desta revisão de leitura, um roteiro diagnóstico para o sangramento gastrointestinal baixo em pediatria, discutindo ainda os principais diagnósticos diferenciais.

Doença de Whipple com comprometimento hepático: relato de caso / Whipple's disease with liver involvement

Neste relato apresenta-se um caso de Doença de Whipple (DW) em um paciente com sintomas de diarréia crônica,perda de peso e poliartralgia, com acometimento hepático e pulmonar. O diagnóstico de DW foi confirmado por endoscopia digestiva alta com biópsia duodenal, e o comprometimento hepático por biópsia hepática percutânea com achado de granulomas e estruturas PAS positivas. Penicilina G cristalina seguida de Sulfametoxazol / Trimetoprima foi a terapêutica instituída e observamos significativa melhora clínica e praticamente normalizaçäo das enzimas colestáticas após 30 dias de tratamento. Salientamos a importância de incluir a DW no diagnóstico diferencial de todos os pacientes que apresentem as manifestaçöes cardinais da doença (dor abdominal, diarréia crônica, artralgia e perda de peso), uma vez que adequada terapia em tempo hábil pode prevenir complicaçöes. Além disso, DW cursando com elevaçäo das enzimas colestáticas deve sugerir infiltraçäo hepática pelos bacilos causadores da doença ou a presença de granulomas reacionais.