Diagnosis and treatment of inflammatory bowel disease: First Latin American Consensus of the Pan American Crohn's and Colitis Organisation. / Diagnóstico y tratamiento de la enfermedad inflamatoria intestinal: Primer Consenso Latinoamericano de la Pan American Crohn's and Colitis Organisation.

The incidence and prevalence of inflammatory bowel disease (IBD) has increased in recent years in several Latin American countries. There is a need to raise awareness in gastroenterologists and the population in general, so that early diagnosis and treatment of ulcerative colitis (UC) and Crohn's Disease (CD) can be carried out. It is important for all physicians to have homogeneous criteria regarding the diagnosis and treatment of IBD in Latin America. The Pan American Crohn's and Colitis Organisation (PANCCO) is an organization that aims to include all the countries of the Americas, but it specifically concentrates on Latin America. The present Consensus was divided into two parts for publication: 1) Diagnosis and treatment and 2) Special situations. This is the first Latin American Consensus whose purpose is to promote a perspective adapted to our Latin American countries for the diagnosis, treatment, and monitoring of patients with UC and CD.

Special situations in inflammatory bowel disease: First Latin American consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) (Second part). / Situaciones especiales en la enfermedad inflamatoria intestinal: primer consenso latinoamericano de la Pan American Crohn's and Colitis Organisation (PANCCO) (Segunda parte).

This is the first Latin American Consensus of the Pan American Crohn's and Colitis Organisation (PANCCO) regarding special situations in patients with inflammatory bowel disease (IBD). The aim of this consensus is to raise awareness in the medical community in all Latin American countries with respect to pregnancy, vaccinations, infections, neoplasms, including colorectal cancer, and pediatric issues in patients with IBD.

Antigenotoxic, and anticytotoxic activities of an ethanolic extract of Lafoensia pacari (Lythraceae) stem bark in bacteria and mice.

Lafoensia pacari (Lythraceae), popularly known in Brazil as "pacari", is a small tree native to the Cerrado that is used in folk medicine to treat cancer and as an anti-inflammatory and cicatrizing agent. We evaluated the genotoxic, cytotoxic, antigenotoxic, and anticytotoxic activities of an ethanol extract of L. pacari stem bark (EESB) using the Ames test and the mouse bone marrow micronucleus test. In the Ames test, EESB did not significantly increase the number of His(+) revertants in Salmonella typhimurium tester strains TA98 and TA100 at all doses, demonstrating lack of mutagenicity. Only the highest dose of EESB significantly increased the micronucleated polychromatic erythrocyte frequency in the micronucleus test, indicating mild genotoxicity. EESB produced a mutagenic index lower than the negative control in the Ames test. In the micronucleus test, at all doses, EESB caused a significant decrease in the polychromatic/normochromatic erythrocyte ratio (PCE/NCE) at 24 h compared with the negative control. EESB co-administered together with the respective positive control caused a significant decrease in the number of His(+) revertant colonies in the Ames test and in the frequency of micronucleated polychromatic erythrocytes in the micronucleus test, demonstrating a DNA protector effect. EESB co-administered with mitomycin C significantly increased the PCE/NCE ratio at all doses, showing an anticytotoxic effect. We conclude that EESB has antigenotoxic and anticytotoxic properties.

Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial.

IMPORTANCE: The current recommendation is for at least 12 months of dual antiplatelet therapy after implantation of a drug-eluting stent. However, the optimal duration of dual antiplatelet therapy with specific types of drug-eluting stents remains unknown. OBJECTIVE: To assess the clinical noninferiority of 3 months (short-term) vs 12 months (long-term) of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) with zotarolimus-eluting stents. DESIGN, SETTING, AND PATIENTS: The OPTIMIZE trial was an open-label, active-controlled, 1:1 randomized noninferiority study including 3119 patients in 33 sites in Brazil between April 2010 and March 2012. Clinical follow-up was performed at 1, 3, 6, and 12 months. Eligible patients were those with stable coronary artery disease or history of low-risk acute coronary syndrome (ACS) undergoing PCI with zotarolimus-eluting stents. INTERVENTIONS: After PCI with zotarolimus-eluting stents, patients were prescribed aspirin (100-200 mg daily) and clopidogrel (75 mg daily) for 3 months (n = 1563) or 12 months (n = 1556), unless contraindicated because of occurrence of an end point. MAIN OUTCOMES AND MEASURES: The primary end point was net adverse clinical and cerebral events (NACCE; a composite of all-cause death, myocardial infarction [MI], stroke, or major bleeding); the expected event rate at 1 year was 9%, with a noninferiority margin of 2.7%. Secondary end points were major adverse cardiac events (MACE; a composite of all-cause death, MI, emergent coronary artery bypass graft surgery, or target lesion revascularization) and Academic Research Consortium definite or probable stent thrombosis. RESULTS: NACCE occurred in 93 patients receiving short-term and 90 patients receiving long-term therapy (6.0% vs 5.8%, respectively; risk difference, 0.17 [95% CI, -1.52 to 1.86]; P = .002 for noninferiority). Kaplan-Meier estimates demonstrated MACE rates at 1 year of 8.3% (128) in the short-term group and 7.4% (114) in the long-term group (HR, 1.12 [95% CI, 0.87-1.45]). Between 91 and 360 days, no statistically significant association was observed for NACCE (39 [2.6%] vs 38 [2.6%] for the short- and long-term groups, respectively; HR, 1.03 [95% CI, 0.66-1.60]), MACE (78 [5.3%] vs 64 [4.3%]; HR, 1.22 [95% CI, 0.88-1.70]), or stent thrombosis (4 [0.3%] vs 1 [0.1%]; HR, 3.97 [95% CI, 0.44-35.49]). CONCLUSIONS AND RELEVANCE: In patients with stable coronary artery disease or low-risk ACS treated with zotarolimus-eluting stents, 3 months of dual antiplatelet therapy was noninferior to 12 months for NACCE, without significantly increasing the risk of stent thrombosis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01113372.

Optimized duration of clopidogrel therapy following treatment with the Endeavor zotarolimus-eluting stent in real-world clinical practice (OPTIMIZE) trial: rationale and design of a large-scale, randomized, multicenter study.

BACKGROUND: Current recommendations for antithrombotic therapy after drug-eluting stent (DES) implantation include prolonged dual antiplatelet therapy (DAPT) with aspirin and clopidogrel ≥12 months. However, the impact of such a regimen for all patients receiving any DES system remains unclear based on scientific evidence available to date. Also, several other shortcomings have been identified with prolonged DAPT, including bleeding complications, compliance, and cost. The second-generation Endeavor zotarolimus-eluting stent (E-ZES) has demonstrated efficacy and safety, despite short duration DAPT (3 months) in the majority of studies. Still, the safety and clinical impact of short-term DAPT with E-ZES in the real world is yet to be determined. METHODS: The OPTIMIZE trial is a large, prospective, multicenter, randomized (1:1) non-inferiority clinical evaluation of short-term (3 months) vs long-term (12-months) DAPT in patients undergoing E-ZES implantation in daily clinical practice. Overall, 3,120 patients were enrolled at 33 clinical sites in Brazil. The primary composite endpoint is death (any cause), myocardial infarction, cerebral vascular accident, and major bleeding at 12-month clinical follow-up post-index procedure. CONCLUSIONS: The OPTIMIZE clinical trial will determine the clinical implications of DAPT duration with the second generation E-ZES in real-world patients undergoing percutaneous coronary intervention.

[Reflections on the clinical reports «minimum data set¼]. / Reflexiones sobre el «conjunto mínimo de datos¼ de los informes clínicos.

Royal Decree 1093/2010 (3 September 2010) establishes the minimum data set that the clinical reports of discharges and outpatient visits elaborated in the facilities of the National Health System should contain, among others. Until then, the Ministerial Order 221/1984, that only required the drawing up of a discharge report for patients seen in a hospital-regime health care establishment, was in force. In spite of the importance of these documents, their quality is far from that desired, especially that of the reports on visits, which, among other things, are not performed in a high percentage of the cases. Recently the Sociedad Española de Medicina Interna (SEMI) (Spanish Society of Internal Medicine), in collaboration with other scientific societies, issued some recommendations for the drawing up of the discharge reports. In this present work, a series of thoughts are made on the implications of the new decree, especially in the case of the reports of the outpatient clinics.

Latin American consensus on the quality indicators for comprehensive care clinics for patients with inflammatory bowel disease: PANCCO-GETECCU.

INTRODUCTION: Inflammatory bowel disease (IBD) is a chronic and incurable entity. The aim of the Pan American Crohn's and Colitis Organisation (PANCCO) is to create awareness of IBD, with special emphasis on Latin America, and the primary objective of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU, the Spanish acronym) is to obtain the accreditation of the clinical and therapeutic criteria for the diagnosis and treatment of IBD. AIM: To carry out a consensus for evaluating the approval criteria that a Comprehensive Care Clinic for Latin American IBD patients must meet, to be considered a center of excellence. MATERIALS AND METHODS: Fourteen clinical experts participated in the consensus. They were made up of specialists in gastroenterology, with broad clinical experience, spanning several years, in managing the care of a large number of patients with IBD, as well as advanced specialists in IBD. Thirteen of the participants came from 11 Latin American countries (Argentina, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Mexico, Peru, Puerto Rico, Uruguay, and Venezuela) that have IBD clinics. An expert from Spain, representing the GETECCU, provided the methodologic support. The consensus consisted of 52 statements divided into three sections: 1) Structure indicators, 2) Process indicators, and 3) Result indicators. The Delphi panel method was applied. RESULTS: The present Latin American consensus describes the quality indicators that a Comprehensive Care Clinic for IBD patients must meet, to be considered a center of excellence, taking into account the needs of our region. CONCLUSIONS: This is the first Latin American consensus, jointly carried out by the PANCCO and GETECCU, to present accreditation standards for centers of excellence in the care of patients with IBD.

Children's behavioral problems, screen time, and sleep problems' association with negative and positive parenting strategies during the COVID-19 outbreak in Brazil.

Families' health, safety, and economic stability were jeopardized during the pandemic. Parental stress is a risk factor for hostile and less supportive parenting. Parenting styles are a set of attitudes, feelings and behaviors related to parenting that modulate the child's psychosocial functioning and might impact on the adaptability to a stressful time. OBJECTIVE: To investigate the group differences among children raised by negative and positive parenting families during COVID-19 pandemic. METHODS: We have done an online survey with 329 parents. Parents answer about parenting strategies and styles, children's behavior, Covid related questions, socio-economic information, sleep and gaming disorders. RESULTS: Parents' frequent use of negative strategies were a risk factor to have a negative outcome related to mental health, games, sleep, and children behavior. DISCUSSION: Parenting strategies are some targets pointed in this study for intervention. Parents' styles and strategies training to better manage children might be even more important to avoid negative consequences for children in stressful times.

Update of the PANCCO clinical practice guidelines for the treatment of ulcerative colitis in the adult population.

Ulcerative colitis (US) is a chronic disease of unknown etiology. It is incurable and its clinical course is intermittent, characterized by periods of remission and relapse. The prevalence and incidence of the disease has been increasing worldwide. The update presented herein includes the participation of healthcare professionals, decision-makers, and a representative of the patients, all of whom declared their conflicts of interest. Answerable clinical questions were formulated, and the outcomes were graded. The information search was conducted on the Medline/PubMed, Embase, Epistemonikos, and LILACS databases, and covered grey literature sources, as well. The search was updated on November 30, 2020, with no restrictions regarding date or language. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification system was implemented to establish the strength of the recommendation and quality of evidence. A formal consensus was developed, based on the RAND/UCLA methodology and the document was peer reviewed. The short version of the Clinical Practice Guidelines for the Treatment of Ulcerative Colitis in the Adult Population is presented herein, together with the supporting evidence and respective recommendations. In mild-to-moderate UC, budesonide MMX is an option when treatment with 5-ASA fails, and before using systemic steroids. In moderate-to-severe UC, infliximab, adalimumab, vedolizumab, ustekinumab, and tofacitinib can be used as first-line therapy. If there is anti-TNF therapy failure, ustekinumab and tofacitinib provide the best results. In patients with antibiotic-refractory pouchitis, anti-TNFs are the treatment of choice.

Orthopaedic evaluation in children with severe haemophilia A or B submitted to primary prophylaxis therapy in a coagulopathy treatment centre.

There is a lack of publications concerning the use of primary prophylaxis in developing countries. The aim of this study was to evaluate the effectiveness of primary prophylaxis therapy in preventing the development of arthropathy in children with severe haemophilia A or B. From January 1999 to April 2009, a prospective study was carried out involving 39 patients with severe haemophilia A or B. These haemophilia A and haemophilia B patients received 20-40 UI kg(-1) of factors VIII and IX, three and two times per week, respectively. The patients were followed up by a multidisciplinary team. The analysis was carried out in 23 patients who had been on prophylaxis therapy for at least 12 months. The orthopaedic evaluation was performed according to the recommendations of the Orthopedic Advisory Committee of the World Federation of Hemophilia, by evaluating pain and bleeding, and by conducting physical examination and radiological assessment (Pettersson's Joint Score and magnetic resonance): 82.6% of patients who had used the factor regularly did not present any clinical or radiographic changes in the studied joints; 17.4% used the factor irregularly at the beginning of the treatment and of those, most patients presented mild changes in the joints; and 4.3% presented transient knee and ankle pain in spite of regular factor use. The preliminary results of primary prophylaxis confirm its effectiveness in preventing haemophilic arthropathy. Socioeconomic factors did not play a significant role.

Anomalous diffusion governed by a fractional diffusion equation and the electrical response of an electrolytic cell.

The electrical response of an electrolytic cell in which the diffusion of mobile ions in the bulk is governed by a fractional diffusion equation of distributed order is analyzed. The boundary conditions at the electrodes limiting the sample are described by an integro-differential equation governing the kinetic at the interface. The analysis is carried out by supposing that the positive and negative ions have the same mobility and that the electric potential profile across the sample satisfies the Poisson's equation. The results cover a rich variety of scenarios, including the ones connected to anomalous diffusion.

Telomere shortening in patients with drug-resistant epilepsy.

Epilepsy affects about 1 % of the world population. Mesial temporal lobe epilepsy (mTLE) presents with seizures initiated in hippocampus and is the most frequent form of epilepsy. About 30 % of individuals with mTLE do not respond to conventional medications maintaining seizures and consequently new lesions on a daily basis. Treatment-resistant epilepsy has a huge social and individual burden due to impaired quality of life and increased mortality rate. There are many reasons for telomere shortening in individuals with mTLE, such as a chronic mitochondrial oxidative stress and increased levels of pro-inflammatory mediators. In the past 10 years, there was a boom of studies establishing association between telomere length and chronic/complex disorders. Telomeres are essential for the maintenance of genomic integrity. Telomere length has been assumed as a biological marker for stress and cellular ageing. Here we hypothesized that individuals affected with treatment-resistant mTLE would course with a shorter telomere than controls. So, we measured leucocytes telomere length in a sample of 89 individuals, 48 treatment-resistant mTLE compared to 41 healthy controls. As expected, we observed a significant shorter telomere in the peripheral cell leukocytes of treatment-resitant mTLE group. Telomere length was not associated with sex, side of hippocampal sclerosis, family history, etiology of seizures, duration of disease or the Engel score. Our results points towards the need of further investigation to shed light on the relation of telomeres shortening and the outcomes and impacts of epilepsy.

Clinical evaluation after 1 year of 153-samarium hydroxyapatite synovectomy in patients with haemophilic arthropathy.

The aim is to evaluate the efficiency of the treatment with 153-samarium hydroxyapatite (153-Sm-HA) in haemophilic arthropathy. Thirty-one patients (30 males) with ages ranging from 8 to 34 years (average age = 20.6 years) were treated with fixed intra-articular dose of 185 MBq (5 mCi) and divided into two groups: infantile-juvenile (13 patients with up to 18 years of age, an average age of 12.7 years and arthropathy evolution of 7.8 years), and adult (18 patients older than 18 years, an average age of 24 years and arthropathy evolution of 18.7 years). The clinical evaluation before and after 1 year of synovectomy used the following criteria: subjective (pain through visual scale, articulation inspection), objective (articular movement through flexion level, sensitivity to palpation and leakage through joint circumference), reduction on the use of the coagulation factor, number of haemarthrosis, and the occurrence of adverse effects. The results were classified as: 1, good (remission from 70% to 100% of manifestations); 2, moderate (remission from 40% to 69%); and 3, poor (remission from 0% to 39%). Seventy-eight joints were tested: 15 knees, 36 elbows, 24 ankles, 1 shoulder and 2 hips. Early scintigraphic (1-2 h) and late scintigraphic (24-72 h) studies were performed after synoviorthesis. The cost of the procedure per joint was also estimated. No significant difference in the synoviorthesis result between groups was observed. The results were good for 75% of elbows, 87.5% of ankles and 40% of knees; the reduction in haemarthrosis and use of the coagulation factor was respectively 78% and 80% for elbows, 82% and 85% for ankles and 30% and 35% for knees. Four cases of reactional synovitis were observed in the 31 patients. The scintigraphic control showed homogeneous distribution of the material with no articular escape. The use of 153 Sm-HA in the treatment of the haemophilic arthropathy is effective for intermediate-size joints (elbows and ankles), but less effective for knees. Moreover, this treatment presents an excellent safety profile and accessible cost.

Sclerosing encapsulating peritonitis: imaging findings in an uncommon entity. / Peritonitis esclerosante encapsulante: hallazgos en imágenes de una entidad poco frecuente.

OBJECTIVES: To describe the most characteristic imaging findings for sclerosing encapsulating peritonitis, with an emphasis on the computed tomography findings. CONCLUSION: The incidence of sclerosing encapsulating peritonitis is low. The pathophysiology of this condition is unclear. Two types are recognized: idiopathic and secondary; the secondary type is generally a complication of peritoneal dialysis. Its nonspecific clinical presentation and the absence of blood markers mean that sclerosing encapsulating peritonitis is usually diagnosed late. Thus, it is important to know the imaging signs; these include thickening and calcification of the peritoneum and dilation of bowel loops with thickening and calcification of bowel walls, whether in isolation or in association with loculated ascites. Although ultrasonography allows the complexity of the collections to be evaluated, computed tomography is the most useful technique for the general assessment of the signs mentioned above.

[Reason for consultation: Weight loss]. / Motivo de consulta: pérdida de peso.

BACKGROUND AND OBJECTIVE: Unintentional weight loss is frequent reason to visit a doctor and it has multiple diagnostic possibilities. The objective of this study is to examine the background of the patients who seek consultation for weight loss and to establish the relationship between weight loss and neoplasia. METHOD: An analysis was performed on the demographic data, quantified weight loss, accompanying symptomatology, and diagnosis of patients who sought medical advice for unintentional weight loss during the year 2015. RESULTS: A total of 226 patients were included, of whom 44.2% of them had an intentional weight loss ≥ 5% in 6 months. The most frequent diagnosis in this group was a neoplasia, whereas in the rest of patients the most common diagnosis was a gastrointestinal disease. In light of this study we can conclude that there is a relationship between unintentional weight loss≥5% and the presence of neoplasia. CONCLUSION: An unintentional weight loss greater than 5% in the previous 6 months is associated with the presence of neoplastic diseases, and therefore requires further diagnostic study.

Larvicidal activities against Aedes aegypti of some Brazilian medicinal plants.

Larvicidal activities against Aedes aegypti have been determined in the ethanolic extracts obtained from 51 Brazilian medicinal plants. Eleven of the 84 extracts studied showed significant (LC50 < 100 microg mL(-1)) activities against larvae, with extracts from Annona crassiflora (root bark, LC50 = 0.71 microg mL(-1); root wood, LC50 = 8.94 microg mL(-1)) and Annona glabra (seed, LC50 = 0.06 microg mL(-1)) showing the highest activities. The results obtained should be of value in the search for new natural larvicidal compounds.

In vitro antiplasmodial activity of Brazilian Cerrado plants used as traditional remedies.

Twenty-seven species of native Brazilian Cerrado plants commonly used by traditional healers to treat malaria and other diseases were collected and 204 hexanic and ethanolic extracts were obtained by maceration. The antiplasmodial activity of the extracts was tested in vitro against a chloroquine resistant strain (FcB1) of Plasmodium falciparum, and cytotoxicity against the cell lines L-6 of rats and MRC-5 of human was evaluated. Thirty-two extracts showed significant inhibition rates of Plasmodium falciparum growth and of these six showed cytotoxicity against the cell lines. The strongest antiplasmodial activity was found for the hexanic extracts of Xylopia aromatica root wood (IC(50)=4.7 microg/ml), Xylopia emarginata root bark (IC(50)=4.9 microg/ml), Casearia sylvestris var. lingua leaves, stem wood and stem bark, and root wood and root bark (IC(50) values from 0.9 to 2.3 microg/ml), and Cupania vernalis leaves (IC(50)=0.9 microg/ml); and for the ethanolic extract of Aspidosperma macrocarpon root bark (IC(50)=4.9 microg/ml). However, the best selectivity towards Plasmodium falciparum was observed for the hexanic root bark extract of Matayba guianensis (IC(50) on Plasmodium falciparum=6.1 microg/ml, SI=16.4 for MRC-5) and the ethanolic root bark extract of Aspidosperma macrocarpon (IC(50) on Plasmodium falciparum=4.9 micro/ml, SI=16.2 for MRC-5).

[69 years old male patient, with impairment of physical condition, hyperpigmentation, cutaneous lesion and a deficient response to treatment]. / Varón de 69 años con afectación del estado general, hiperpigmentación, lesión cutánea y respuesta deficiente al tratamiento.

We submit the case of a male patient, suffering from a tuberculous ethiology adrenal primary insufficiency, showing a dermal lesion, in which necrotizing granulomas were found, and from which bacterial culture growth yielded mycobacterium bovis. Given the clinical findings, and awaiting for the bacterial culture result, a triple treatment with tuberculostatics was started, but had to be discontinued because of hepatic toxicity. After culture of cutaneous biopsy yielded micobaterium tuberculosis, treatment with streptomycin, rifampicin and etambutol was restarted. Three weeks later, in spite of increasing hydrocortisone dose to 40 mg, adrenal insufficiency reappeared. Under the circumstances, we chose to continue rifampicin and double hydrocortisone dose. The case is of concern because of the concurrency of three nowadays infrequent disorders: tuberculous ethiology adrenal insufficiency, cutaneous tuberculosis due to mycobacterium bovis and primary adrenal insufficiency due to rifampicin treatment, the latter resolved after increasing hydrocortisone dose.