Percutaneous Endoscopic Gastrostomy Placement under NIV in Amyotrophic Lateral Sclerosis with Severe Ventilatory Dysfunction: A Safe and Effective Procedure.

Introduction: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with an inexorably progressive course which leads to a progressive neuromuscular weakness. Weight loss is one of the major bad prognostic factors in ALS. The placement of percutaneous endoscopic gastrostomy (PEG) is of paramount importance in patients with dysphagia to improve the disease outcomes, although some fear exists regarding the possible ventilatory complications during the procedure. The aim of this study was to evaluate the safety and effectiveness of PEG tube insertion under non-invasive ventilation (NIV) in patients with ALS and severe ventilatory impairment. Methods: A retrospective study of all consecutive PEGs placed in our department from May 2011 to January 2018 in patients with ALS was performed. The procedure was performed under non-invasive positive-pressure ventilation for ventilatory support. Results: We included 59 patients with ALS with severe ventilatory impairment, 58% were female, with a mean age of 67.2 ± 10.1 years and a median follow-up of 6 [2-15] months. The main indication for PEG placement was dysphagia (98%). The median time for PEG tube insertion since the established diagnosis of ALS was 12 [6-25] months and 4 [2-18] months since the beginning of bulbar symptoms. The majority of the patients had placed a 20-Fr PEG (63%) and under mild sedation with midazolam (80%), all under NIV. There were no immediate complications during and after the procedure (no episodes of aspiration or orotracheal intubation) and mortality. Conclusion: The placement of PEG is a very important procedure in patients with ALS and severe ventilatory impairment. The interdisciplinary department collaboration permitted the placement of PEG under NIV, in a safe and effective procedure in this special population.

Introdução: A esclerose lateral amiotrófica (ELA) é uma doença neurodegenerativa com um curso inexorável que leva a fraqueza neuromuscular progressiva. A perda de peso é um dos principais fatores de mau prognóstico na ELA. Apesar do receio de complicações ventilatórias durante o procedimento, a colocação de gastrostomia percutânea endoscópica em doentes com disfagia é extremamente importante para melhorar o prognóstico. O objetivo deste estudo é avaliar a segurança e eficácia da colocação de gastrostomia percutânea endoscópica (GEP) sob ventilação não invasiva (VNI) em doentes com ELA e disfunção ventilatória grave. Métodos: Estudo retrospetivo de todas as gastrostomias percutâneas endoscópicas colocadas em doentes com ELA no nosso departamento entre Maio 2011 e Janeiro 2018. O procedimento foi realizado sob VNI para suporte ventilatório. Resultados: Foram incluídos 59 doentes com ELA e disfunção ventilatória grave, 58% do sexo feminino, com uma idade média de 67.2 ± 10.1 anos e um follow-up mediano de 6 [2­15] meses. A principal indicação para colocação de gastrostomia percutânea endoscópica foi disfagia (98%). O tempo mediano para a colocação de GEP desde o diagnóstico de ELA foi 12 [6­25] meses e 4 [2­18] meses desde o início dos sintomas bulbares. A maioria dos doentes colocaram uma GEP de 20 Fr (63%) e sob sedação com midazolam (80%), todos sob VNI. Não se verificaram complicações imediatas durante e após o procedimento (sem episódios de aspiração ou entubação orotraqueal) e mortalidade. Conclusão: A colocação de GEP é um procedimento muito importante em doentes com ELA e disfunção ventilatória grave. A colaboração interdisciplinar permitiu a colocação de GEP sob ventilação não invasiva, tornando-o um procedimento seguro e eficaz nesta população especial.

Implantação e implementação de serviços em cuidados paliativos / Establishing and implementing palliative care services / Implantación e implementación de servicios en cuidados paliativos

Resumo Considerando que a demanda de ampliação de serviços de cuidados paliativos nos hospitais gerais do Brasil torna necessário enfrentar obstáculos e estabelecer estratégias para viabilizar a implantação desses serviços no sistema de saúde, buscou-se identificar o processo de implantação e a efetivação de serviços de cuidados paliativos em hospitais gerais do país. Mediante revisão integrativa da literatura, que consistiu na análise de quatro artigos, foram identificadas as seguintes etapas para implantação e efetivação de serviços de cuidados paliativos: elaboração de protocolo, cuidado humanizado, multidisciplinariedade e educação. Além disso, detectaram-se os desafios a seguir: ausência de treinamento e educação em cuidados paliativos, dificuldade de consenso sobre práticas paliativas, comunicação, oferta de fármacos e apoio dos governos. Considera-se que o estabelecimento de políticas públicas é essencial para garantir a implantação dos cuidados paliativos em hospitais.

Abstract Since expanding palliative care services within general hospitals in Brazil involves confronting obstacles and establishing strategies to enable their implementation in the health system, this study sought to identify the process around establishing and implementing palliative care services in Brazilian general hospitals. An integrative literature review of four articles identified the following steps for establishing and implementing palliative care services: protocol development, humanized care, multidisciplinarity, and education. As for the obstacles, the analysis highlighted the lack of training and education in palliative care, difficulty in reaching consensus on palliative practices, communication, drug supply, and government support. In conclusion, public policy development is essential to guarantee the implementation of palliative care in hospitals.

Resumen Teniendo en cuenta que la demanda de servicios de cuidados paliativos en los hospitales generales de Brasil requiere el enfrentamiento de obstáculos y el establecimiento de estrategias para viabilizar la implementación de estos servicios en el sistema de salud, se plantea identificar el proceso de implantación y la efectividad de los servicios de cuidados paliativos en hospitales generales del país. Desde una revisión integradora de la literatura, que consistió en el análisis de cuatro artículos, se identificaron las siguientes etapas para la implantación y efectividad de los servicios de cuidados paliativos: Elaboración de protocolos, cuidado humanizado, multidisciplinariedad y educación. Además, se constataron como desafíos la falta de formación y educación en cuidados paliativos, la dificultad para llegar a consensos sobre prácticas paliativas, la comunicación, el suministro de medicamentos y el apoyo gubernamental. Es fundamental establecer políticas públicas para garantizar la implantación de los cuidados paliativos en los hospitales.

Physical Fitness and Health-related Quality of Life in Patients with Colorectal Cancer.

Colorectal cancer is now a frequently treatable illness for most and a chronic disease for many. The number of people living with a diagnosis of colorectal cancer is thus expected to rise. Yet even after successful treatment, colorectal cancer survivors, mostly the elderly, frequently experience health problems and impaired health-related quality of life. We investigated the cross-sectional association between physical fitness, measured with the 6-min walk test, 30-second chair-stand test, and isometric handgrip strength, as well as health-related quality of life, in a cohort of colorectal cancer patients (n=71, mean [SD] age 67±10 years, 63% men; 35, 39 and 25% in stages I, II and III, respectively). Greater performance in the 6-minute walk test and 30-second chair-stand test was associated with higher levels of global health status (p<0.001, p=0.001 respectively), higher functioning (p<0.001) and lower levels of symptomatology (p<0.001; pain and fatigue). Additionally, greater 6-min walk test performance was associated with a better cognitive function (p=0.005). Our results suggest that greater aerobic fitness and lower-extremity muscle strength are cross-sectionally associated with higher levels of global health status, higher functioning and lower levels of symptomatology such as pain and fatigue in colorectal cancer patients.

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study.

Background and study aims Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.

Large desmoid tumors in familial adenomatous polyposis: a successful outcome

Desmoid tumors develop from connective tissue, fasciae, and aponeuroses, and may occur in the context of familial adenomatous polyposis or may arise sporadically; also, they may be extra-abdominal, intra-abdominal, or located in the abdominal wall. These benign tumors have a great aggressiveness with a high rate of local recurrence. Familial adenomatous polyposis is an inherited condition with autosomal dominant transmission, and is characterized by the development of multiple colonic and rectal adenomatous polyps, as well as desmoid tumors. We present the case of a 54-year-old woman with germline APC gene mutation, who underwent a total colectomy, subsequently developing two large infiltrative solid intra-abdominal lesions consistent with desmoid tumors. Medical treatment with Cox-2 inhibitors was initiated without result. She was submitted to resection for intestinal obstruction, but developed local recurrence. The lesions were also unresponsive to tamoxifen, and chemotherapy was initiated with dacarbazine plus doxorubicin, switching to vinorelbine plus methotrexate, achieving a good response in all lesions after 12 months. The approach to these intra-abdominal lesions should be progressive, beginning with observation, then a medical approach with non-steroidal anti-inflammatory drugs or with an anti-hormonal agent. Afterwards, if progression is still evident, chemotherapy should be started. Surgery should be reserved for resistance to medical treatment, in palliative situations, or for extra-abdominal or abdominal wall desmoids tumors.

Large desmoid tumors in familial adenomatous polyposis: a successful outcome.

Desmoid tumors develop from connective tissue, fasciae, and aponeuroses, and may occur in the context of familial adenomatous polyposis or may arise sporadically; also, they may be extra-abdominal, intra-abdominal, or located in the abdominal wall. These benign tumors have a great aggressiveness with a high rate of local recurrence. Familial adenomatous polyposis is an inherited condition with autosomal dominant transmission, and is characterized by the development of multiple colonic and rectal adenomatous polyps, as well as desmoid tumors. We present the case of a 54-year-old woman with germline APC gene mutation, who underwent a total colectomy, subsequently developing two large infiltrative solid intra-abdominal lesions consistent with desmoid tumors. Medical treatment with Cox-2 inhibitors was initiated without result. She was submitted to resection for intestinal obstruction, but developed local recurrence. The lesions were also unresponsive to tamoxifen, and chemotherapy was initiated with dacarbazine plus doxorubicin, switching to vinorelbine plus methotrexate, achieving a good response in all lesions after 12 months. The approach to these intra-abdominal lesions should be progressive, beginning with observation, then a medical approach with non-steroidal anti-inflammatory drugs or with an anti-hormonal agent. Afterwards, if progression is still evident, chemotherapy should be started. Surgery should be reserved for resistance to medical treatment, in palliative situations, or for extra-abdominal or abdominal wall desmoids tumors.

Detection of Fusobacterium spp in colorectal tissue samples using reverse transcription polymerase chain reaction with minor groove binder probes: an exploratory research.

An unhealthy microbiome is intimately correlated with several disease states, including colorectal cancer, wherein bacteria might be the key to neoplastic initiation and progression. Recent studies revealed an enrichment of Fusobacterium in colorectal tumor tissues relative to surrounding normal mucosa. Given the available evidence, we conducted an exploratory study quantifying the relative expression of Fusobacterium spp in 28 tissue samples from patients treated at Centro Hospitalar de São João belonging to 4 different groups: adenomas, paired normal tissue from patients with adenomas, carcinomas, and paired normal tissue from patients with colorectal carcinomas. To increase reverse transcription polymerase chain reaction quantification sensitivity, minor groove binders fluorescent probes were used, having in mind its implementation into routine clinical practice. Differences of Fusobacterium spp relative abundance between paired neoplastic lesions/normal tissue were examined by Wilcoxon signed-rank test and for all the other 2-group comparisons the Mann-Whitney U test was used. Most of the adenomas studied belonged to clinical specimens showing either tubular or villous low-grade dysplasia and an enrichment of Fusobacterium relative to paired normal tissue was not found (P = .180). In the carcinoma group, 57% of samples displayed a positive status for this bacterium with the highest burden of detectable Fusobacterium belonging to a specimen with positive regional lymph node metastasis. This is the first Portuguese study confirming a trend toward an overabundance of Fusobacterium in colorectal carcinomas compared to adenomas and paired samples of normal-looking mucosa, in keeping with the role of this bacterium in colorectal carcinogenesis. Further studies are needed to elucidate the relevance of Fusobacterium detection for the prevention and treatment of colorectal cancer.

Cancer Survivor Study (CASUS) on colorectal patients: longitudinal study on physical activity, fitness, nutrition, and its influences on quality of life, disease recurrence, and survival. Rationale and design.

PURPOSE: Evidence suggests that being physically active in combination with a healthy diet contributes to diminish colorectal cancer risk. However, if this is true for colorectal cancer primary prevention, the same is not clear for its recurrence after colorectal cancer treatments. Data on cancer survival are scarce, and there is a need for greater attention on these survivors' lifestyle behavior. This manuscript describes rationale and design of the Cancer Survival Study (CASUS) on colorectal patients, a longitudinal observational study with the aim of investigating how physical activity, physical fitness, and dietary intake are related with their quality of life, disease recurrence, and survival. METHODS: The CASUS on colorectal patients is a longitudinal cohort study on colorectal survivors, aged 18 years or older, recruited 6, 12, and 24 months after surgery. Upon recruitment, patients fill in a battery of questionnaires about physical activity, dietary intake, and quality of life, donate blood samples, do physical fitness tests, and use an accelerometer during 7 days. Repeated analyses will be performed to assess changes over time in physical activity, physical fitness, dietary intake, and other factors in relation to recurrence and survival. CONCLUSIONS: Results will contribute to highlight the role of physical activity, physical fitness, and nutrition in the quality of life of colorectal cancer survivors, recurrence, and survival. This study will provide important information for policymakers on the potential benefits of future physical activity and nutritional interventions, which are inexpensive, as a way to improve general health of colorectal cancer survivors.

Routine Colonoscopy after Acute Uncomplicated Diverticulitis - Challenging a Putative Indication.

BACKGROUND AND AIMS: Most international guidelines recommend performing a routine colonoscopy after the conservative management of acute diverticulitis, mainly to rule out a colorectal malignancy; however, data to support these recommendations are scarce and conflicting. This study is aimed at determining the rate of advanced colonic neoplasia (ACN) found by colonoscopy, and hence the need for routine colonoscopy after CT-diagnosed acute diverticulitis. METHODS: We retrospectively analyzed all patients hospitalized for acute diverticulitis between July 2008 and June 2013. Patients who underwent colonoscopy more than 1 year after the acute episode were excluded. Advanced adenoma (AA) was defined as an adenoma with: (i) ≥10 mm, (ii) ≥25% villous features, or (iii) high-grade dysplasia. ACN included cases of colorectal cancer (CRC) and AA. RESULTS: Of the 364 selected patients, 252 (69%) underwent colonoscopy (51% women, median age 55 ± 11 years). Adenomatous polyps were evident in 14.7% patients; 5.1% had AA and 3.2% had CRC. Patients with complicated diverticulitis had a higher number of ACN compared to those with uncomplicated diverticulitis (20.9 vs. 5.7%, p = 0.003). On multivariate analysis, age ≥50 years (OR 8.12, 95% CI 2.463-45.112; p = 0.017) and abscess on CT (OR 3.15, 95% CI 1.586-11.586; p = 0.036) were identified as significant risk factors for ACN. CONCLUSIONS: Patients with diverticulitis complicated with abscess have a higher risk of ACN on follow-up colonoscopy. The prevalence of ACN in patients with uncomplicated diverticulitis is quite similar to the average-risk population, and therefore an episode of CT-diagnosed uncomplicated diverticulitis, per se, does not seem to be a recommendation for colonoscopy.

Loose ends in the eradication of Helicobacter pylori infection.

The eradication of Helicobacter pylori is essential for prevention and treatment of various conditions associated with this infection. However, its effectiveness is limited and influenced by factors linked to the bacteria and the host. In particular, influence of the biotype, smoking, diabetes mellitus, and previous treatment failure in eradication is understudied. Our center proposed to evaluate these aspects in a real life cohort by applying a questionnaire with demographic and lifestyle variables in patients who consecutively underwent urease breath test after the eradication therapy.