Potential performance of a 0 h/1 h algorithm and a single cut-off measure of high-sensitivity troponin T in a diverse population: main results of the IN-HOPE study.

AIMS: Chest pain is a major cause of medical evaluation at emergency department (ED) and demands observation to exclude the diagnosis of acute myocardial infarction (AMI). High-sensitivity cardiac troponin assays used as isolated measure and by 0- and 1-h algorithms are accepted as a rule-in/rule-out strategy, but there is a lack of validation in specific populations. METHODS AND RESULTS: The IN-HOspital Program to systematizE Chest Pain Protocol (IN-HOPE study) is a multicentre study that prospectively included patients admitted to the ED due to suspected symptoms of AMI at 16 sites in Brazil. Medical decisions of all patients followed the standard approach of 0 h/3 h protocol, but, in addition, blood samples were also collected at 0 and 1 h and sent to a central laboratory (core lab) to measure high-sensitivity cardiac troponin T (hs-cTnT). To assess the theoretical performance of 0 h/1 h algorithm, troponin < 12 ng/L with a delta < 3 was considered rule-out while a value ≥ 52 or a delta ≥ 5 was considered a rule-in criterion (the remaining were considered as observation group). The main objective of the study was to assess, in a population managed by the 0 h/3 h protocol, the accuracy of 0 h/1 h algorithm overall and in groups with a higher probability of AMI. All patients were followed up for 30 days, and potential events were adjudicated. In addition to the prospective cohort, a retrospective analysis was performed assessing all patients with hs-cTnT measured during the year of 2021 but not included in the prospective cohort, regardless of the indication of the test. A total of 5.497 patients were included (583 in the prospective and 4.914 in the retrospective analysis). The prospective cohort had a mean age of 57.3 (± 14.8) and 45.6% of females with a mean HEART score of 4.0 ± 2.2. By the core lab analysis, 74.4% would be eligible for a rule-out approach (45.3% of them with a HEART score > 3) while 7.3% would fit the rule-in criteria. In this rule-out group, the negative predictive value for index AMI was 100% (99.1-100) overall and regardless of clinical scores. At 30 days, no death or AMI occurred in the rule-out group of both 0/1 and 0/3 h algorithms while 52.4% of the patients in the rule-in group (0 h/1 h) were considered as AMI by adjudication. In the observation group (grey zone) of 0 h/1 h algorithm, GRACE discriminated the risk of these patients better than HEART score. In the retrospective analysis, 1.091 patients had a troponin value of <5 ng/L and there were no cardiovascular deaths at 30 days in this group. Among all 4.914 patients, the 30-day risk of AMI or cardiovascular death increased according to the level of troponin: 0% in the group < 5 ng/L, 0.6% between 5 and 14 ng/L, 2.2% between 14 and 42 ng/L, 6.3% between 42 and 90 ng/L, and 7.7% in the level ≥ 90 ng/L. CONCLUSION: In this large multicentre study, a 0 h/1 h algorithm had the potential to classify as rule-in or rule-out in almost 80% of the patients. The rule-out protocol had high negative predictive value regardless of clinical risk scores. Categories of levels of hs-cTn T also showed good accuracy in discriminating risk of the patients with a very favourable prognosis for cardiovascular death in the group with value < 5 ng/L. CLINICALTRIALS.GOV: NCT04756362.

POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS PROPHYLAXIS: EVALUATION OF TWO DIFFERENT NSAID REGIMENS.

BACKGROUND: Endoscopic retrograde cholangiopancreatography is a widely used therapeutic modality for the pancreaticobiliary tree. However, it is responsible for the highest rates of complications among the endoscopic procedures, especially post-endoscopic retrograde cholangiopancreatography pancreatitis. The preventive methods include mechanical and pharmacological approaches, such as the use of non-steroidal anti-inflammatory drugs. OBJECTIVE: To compare the efficacy of two different strategies using non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis, and to clarify the uncertainty about the route of administration of non-steroidal anti-inflammatory drugs in the prevention of this complication. METHODS: This was a prospective trial. Two therapeutic groups were compared with a control group that was composed of patients who underwent endoscopic retrograde cholangiopancreatography, performed in the same service and by the same team in the period preceding the study (historical series), without the administration of any type of prophylaxis. The first group received 100 mg rectal diclofenac. The second group received 100 mg intravenous ketoprofen. Both groups were compared, separately and jointly, with the control group. RESULTS: Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 4.39% (12/273) of the participants. In the group without prophylaxis, the incidence was 6.89% (10/145). Among those who received intravenous ketoprofen, the incidence was 2.56% (2/78). No cases of acute post-procedural pancreatitis were observed in the group that received rectal diclofenac (0/52). Although there was no statistical difference between the therapeutic groups when they were separately analyzed, a statistical difference in the prevention of post-procedural pancreatitis was observed when they were analyzed together (P=0.037). CONCLUSION: This study provides evidence for the efficacy of non-steroidal anti-inflammatory drugs in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis.

Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques.

BACKGROUND: Endovascular repair of thoracic aneurysm has demonstrated low risks of mortality and spinal cord ischemia (SCI), but few large series have been published on endovascular thoracoabdominal aneurysm repair, and reports suffer from a lack of accurate comparison with similar open surgical procedures. METHODS AND RESULTS: A consecutive cohort of patients with thoracic and thoracoabdominal aneurysms treated electively with endovascular repair (ER) or surgical repair (SR) techniques between 2001 and 2006 were analyzed. The association between repair technique and SCI was evaluated with univariable analysis. Adjustments for potential confounders and for the propensity to receive ER or SR were also performed in multivariable analysis. A total of 724 patients (352 ER, 372 SR) underwent repair. The mean age was 67 years, and 65% were male. ER patients were on average 9 years older (P<0.001), had more comorbid conditions, and more frequently had prior distal repair (P<0.001) or underwent a type I or IV repair. SR patients more commonly had chronic dissection or required type II or type III repairs (P<0.001). Mortality at 30 days (5.7% ER versus 8.3% SR, P=0.2) and 12 months (15.6% ER versus 15.9% SR, P=0.9) was similar. A borderline difference in SCI was found between repair techniques: 4.3% of ER and 7.5% of SR patients (P=0.08) had SCI. In patients with ER, prior distal aortic operation was associated with the development of SCI in univariable analysis (odds ratio 4.1, 95% confidence interval 1.4 to 11.7). Multivariable analysis showed that the type of required repair (type I, II, III, or IV) was the primary factor associated with the development of SCI in ER and SR patients. CONCLUSIONS: No significant difference in the incidence of mortality or SCI was found between ER and SR techniques. The strongest factor associated with SCI remains the extent of the disease. Further studies are indicated to compare ER with patients considered eligible for SR.

International consensus guidelines for surgical resection of mucinous neoplasms cannot be applied to all cystic lesions of the pancreas.

BACKGROUND & AIMS: International consensus guidelines, aimed at predicting malignancy, are available for surgical resection of mucinous cysts but not for other cystic lesions of the pancreas. We sought to determine whether the consensus guidelines can be applied to all cystic lesions of the pancreas. METHODS: We identified all patients who underwent surgical resection of pancreatic cysts from 2001-2007. Pathology analyses of surgical specimens served as the reference standard. Surgical resection criteria proposed by the Sendai Guidelines and 5 modifications of these criteria were tested to determine their accuracy for diagnosis of malignant cysts. RESULTS: Patients with cystic lesions of the pancreas (n = 154; mean age, 59.8 years; 64% women) underwent resection and met prespecified study criteria. Twenty-one patients had a malignancy. The classification cyst size > or = 3 cm had an accuracy of 56%, negative predictive value of 84%, and identified only 57% of the malignant cysts. The classification cyst size > or = 3 cm or cyst with main pancreatic duct > or = 10 mm had an accuracy of 55%, negative predictive value of 86%, and identified 66% of malignant cysts. The modified criterion of cyst size > or = 3 cm or cyst with main pancreatic duct > 3 mm had an accuracy of 48%, negative predictive value of 94%, and identified 91% (19/21) of the malignancies. Cyst size (odds ratio, 1.05) and pancreatic duct dilation > 3 mm (odds ratio, 10.5) were strong and independent predictors of malignancy. CONCLUSIONS: When applied to all cystic lesions of the pancreas, the international consensus criteria cause some malignant cysts to be missed. Modified criteria could identify most malignant cysts, although overall accuracy remains low.

Effect of institution-wide policy of colonoscopy withdrawal time > or = 7 minutes on polyp detection.

BACKGROUND & AIMS: Practice guidelines recommend that endoscopists spend at least 7 minutes examining the colonic mucosa during colonoscopy withdrawal to optimize polyp yield. The aim of this study was to determine if the implementation of an institution-wide policy of colonoscopy withdrawal time > or = 7 minutes was associated with an increase in colon polyp detection. METHODS: All 42 endoscopists at our institute were asked to attain a colonoscopy withdrawal time of at least 7 minutes. Compliance with 7-minute withdrawal time was recorded for all nontherapeutic colonoscopies. Polyp detection ratio (number of polyps detected divided by number of colonoscopies performed) was computed. Regression models were used to assess the association between compliance with 7-minute withdrawal time and polyp detection. RESULTS: During the study period, 23,910 colonoscopies were performed. The average age of patients was 56.8 years, and 54% were female. Colon cancer screening or surveillance was the indication for 42.5% of colonoscopies. At the beginning of the study, the polyp detection ratio was 0.48. Compliance with 7-minute withdrawal time for nontherapeutic procedures increased from 65% at the beginning of the initiative to almost 100%. However, no increase in polyp detection ratio was noted over the same period for all polyps (slope, 0.0006; P = .45) or for polyps 1-5 mm (slope, 0.001; P = .26), 6-9 mm (slope, 0.002; P = .43), or > or = 10 mm (slope, 0.006; P = .13). No association was detected when only colonoscopies performed for screening or surveillance were analyzed. CONCLUSIONS: An institution-wide policy of colonoscopy withdrawal time > or = 7 minutes had no effect on colon polyp detection.

Supra-aortic vessels aneurysms: diagnosis and prompt intervention.

PURPOSE: Aneurysms involving the supra-aortic vessels are rare but carry serious risk of embolization, thrombosis, and rupture. We describe our experience with the diagnosis, treatment strategies, and outcomes in patients with extended follow-up. METHODS: Data during a 17-year period (January 1990 to December 2007) was analyzed. We assessed age, gender, presenting symptoms, localization, pathologic diagnosis, type of procedures, complications, and survival. RESULTS: A total of 74 patients were treated for supra-aortic aneurysms. Of all aneurysms treated, 63% were degenerative, 24% iatrogenic, 8% traumatic, 3% genetic, and 1% mycotic. The subclavian artery was most commonly affected (50%, 2/3 in the right side), followed by the common carotid (36%), internal carotid (10%), innominate (3%), and vertebral (1%). At the time of diagnosis, 52 patients (70%) were asymptomatic, but of those symptomatic 68% had an embolic event as a presenting symptom. Embolic episodes were more common in patients with smaller aneurysms (P < .006). Open surgery was performed in 77% of all cases, and the use of endovascular techniques became the predominant treatment modality over the last 4 years. Survival at 30 days was 100%. Five- and 10-year survival rates were 87% and 43%, respectively. CONCLUSION: Most cases of supra-aortic aneurysm are asymptomatic and embolization as opposed to rupture represents the greatest risk to the patient. Most cases can be detected prior to symptoms. Endovascular repair is an emerging alternative of treatment and, with the current development of appropriate devices, will likely form the mainstay of therapy in the near future.

Revised duplex criteria and outcomes for renal stents and stent grafts following endovascular repair of juxtarenal and thoracoabdominal aneurysms.

OBJECTIVES: To assess outcomes and develop duplex scan criteria that will reliably determine the luminal status of covered and uncovered renal stents following fenestrated and branched endovascular repair. METHODS: A prospective database of patients treated with fenestrated and branched endografts between 2001 and 2006 was reviewed. All patients with evidence of renal artery pathology including duplex scan assessed peak systolic velocity (PSV) <50 or >200 cm/s, renal aortic ratio (RAR) >3.5, elevation of the serum creatinine >30%, computed tomography (CT) evidence of renal stenosis underwent further analyses including medical chart review, and a review of CT and duplex scan imaging data. Correlations of ultrasound scan, CT, angiographic, and clinical outcomes were conducted and receiver operator curve (ROC) analysis was performed. Freedom from stenosis or occlusion was determined by Kaplan-Meier analysis with differences assessed by log rank tests. RESULTS: A total of 518 renal arteries were treated with uncovered or covered renal stents (287 patients). Mean follow-up was 25 months. The estimated freedom from stenosis at 12, 24, and 36 months were 95% (95% confidence interval [CI] 93-98), 92% (89-96), and 89% (85-93) for uncovered stents, and 98% (96-100), 97% (95-100), and 95% (91-100) for covered stents (log rank P = .04). Secondary interventions were performed in 20% of the patients who developed stenoses. Only one of the detected stenoses that was not treated with a secondary intervention progressed to occlusion. Duplex scan criteria derived from ROC analysis correlating with curved planar reconstruction (CPR) from axial imaging data calculated a 60-99% in-stent stenosis to be associated with a PSV >280 cm/s or RAR >4.5. Occlusions were best identified by a mid renal artery PSV <57 cm/s in conjunction with an RAR <1.2. CONCLUSION: Revised ultrasound scan criteria have been developed to improve the sensitivity and specificity of non-invasive interrogation of renal stents following endovascular aneurysm repair (EVAR). Covered renal stents are associated with a lower incidence of in-stent stenosis and are thus recommended over uncovered stents for use in fenestrated or branched endografts.

Comparison of carcinoembryonic antigen and molecular analysis in pancreatic cyst fluid.

BACKGROUND: Pancreatic-cyst fluid carcinoembryonic antigen (CEA) levels and molecular analysis are useful diagnostic tests in differentiating mucinous from nonmucinous cysts. OBJECTIVE: To assess agreement between CEA and molecular analysis for differentiating mucinous from nonmucinous cysts. DESIGN: Retrospective analysis. SETTING: Academic medical center. METHODS: Patients who underwent EUS-guided FNA for evaluation of pancreatic cysts were identified. The following information was used to designate a cyst mucinous: the CEA criterion was CEA level >or=192 ng/mL and the molecular analysis criteria were DNA quantity >or=40 ng/microL and/or k-ras 2-point mutation and/or >or=2 allelic imbalance mutations. Pathologic analysis of cysts served as the criterion standard. RESULTS: From 2006 to 2007, 100 patients met the study criteria. The average age of the patients was 63 years, 65% were women, and 30% were symptomatic. The mean diameter of pancreatic cysts was 2.5 cm. The median CEA value was 83 ng/mL (range 1-50,000 ng/mL), the mean DNA content was 16 ng/microL (range 1-212 ng/microL), 11% had K-ras mutations, and 43% had >or=2 allelic imbalance mutations. When using prespecified criteria, there was poor agreement between CEA and molecular analysis for the classification of mucinous cysts (kappa = 0.2). Poor agreement existed between CEA and DNA quantity (Spearman correlation = 0.2; P = .1), K-ras mutation (kappa = 0.3), and >or=2 allelic imbalance mutations (kappa = 0.1). Of the 19 patients for whom a final pathologic diagnosis was available, CEA had a sensitivity of 82% compared with 77% for molecular analysis. When CEA and molecular analysis were combined, 100% sensitivity was achieved. LIMITATIONS: Retrospective analysis and small sample size. CONCLUSION: There was poor agreement between CEA levels and molecular analysis for diagnosis of mucinous cysts. Diagnostic sensitivity was improved when results of CEA levels and molecular analysis were combined.

[Undetected surgical glove perforation during emergency procedures]. / Perfurações não detectadas de luvas em procedimentos de urgência.

OBJECTIVE: Gloves are the most important barriers that protect hospital personnel and patients. Unfortunately, glove perforation rates reach up to 78% in high risk procedures. The purpose of this prospective study was to evaluate the glove perforation rate in emergency procedures carried out in the Emergency Service of 'Santa Casa de São Paulo', School of Medicine. METHODS: The study analyzed all gloves used in the emergency room during a 2 months period. Gloves were tested immediately after the surgical procedure using the approved standardized water leak method. RESULTS: A total of 252 surgical gloves used by residents in 42 surgical procedures and 2361 gloves used in emergency procedures were tested for the presence of punctures by the water insuflation method. Forty one (16.3%) of the gloves tested showed at least one puncture, 18 (33%) in traumatic emergencies. The overall perforation rate in the emergency room was 7,3%. CONCLUSION: We concluded that the incidence of punctures in gloves during surgical procedures was high, and occurred mostly with surgeons.

Gastric intramural hematoma subsequent to thoracic aortic dissection: Case report and literature review.

INTRODUCTION: Intramural hematomas of the gastrointestinal tract are uncommom, usually located in the esophagus or duodenum, with idiophatic or secondary causes. We present a very rare case of gastric intramural hematoma caused by an unpublished etiology, with literature review. CASE PRESENTATION: An elderly woman suffered acute thoracic aorta dissection followed by gastric intramural hematoma, diagnosed through endoscopy and computed tomography angiography. The treatment included endovascular aortic repair and conservative management. DISCUSSION: The postulated mechanism for the bleeding in gastric intramural hematoma is shredding of terminal arteries at the point of penetration into the muscular layer with subsequent dissection of the muscularis propria from the submucosa. The most frequently cited risk factor is hemorrhagic diathesis/anticoagulant use and the main etiologies are trauma and post-interventional endoscopy. In the diagnosis work-up, computed tomography is the method of choice, usually associated with endoscopy. There is no standard of care for such rare condition. Thus, treatment may be cause-dependent, ranging from conservative to minimally invasive and/or surgery. CONCLUSIONS: Gastric intramural hematoma is a rare disorder with many causes and we described a new etiology for it. The computed tomography is the diagnostic modality of choice, with the aid of other examinations. The treatment comprises conservative measures, minimally invasive approach or most commonly surgery.

Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience.

OBJECTIVE: to assess the short-term efficacy, tolerance and complications in high-risk morbidly obese patients treated with an intragastric balloon as a bridge for surgery. METHODS: we conducted a post-hoc analysis study in a Brazilian teaching hospital from 2010 to 2014, with 23 adult patients with a BMI of 48kg/m2, who received a single intragastric air or liquid balloon. We defined efficacy as 10% excess weight loss, and complications, as adverse events consequent to the intragastric balloon diagnosed after the initial accommodative period. We expressed the anthropometric results as means ± standard deviation, comparing the groups with paired T / Student's T tests, when appropriate, with p<0.05 considered statistically significant. RESULTS: the balloons were effective in 91.3% of the patients, remained in situ for an average of 5.5 months and most of them (65.2%) were air-filled, with a mean excess weight loss of 23.7kg±9.7 (excess weight loss 21.7%±8.9) and mean BMI reduction of 8.3kg/m2±3.3. Complications (17.3%) included abdominal discomfort, balloon deflation and late intolerance, without severe cases. Most of the participants (82.7%) did not experience adverse effects. We removed the intragastric balloons in time, without intercurrences, and 52.2% of these patients underwent bariatric surgery within one month. CONCLUSION: in our center, intragastric balloons can be successfully used as an initial weight loss procedure, with good tolerance and acceptable complications rates.

ERCP PERFORMANCE IN A TERTIARY BRAZILIAN CENTER: FOCUS ON NEW RISK FACTORS, COMPLICATIONS AND QUALITY INDICATORS.

BACKGROUND: ERCP can lead to complications, which can be prevented by the recognition of risk factors. AIM: To identify these risk factors, with quality evaluation. METHODS: Retrospective study in a Brazilian hospital in 194 patients, excluding surgically altered anatomy. RESULTS: 211 ERCPs were performed: 97.6% were therapeutic, 83.4% were started by trainees, with deep cannulation rate of 89.6%. Precut was needed in 16.6% of the ERCPs and classic sphincterotomy in 67.3%, with 75.4% of ductal clearance at single session and 8.0% of technical failure. Inacessible papillas ocurred in 2.5% of cases. There were 2.5% of late complications and 16% of early complications. Multivariate analysis identified six predictors for early complications: fistulotomy precut (OR=3.4, p=0.010), difficult cannulation (OR=21.5, p=0.002), attending's procedural time (OR=2.4, p=0.020), choledocholithiasis (adjusted OR=1.8, p=0.015), cannulation time (adjusted OR=3.2, p=0.018) and ERCP duration (adjusted OR=2.7, p=0.041). CONCLUSION: Six risk factors for post-ERCP complications were identified. ERCP duration and cannulation time are suggested as new potential quality indicators.

Endoscopic polymer injection and endoluminal plication in treatment of gastroesophageal reflux disease: evaluation of long-term results.

BACKGROUND AND STUDY AIMS: Us of proton pump inhibitors (PPIs) has made endoscopic treatment of gastroesophageal reflux disease (GERD) more efficient, with reduction in morbidity and complications. However, some patients persist with symptoms despite medical treatment and some are not compliant with it or cannot afford it for financial reasons, and thus they require non-pharmacological therapeutic options such as surgical fundoplication. Surgery may be effective in the short term, but there is related morbidity and concern about its long-term efficacy. The possibility of minimally invasive endoluminal surgeries has resulted in interest in and development of newly endoscopic devices. Good short-term results with surgical fundoplication lack of studies of is with long follow-up justify our interest in this study. The aim of this study was to investigate the efficacy of endoscopic polymer injection and endoluminal full-thickness plication in the long-term control of GERD. PATIENTS AND METHODS: Forty-seven patients with GERD who underwent an endoscopic procedure were followed up for 60 months and evaluated for total response (RT), partial response (RP) and no response (SR) to endoscopic treatment with reintroduction of PPIs. RESULTS: Twenty-one patients received polymer injection (G0) and 26 endoluminal plication (G1). The number of patients with no response to endoscopic treatment with reintroduction of PPIs increased in time for both techniques (G0 P  = 0.006; G1 P  < 0.001). There was symptomatic improvement up to 12 months, with progressive loss of this trending up to 60 months in G0 and G1 ( P  < 0.001). Health-related quality of life score (GERD-HRQL) demonstrated TR in G0 and G1 at 1, 3, 6 and 12 months. The 60-month analysis showed an increased number of patients with SR in both groups. The quality of life assessment (SF-36) showed benefit in G0 up to 3 months. G0 showed a higher rate of complications. There were no deaths. There was healing of esophagitis at 3 months in 45 % of patients in G0 and 40 % in G1. There was no improvement in manometric or pH findings. CONCLUSION: Endoscopic therapies were ineffective in controlling GERD in the long term.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION.

Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

[I Brazilian consensus of endoscopic ultrasonography]. / I Consenso Brasileiro de Ecoendoscopia.

BACKGROUND: In the last 20 years, several papers have focused on demonstrating the impact of endoscopic ultrasonography findings on the management of different clinical scenarios in digestive disease. This fact is an indirect evidence of the difficulty of popularization of the method. On other hand, the limited availability of endoscopic ultrasonography in Brazil is a direct evidence of this limitation. This was the rationale for the organization of a consensus meeting on endoscopic ultrasonography. It was aimed to identify the best evidence that support the use of endoscopic ultrasonography in gastroenterology. METHODS: A panel of experts on endoscopic ultrasonography was selected based on the files of the Gastroenterology and Endoscopy Societies and on the registries of endoscope manufacturers. Two members of the meeting selected the relevant topics that were transformed into questions. The topics and the questions were debated among the experts five months before the consensus meeting. The experts were asked to perform systematic reviews in order to answer the questions so it could be possible to grade the answers based on the strength of the evidence. During the two days of the meeting the answers were presented, debated and voted. Consensus was reached when a minimum of 70% of the voters were in agreement. The final consensus report was submitted to the experts' evaluation and approval. RESULTS: Seventy nine questions were debated by the experts at the pre-Consensus meeting. As the result of this debate 85 questions came out and were assigned to the members of the panel. During the Consensus meeting 22 experts debated and voted 85 answers. Consensus was reached for several clinical scenarios for which the impact of endoscopic ultrasonography findings were supported by level 1 evidences: differential diagnosis of subepithelial lesions and thickening of gastric folds, staging and diagnosis of unresectable esophageal cancer, indirect signs of peritoneal involvement of gastric cancer, MALT gastric lymphoma and rectal cancer staging, diagnosis of common bile duct and gallbladder stones, diagnosis of chronic pancreatitis and differential diagnosis of a solid mass in chronic pancreatitis, differential diagnosis of the pancreatic cyst, prediction of the results of the endoscopic treatment of esophageal varices and diagnosis and staging of non-small cell lung cancer. CONCLUSIONS: There are the highest levels of evidences that support the indication of endoscopic ultrasonography for several digestive diseases and even for non-small cell lung cancer.

Profilaxia da pancreatite pós-colangiopancreatografia retrógrada endoscópica: avaliação de dois regimes com AINEs diferentes / Post endoscopic retrograde cholangiopancreatography pancreatitis prophylaxis: evaluation of two different nsaid regimens

ABSTRACT BACKGROUND: Endoscopic retrograde cholangiopancreatography is a widely used therapeutic modality for the pancreaticobiliary tree. However, it is responsible for the highest rates of complications among the endoscopic procedures, especially post-endoscopic retrograde cholangiopancreatography pancreatitis. The preventive methods include mechanical and pharmacological approaches, such as the use of non-steroidal anti-inflammatory drugs. OBJECTIVE: To compare the efficacy of two different strategies using non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis, and to clarify the uncertainty about the route of administration of non-steroidal anti-inflammatory drugs in the prevention of this complication. METHODS: This was a prospective trial. Two therapeutic groups were compared with a control group that was composed of patients who underwent endoscopic retrograde cholangiopancreatography, performed in the same service and by the same team in the period preceding the study (historical series), without the administration of any type of prophylaxis. The first group received 100 mg rectal diclofenac. The second group received 100 mg intravenous ketoprofen. Both groups were compared, separately and jointly, with the control group. RESULTS: Post-endoscopic retrograde cholangiopancreatography pancreatitis occurred in 4.39% (12/273) of the participants. In the group without prophylaxis, the incidence was 6.89% (10/145). Among those who received intravenous ketoprofen, the incidence was 2.56% (2/78). No cases of acute post-procedural pancreatitis were observed in the group that received rectal diclofenac (0/52). Although there was no statistical difference between the therapeutic groups when they were separately analyzed, a statistical difference in the prevention of post-procedural pancreatitis was observed when they were analyzed together (P=0.037). CONCLUSION: This study provides evidence for the efficacy of non-steroidal anti-inflammatory drugs in the prophylaxis of post-endoscopic retrograde cholangiopancreatography pancreatitis.

RESUMO CONTEXTO: A colangiopancreatografia retrógrada endoscópica (CPRE) é uma modalidade terapêutica amplamente utilizada para vias biliopancreáticas, responsável pelas taxas mais elevadas de complicações entre os procedimentos endoscópicos, especialmente a pancreatite pós-CPRE (PPC). Os métodos preventivos incluem abordagens mecânicas e farmacológicas, entre elas, a utilização de antinflamatórios não esteroidais (AINEs). OBJETIVO: Comparar a eficácia de duas estratégias diferentes utilizando AINEs para a prevenção de PPC. Elucidar o cenário incerto sobre a via de administração do AINEs na prevenção da PPC. MÉTODOS - Ensaio clínico prospectivo. Duas estratégias terapêuticas foram comparadas a um grupo controle, composto por pacientes submetidos a CPRE no mesmo serviço e com a mesma equipe no período anterior ao estudo (série histórica), que não recebeu qualquer tipo de profilaxia. O primeiro grupo experimental recebeu 100 mg de diclofenaco via retal, o segundo grupo recebeu 100 mg de cetoprofeno endovenoso. Ambos os grupos foram comparados separadamente e em associação com o grupo de controle. RESULTADOS: A PPC ocorreu em 4,39% (12/273) dos participantes. No grupo sem profilaxia, esta incidência foi de 6,89% (10/145); entre os que receberam cetoprofeno endovenoso foi de 2,56% (2/78). Não houve casos de pancreatite aguda após o procedimento no grupo que recebeu diclofenaco via retal (0/52). Apesar de não haver diferença estatística entre estes grupos analisados separadamente, quando os dois grupos terapêuticos são analisados em conjunto estes apresentam diferenças estatísticas na prevenção da PPC (P=0,037). CONCLUSÃO: Este estudo foi capaz de corroborar a eficácia da utilização de AINEs para a profilaxia de pancreatite pós-CPRE.

[Colonic polyps diagnosis by conventional video colonoscopes and chromoscopy with indigo carmine dye solution]. / Videocolonoscopia convencional e cromoscopia com índigo carmim no diagnóstico de pólipos colônicos.

BACKGROUND: Magnification colonoscopy and contrast chromoscopy with indigo carmine dye solution have been used to differentiate neoplastic polyps (adenomas and adenocarcinomas) from non-neoplastic (hyperplastic, inflammatory, juvenile) in an attempt to obviate endoscopic polypectomy. On the other hand, little published information exists concerning conventional video colonoscopes and chromoscopy for polyp histology prediction. Aim - To assess usefullness of conventional video colonoscopes and contrast chromoscopy with indigo carmine solution for differential diagnosis of colon polyps. METHODS: In a routine colonoscopy series, we performed chromoscopy with conventional video colonoscopes before endoscopic excision of detected polyps. If a sulcus pattern was observed on the surface of the lesion, it was classified as neoplastic. Polyps were classified as non-neoplastic if no sulcus was detected on its surface. These observations were then compared with histology. RESULTS: In the study period (18 months), we detected 133 polyps in 53 patients. We were able to compare results of histology and chromoscopy in 126 lesions. The sensitivity, specificity, diagnostic accuracy, negative predictive value, and positive predictive value were 56,4%, 79,2%, 65,1%, 52,8%, and 81,5%, respectively. CONCLUSION: On the base of the presented data, we concluded that conventional video colonoscopes and contrast chromoscopy with indigo carmine solution is not a good technique for differential diagnosis of colon polyps.

[Survival of patients with malignant biliary stricture based on endoscopic brushing and on bilirubinemia]. / Sobrevida de pacientes com estenose biliar maligna baseada no escovado endoscópico e na bilirrubinemia.

BACKGROUND: Pancreatic cancer and cholangiocarcinoma are the main causes of malignant biliary stricture. Both types of cancers have dismal survival rates, and treatment has little or no effect on prolonging the patients lives. Prognostic definition at initial endoscopic retrograde cholangiopancreatography is important to choose the most suitable management. AIM: To analyse endoscopic brushing and bilirubinemia importance in determination of the survival of patients with malignant biliary stricture. METHODS: Patients with biliary strictures diagnosed during endoscopic retrograde cholangiopancreatography were submitted to double brushing cytology. Serum samples were taken from all patients for bilirubinemia assay. Patients were followed to determine the final diagnosis and survival rates. RESULTS: A total of 50 patients with biliary stricture underwent endoscopic retrograde cholangiopancreatography (40 ultimately found to have a final diagnosis of malignant disease). Hyperbilirubinemia or cytology brushing positive for malignancy was related to a shorter survival rate. CONCLUSION: This research data demonstrate the possibility of determining the prognosis of patients with malignant biliary stricture using endoscopic brushing results and bilirubinemia levels.

Aortic disease in the young: genetic aneurysm syndromes, connective tissue disorders, and familial aortic aneurysms and dissections.

There are many genetic syndromes associated with the aortic aneurysmal disease which include Marfan syndrome (MFS), Ehlers-Danlos syndrome (EDS), Loeys-Dietz syndrome (LDS), familial thoracic aortic aneurysms and dissections (TAAD), bicuspid aortic valve disease (BAV), and autosomal dominant polycystic kidney disease (ADPKD). In the absence of familial history and other clinical findings, the proportion of thoracic and abdominal aortic aneurysms and dissections resulting from a genetic predisposition is still unknown. In this study, we propose the review of the current genetic knowledge in the aortic disease, observing, in the results that the causative genes and molecular pathways involved in the pathophysiology of aortic aneurysm disease remain undiscovered and continue to be an area of intensive research.

Intragastric balloons in high-risk obese patients in a Brazilian center: initial experience / Balões intragástricos em obesos de alto risco em um centro brasileiro: experiência inicial

ABSTRACT Objective: to assess the short-term efficacy, tolerance and complications in high-risk morbidly obese patients treated with an intragastric balloon as a bridge for surgery. Methods: we conducted a post-hoc analysis study in a Brazilian teaching hospital from 2010 to 2014, with 23 adult patients with a BMI of 48kg/m2, who received a single intragastric air or liquid balloon. We defined efficacy as 10% excess weight loss, and complications, as adverse events consequent to the intragastric balloon diagnosed after the initial accommodative period. We expressed the anthropometric results as means ± standard deviation, comparing the groups with paired T / Student's T tests, when appropriate, with p<0.05 considered statistically significant. Results: the balloons were effective in 91.3% of the patients, remained in situ for an average of 5.5 months and most of them (65.2%) were air-filled, with a mean excess weight loss of 23.7kg±9.7 (excess weight loss 21.7%±8.9) and mean BMI reduction of 8.3kg/m2±3.3. Complications (17.3%) included abdominal discomfort, balloon deflation and late intolerance, without severe cases. Most of the participants (82.7%) did not experience adverse effects. We removed the intragastric balloons in time, without intercurrences, and 52.2% of these patients underwent bariatric surgery within one month. Conclusion: in our center, intragastric balloons can be successfully used as an initial weight loss procedure, with good tolerance and acceptable complications rates.

RESUMO Objetivo: identificar a eficácia em curto prazo, a tolerância e as complicações em obesos mórbidos de alto risco, tratados com balão intragástrico como ponte para cirurgia. Métodos: estudo de análise post-hoc em um hospital acadêmico brasileiro durante o período de 2010 a 2014, de 23 pacientes adultos com IMC de 48kg/m2 que receberam um único balão intragástrico de ar ou líquido. Eficácia foi definida como perda de excesso de peso de 10%, e complicações como eventos adversos consequentes ao balão intragástrico diagnosticados após o período acomodativo inicial. Expressaram-se os resultados antropométricos com média ± desvio padrão, comparando os grupos com testes T Pareado / T de Student, quando apropriado, com p<0,05 considerado estatisticamente significante. Resultados: os balões foram efetivos em 91,3% dos pacientes, permaneceram in situ por em média 5,5 meses e a maioria deles (65,2%) era de ar, com perda média de excesso peso de 23,7kg±9,7 (perda de excesso de peso de 21,7%±8,9) e redução média de IMC de 8,3kg/m2±3,3. As complicações (17,3%) compreenderam desconforto abdominal, deflação do balão e intolerância tardia, sem casos graves. A maioria dos participantes (82,7%) não experimentou efeitos adversos, seus balões intragástricos foram extraídos em tempo, sem intercorrências e 52,2% desses pacientes submeteram-se à cirurgia bariátrica no intervalo de um mês. Conclusão: no nosso centro, balões intragástricos podem ser usados com sucesso como procedimento inicial de perda ponderal, com boa tolerância e taxas aceitáveis de complicações.