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1.
Horm Metab Res ; 53(9): 575-587, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34496408

RESUMO

Global warming and the rising prevalence of obesity are well described challenges of current mankind. Most recently, the COVID-19 pandemic arose as a new challenge. We here attempt to delineate their relationship with each other from our perspective. Global greenhouse gas emissions from the burning of fossil fuels have exponentially increased since 1950. The main contributors to such greenhouse gas emissions are manufacturing and construction, transport, residential, commercial, agriculture, and land use change and forestry, combined with an increasing global population growth from 1 billion in 1800 to 7.8 billion in 2020 along with rising obesity rates since the 1980s. The current Covid-19 pandemic has caused some decline in greenhouse gas emissions by limiting mobility globally via repetitive lockdowns. Following multiple lockdowns, there was further increase in obesity in wealthier populations, malnutrition from hunger in poor populations and death from severe infection with Covid-19 and its virus variants. There is a bidirectional relationship between adiposity and global warming. With rising atmospheric air temperatures, people typically will have less adaptive thermogenesis and become less physically active, while they are producing a higher carbon footprint. To reduce obesity rates, one should be willing to learn more about the environmental impact, how to minimize consumption of energy generating carbon dioxide and other greenhouse gas emissions, and to reduce food waste. Diets lower in meat such as a Mediterranean diet, have been estimated to reduce greenhouse gas emissions by 72%, land use by 58%, and energy consumption by 52%.


Assuntos
Mudança Climática , Obesidade/etiologia , Agricultura/economia , Agricultura/tendências , COVID-19/complicações , COVID-19/epidemiologia , COVID-19/patologia , Mudança Climática/história , Comorbidade , Disruptores Endócrinos/toxicidade , Meio Ambiente , Exposição Ambiental/história , Exposição Ambiental/estatística & dados numéricos , Gases de Efeito Estufa/toxicidade , História do Século XIX , História do Século XX , História do Século XXI , Humanos , Obesidade/epidemiologia , Obesidade/metabolismo , Pandemias , Fatores de Risco
4.
Gastrointest Endosc ; 93(6): 1438-1439, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33993916
6.
Pancreas ; 50(1): 54-63, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33370023

RESUMO

OBJECTIVE: Solid organ transplant (SOT) recipients have moderately increased risk of pancreatic adenocarcinoma (PAC). We evaluated the incidence and survival of PAC in 2 cohorts and aimed to identify potential risk factors. METHODS: This study performed a retrospective cohort analysis. Cohort A was extracted from the United Network of Organ Sharing data set and cohort B from SOT recipients evaluated at 3 Mayo Clinic transplant centers. The primary outcome was age-adjusted annual incidence of PAC. Descriptive statistics, hazard ratios, and survival rates were compared. RESULTS: Cohort A and cohort B included 617,042 and 29,472 SOT recipients, respectively. In cohort A, the annual incidence rate was 12.78 per 100,000 in kidney-pancreas, 13.34 in liver, and 21.87 in heart-lung transplant recipients. Receiving heart-lung transplant, 50 years or older, and history of cancer (in either recipient or donor) were independent factors associated with PAC. Fifty-two patients developed PAC in cohort B. Despite earlier diagnosis (21.15% with stage I-II), survival rates were similar to those reported for sporadic (non-SOT) patients. CONCLUSIONS: We report demographic and clinical risk factors for PAC after SOT, many of which were present before transplant and are common to sporadic pancreatic cancer. Despite the diagnosis at earlier stages, PAC in SOT portends a very poor survival.

7.
Gastrointest Endosc ; 93(6): 1276-1282, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33309653

RESUMO

BACKGROUND AND AIMS: EMR and endoscopic submucosal dissection (ESD) are treatment modalities for Barrett's esophagus involving high-grade dysplasia or early cancer. Injectional corticosteroid therapy decreases the risk of procedure-related esophageal stricture (ES) formation. Our aim was to assess the efficacy of topical budesonide on the rate of ES formation after EMR or ESD. METHODS: Patients included prospectively from 3 tertiary endoscopy centers received 3 mg budesonide orally twice a day for 8 weeks after esophageal EMR or ESD of 50% or more of the esophageal circumference between January 1, 2014 and June 30, 2018. These patients were matched (1:3 ratio) retrospectively with a consecutive patient cohort who underwent EMR or ESD of 50% or more of the esophageal circumference without concomitant corticosteroid therapy. The primary endpoint was the presence of ES at the 12-week follow-up. RESULTS: Twenty-five patients (budesonide) were matched with 75 patients (no budesonide). Most underwent EMR for Barrett's esophagus with biopsy-proven high-grade dysplasia or suspected T1a cancer. Although most baseline characteristics did not differ significantly, patients in the budesonide cohort tended to have a higher proportion of circumferential EMR. The proportion of patients with ES was not significantly lower in the budesonide cohort (16% vs 28%). On logistic regression analysis, budesonide remained associated with a lower incidence of ES (P = .023); however, when controlling for baseline characteristics with a propensity score weighted logistic regression model, there was no significant effect on ES formation (P = .176). CONCLUSIONS: Topical budesonide might be associated with a reduction of ES after EMR or ESD; however, further studies are needed to verify our results.


Assuntos
Adenocarcinoma , Esôfago de Barrett , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Estenose Esofágica , Budesonida/uso terapêutico , Ressecção Endoscópica de Mucosa/efeitos adversos , Estenose Esofágica/etiologia , Estenose Esofágica/prevenção & controle , Humanos , Estudos Retrospectivos
8.
Urol Case Rep ; 29: 101077, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31853444

RESUMO

Stauffer's syndrome is a paraneoplastic phenomenon associated with renal cell carcinoma (RCC) characterized by cholestatic hepatitis. We explore the effects of perioperative immunotherapy in a case of Stauffer's syndrome. A 70-year-old female with a locally advanced clear cell RCC (ccRCC) developed severe hyperbilirubinemia. The patient's cholestasis progressed despite initial systemic immunotherapy, but improved after cytoreductive nephrectomy. The patient continued immunotherapy post-operatively and regained normalized hepatic function. To our knowledge, this is the first case reporting use of systemic immunotherapy with surgery in Stauffer's syndrome, and we provide clinical insight into a treatment regimen which may be employed in future cases.

10.
Clin Gastroenterol Hepatol ; 17(9): 1763-1769, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30471457

RESUMO

BACKGROUND & AIMS: In the West, early gastric cancer is increasingly managed with endoscopic resection (ER). This is, however, based on the assumption that the low prevalence and risk of lymph node metastases observed in Asian patients is applicable to patients in the United States. We sought to evaluate the frequency of and factors associated with metastasis of early gastric cancers to lymph nodes, and whether the Japanese ER criteria are applicable to patients in the US. METHODS: We performed a retrospective study of 176 patients (mean age 68.5 years; 59.1% male; 58.5% white) who underwent surgical resection with lymph node dissection of T1 and Tis gastric adenocarcinomas, staged by pathologists, at 7 tertiary care centers in the US from January 1, 1999, through December 31, 2016. The frequency of lymph node metastases and associated risk factors were determined. RESULTS: The mean size of gastric adenocarcinomas was 23.0 ± 16.6 mm-most were located in the lower-third of the stomach (67.0%), invading the submucosa (55.1%), and moderately differentiated (31.3%). Lymphovascular invasion was observed in 18.2% of lesions. Overall, 20.5% of patients had lymph node metastases. Submucosal invasion (odds ratio, 3.9; 95% CI, 1.4-10.7) and lymphovascular invasion (odds ratio, 4.6; 95% CI, 1.8-12.0) were independently associated with increased risk of metastasis to lymph nodes. The frequency of lymph node metastases among patients fulfilling standard and expanded Japanese criteria for ER were 0 and 7.5%, respectively. CONCLUSIONS: The frequency of lymph node metastases among patients with early gastric cancer in a US population is higher than that of published Asian series. However, early gastric cancer lesions that meet the Japanese standard criteria for ER are associated with negligible risk of metastasis to lymph nodes, so ER can be recommended for definitive therapy. Expanded criteria cancers appear to have a higher risk of metastasis to lymph nodes, so ER may be considered for select cases.


Assuntos
Adenocarcinoma/patologia , Gastrectomia , Linfonodos/patologia , Neoplasias Gástricas/patologia , Adenocarcinoma/cirurgia , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células em Anel de Sinete/patologia , Carcinoma de Células em Anel de Sinete/cirurgia , Ressecção Endoscópica de Mucosa , Feminino , Humanos , Japão , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Invasividade Neoplásica , Estadiamento de Neoplasias , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Neoplasias Gástricas/cirurgia , Carga Tumoral , Estados Unidos
11.
Gastrointest Endosc ; 89(4): 880-886, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30342027

RESUMO

BACKGROUND AND AIMS: Incision of the cricopharyngeal (CP) muscle with flexible endoscopy is an important approach for Zenker diverticulum (ZD) repair with symptomatic resolution in approximately 90% of cases, but recurrence has been reported in up to 20%. We report our experience with a new endoscopic myectomy of the CP muscle and compare the outcome with conventional myotomy of ZD. METHODS: Our retrospective study included all patients with ZD who underwent endoscopic repair between August 1, 2014 and July 31, 2017. Conventional CP myotomy was defined as a vertical cut through the CP muscle. CP myectomy was defined as parallel excisions followed by snare resection at the CP resection base. Measurement of ZD size was based on barium esophagram and endoscopic estimation. Outcomes included ZD recurrence, improvement of dysphagia, and procedure adverse events. RESULTS: Sixty-four patients underwent endoscopic repair for ZD, 44 with CP myotomy and 20 with CP myectomy. Mean (standard deviation) size of ZD was 3.3 cm (1.0) and 3.8 cm (1.2) in the myotomy and myectomy cohorts, respectively (P = .11), and median procedure time was 50 and 56 minutes, respectively (P = .73). In the CP myotomy cohort, 10 patients (22.7%) had recurrence of ZD at a median of 19.1 months, whereas no recurrence was documented in the CP myectomy cohort (P = .02). This trend was also shown in multivariate analysis but was not statistically significant (P = .07). There was no statistical difference in improvement of dysphagia and adverse events. CONCLUSIONS: CP myectomy is a new endoscopic technique for ZD repair. In our experience, it was safe and well tolerated, with a high initial success rate and less ZD recurrence when compared with myotomy.


Assuntos
Esofagoscopia/métodos , Miotomia/métodos , Músculos Faríngeos/cirurgia , Divertículo de Zenker/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
12.
Endoscopy ; 51(2): 169-173, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30005444

RESUMO

BACKGROUND: Proximal esophageal stents are poorly tolerated and have a high risk of complications. We report our experience using fully covered, biliary, self-expandable metal stents (B-SEMS) and narrow-diameter, esophageal, self-expandable metal stents (NDE-SEMS) for this group of patients. METHODS: 24 patients underwent placement of B-SEMS or NDE-SEMS for proximal esophageal lesions between 1 January 2011 and 31 July 2016. The outcomes included improvement of dysphagia, healing of fistulas, and adverse events. RESULTS: 10 patients received B-SEMS and 14 had NDE-SEMS. Median follow-up time was 11.5 months (range 0.5 - 62 months). In both cohorts, stents were left in place for a mean of 6 weeks. The dysphagia score decreased in 7 (70 %) and 10 (71.4 %) patients, and fistulas resolved in 3/5 (60.0 %) and 5/8 (62.5 %) patients with B-SEMS and NDE-SEMS, respectively. Stent migration occurred in three patients (30.0 %) with B-SEMS and five patients (35.7 %) with NDE-SEMS. CONCLUSIONS: Both stents were well tolerated and resulted in overall improvement of dysphagia in 70.8 % of patients. B-SEMS appeared to be more favorable for cervical esophageal lesions with narrower diameters, while NDE-SEMS may be better for more distal lesions.


Assuntos
Transtornos de Deglutição/prevenção & controle , Estenose Esofágica/cirurgia , Stents Metálicos Autoexpansíveis , Adulto , Idoso , Tomada de Decisões , Transtornos de Deglutição/etiologia , Remoção de Dispositivo , Estenose Esofágica/complicações , Feminino , Florida , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Implantação de Prótese , Estudos Retrospectivos
13.
Dig Dis Sci ; 63(10): 2786-2791, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29922897

RESUMO

BACKGROUND AND AIM: Twenty-percentage of acute pancreatitis (AP) cases is labeled as idiopathic. Cannabis remains the most frequently used illicit drug in the world. The aim of this study was to identify the prevalence of cannabis use among all patients with a first episode of AP, particularly in those labeled as idiopathic etiology, and determine any effect on AP severity. METHODS: Retrospective cohort of all consecutive patients admitted with a first episode of AP at a large tertiary referral hospital from 01/2013 through 12/2014. AP was identified by ICD9 code, or lipase ≥ 3 times the upper limit of normal and abdominal pain consistent with AP. Cannabis users (CU) were identified via history or urine toxicology. RESULTS: Four hundred and sixty patients were included. 54% were men, with a mean age of 48 years (range 17-89 years). Forty-eight patients (10%) were identified as CU. After adjusting for admission SIRS, age, and gender, cannabis use was not found to be an independent risk factor for persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU admission, length of stay, in-hospital infections, nor recurrent AP. Of note, AKI was least common among non-CU compared to CU (OR 0.4; p = 0.02; CI 0.2-0.9) and non-CU had a higher admission BISAP score (≥ 2) compared to CU (OR 2.5; p = 0.009; CI 1.2-4.9). CONCLUSION: This is the largest study to date examining cannabis use in AP. Cannabis use was found across almost all etiologies of AP with a prevalence of 10% (48 cases), and in 9% (9 cases) of so-called idiopathic AP cases in this cohort, which could account as an association for approximately 2% of all AP cases. Cannabis use did not independently impact AP severity or mortality.


Assuntos
Cannabis , Pancreatite/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Chicago/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite/mortalidade , Estudos Retrospectivos , Adulto Jovem
14.
Gastrointest Endosc ; 88(1): 201, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29935617
15.
Dig Liver Dis ; 50(5): 438-445, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29573963

RESUMO

BACKGROUND: The use of endoscopic ultrasound (EUS) to stage patients with Barrett's esophagus (BE) with suspected neoplasia is controversial due to high rates of over-staging. However, this rate of over-staging has not been adequately investigated or quantified. AIM: To determine the rate of over-staging related EUS in this population. METHODS: Search included Medline, Embase, Web of Science, and Cochrane Central ending on 9/30/2016. The primary effect-estimate of interest was the false positive rate of advanced disease on EUS at the tumor level (T1a vs. T1b). Secondary outcomes included false detection rate, false negative rate, accuracy, sensitivity, and specificity. Study heterogeneity was assessed using the I2 and Cochrane's Q. RESULTS: Of 1872 studies, 11 met our inclusion criteria totaling 895 patients. Based on random effects models, the pooled FPR for advanced disease was 9.1% ([6.5-12.5%], p<0.001). Tests of heterogeneity showed no significant heterogeneity for this outcome. The pooled false negative rate was 9.2% [95%CI: 4.7-17.3%], p<0.01. Overall, the pooled accuracy of EUS results in BE neoplasia patients was low at 74.6% [58.7-85.8%], p=0.004. CONCLUSIONS: The use of EUS in BE patients with dysplasia and early neoplasia results in a large proportion of patients falsely over-staged and under-staged.


Assuntos
Adenocarcinoma/diagnóstico por imagem , Adenocarcinoma/patologia , Esôfago de Barrett/diagnóstico por imagem , Endossonografia , Neoplasias Esofágicas/diagnóstico por imagem , Neoplasias Esofágicas/patologia , Esôfago de Barrett/patologia , Reações Falso-Negativas , Reações Falso-Positivas , Humanos , Estadiamento de Neoplasias , Sensibilidade e Especificidade
16.
Surg Endosc ; 32(6): 2859-2869, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29392469

RESUMO

BACKGROUND: Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD). METHODS: We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients. RESULTS: Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention. CONCLUSIONS: Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.


Assuntos
Neoplasias Duodenais/cirurgia , Ressecção Endoscópica de Mucosa , Endoscopia do Sistema Digestório , Adenoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Carcinoma/cirurgia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Duração da Cirurgia , Tratamentos com Preservação do Órgão , Complicações Pós-Operatórias , Estudos Retrospectivos , Adulto Jovem
19.
Surg Endosc ; 32(5): 2328-2339, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29098434

RESUMO

BACKGROUND: Endoscopic submucosal dissection (ESD) and hybrid-ESD techniques are treatment modalities for colorectal neoplasia, although mostly used in the Eastern hemisphere. Only few data on ESD for colorectal neoplasia have been published in the West. We report the outcomes of colorectal ESD and hybrid ESD in a single Italian center. METHODS: We retrospectively evaluated the outcomes of all ESD and hybrid-ESD procedures for colorectal neoplasia performed over the first 2-year experience from a prospectively recorded database. Neuroendocrine tumors and adenocarcinoma with submucosal infiltration through the submucosal (SM) 2 layer or deeper were excluded. The primary outcome was the recurrence rate at the 6- to 12-month follow-up. RESULTS: Fifty-two patients were included in the study, of which 23 underwent ESD and 29 hybrid ESD. The mean lesion sizes for ESD and hybrid ESD were similar (25.8 vs. 25.4 mm, p = 0.940), while median procedure length was significantly longer for ESD (120 vs. 60 min, p < 0.001). ESD and hybrid ESD yielded similar en-bloc resection rate (82.6 vs. 82.8%) and R0 resection rate (34.8 vs. 31%). ESD had a lower neoplasia recurrence rate than hybrid ESD (11.7 vs. 20%) and a lower bleeding rate (0 vs. 8.7%). One perforation occurred in the hybrid-ESD cohort and two perforations in the ESD cohort, of which one required surgical intervention. Non-recurrence at follow-up was associated with R0 status, en-bloc resection, and lesion size ≤ 20 mm. CONCLUSION: Our outcomes are comparable with other studies in Western series. Studies addressing the cost effectiveness of ESD and comparing its long-term outcome with endoscopic mucosal resection in the West are needed.


Assuntos
Adenocarcinoma/cirurgia , Adenoma/cirurgia , Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Recidiva Local de Neoplasia/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
20.
Gastrointest Endosc ; 87(1): 67-74, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28687439

RESUMO

BACKGROUND AND AIMS: Barrett's intestinal metaplasia may extend beneath normal squamous epithelium at the squamocolumnar junction (SCJ) and therefore escape surveillance biopsy sampling. The prevalence of subsquamous intestinal metaplasia (SSIM) in patients undergoing Barrett's esophagus (BE) surveillance is unknown. Our aim was to examine the prevalence and distribution of SSIM proximal to the SCJ in patients undergoing BE surveillance. METHODS: We enrolled consecutive patients with biopsy specimen-proven BE. Biopsy specimens were obtained from the squamous epithelium at 5 mm and 10 mm above the SCJ. The primary outcomes were the proportion of patients with SSIM at each level. We further assessed factors associated with SSIM. RESULTS: We examined 515 squamous epithelial biopsy specimens from 106 BE patients (95% men; mean age, 66 years) with a mean Barrett's length of 3.0 cm. SSIM was present in 39% at 5 mm (95% CI, 29.4-48.6) and 21% (95% CI, 11.7-32.1) at 10 mm proximal to the SCJ. Among all biopsy specimens, 13% (95% CI, 10.6-16.6) contained SSIM: 17% (95% CI, 13-21.6) of biopsy samples at 5 mm and 8% (95% CI, 4.3-12.2) at 10 mm proximal to the SCJ. SSIM was more common in the anterior/right lateral position compared with the posterior/left lateral position (21% vs 11%, P = .001). None of the biopsy specimens showed dysplasia. Length of BE or duration of reflux symptoms were not associated with the presence of SSIM. CONCLUSIONS: This cross-sectional study found a surprisingly high proportion of SSIM in treatment-naïve patients proximal to the SCJ. These findings raise questions regarding BE management and the prevalence of SSIM in normal-appearing esophagus.


Assuntos
Esôfago de Barrett/patologia , Esôfago/patologia , Lesões Pré-Cancerosas/patologia , Idoso , Biópsia , Estudos Transversais , Endoscopia do Sistema Digestório , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
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