Lewis Score - Prognostic value in patients with isolated small bowel Crohn's disease

Background and aims: Small bowel capsule endoscopy (SBCE) allows mapping of small bowel inflammation in Crohn’s disease (CD). We aimed to assess the prognostic value of the severity of inflammatory lesions, quantified by the Lewis score (LS), in patients with isolated small bowel CD. Methods: A retrospective study was performed in which 53 patients with isolated small bowel CD were submitted to SBCE at the time of diagnosis. The Lewis score was calculated and patients had at least 12 months of follow-up after diagnosis. As adverse events we defined disease flare requiring systemic corticosteroid therapy, hospitalization and/or surgery during follow-up. We compared the incidence of adverse events in 2 patient subgroups, i.e. those with moderate or severe inflammatory activity (LS =790) and those with mild inflammatory activity (135 = LS < 790). Results: The LS was =790 in 22 patients (41.5%), while 58.5% presented with LS between 135 and 790. Patients with a higher LS were more frequently smokers (p = 0.01), males (p = 0017) and under immunosuppressive therapy (p = 0.004). In multivariate analysis, moderate to severe disease at SBCE was independently associated with corticosteroid therapy during follow-up, with a relative risk (RR) of 5 (p = 0.011; 95% confidence interval [CI] 1.5–17.8), and for hospitalization, with an RR of 13.7 (p = 0 .028; 95% CI 1.3–141.9). Conclusion: In patients with moderate to severe inflammatory activity there were higher prevalences of corticosteroid therapy demand and hospitalization during follow-up. Thus, stratifying the degree of small bowel inflammatory activity with SBCE and LS calculation at the time of diagnosis provided relevant prognostic value in patients with isolated small bowel CD.

Deteção e classificação de regiões de interesse em vídeos de endoscopia

Dissertação de mestrado integrado em Engenharia Biomédica (área de especialização em Informática Médica)

Percutaneous closure of atrial septal defects. The role of transesophageal echocardiography

PURPOSE: Evaluation of the role of transesophageal echocardiography in percutaneous closure of atrial septal defects (ASD) with the Amplatzer septal occluder. METHODS: Patients were selected for percutaneous closure of ASD by transesophageal echocardiography (TEE), which was also used to monitor the procedure, helping to select the appropriate size of the Amplatzer device, to verify its position, and to access the immediate results of the procedure. During the follow-up, TEE was used to evaluate the presence and magnitude of residual shunt (RS), device position, and right cardiac chamber diameters. RESULTS: Twenty-two (40%) of a total of 55 studied patients were selected. Thirteen underwent Amplatzer device implantation, eight are still waiting for it, and one preferred the conventional surgical treatment. All procedures were successful, which was mainly due to proper patient selection. Six (23%) patients acutely developed RS, which spontaneously disapeared at the three-month follow-up examination in three patients. There was a significant reduction in the right ventricle diastolic diameter, from 27mm (average) to 24mm and 20mm, one and three months after the procedure, respectively (p<0.0076). CONCLUSION: With the aid of TEE, percutaneous closure of ASD can be successfully, safely, and effectively performed.

Reliability of the interpretation of coronary angiography by the simple visual method

OBJECTIVE: Evaluation of inter and intraobserver reproducibility of by the visual method interpretation of cineangiogram in a clinically based context. METHODS: Five interventional cardiologists analyzed 11 segments of 8 coronary cineangiograms at a two month apart sessions. The percent luminal reduction by the lesions were analyzed by two different classifications: in one (A) the lesions were graded in 0% = absent, 1-50% = mild, 51 - 69 = moderate, and > or = 70% = severe; the other classification (B) was a dichotomic one : <70% = nonsignificant and > or = 70%=significant lesions. The agreement were measured by the kappa (k) index. RESULTS: Interobserver agreement was moderate for classification A (1st measurement, k = 0.36 -- 0.63, k m = 0.49; 2nd measurement, k = 0.39-0.68, k m = 0.52) and good for classification B (1st measurement, k = 0.55-0.73, k m = 0.63; 2nd measurement, k = 0.37-0.82, k m = 0.61). Intraobserver levels of agreement were k = 0.57-0.95 for classification A and 0.62-1.0 for classification B. CONCLUSION: The higher level of reproducibility obtained by adopting the dichotomous criteria usually considered for ischemic limits demonstrates that in the present clinical context, the reliability of the simple visual method is adequate for the identification of patients with clinically significant lesions and candidates for myocardial revascularization procedures.

Hormonal and cardiovascular reflex assessment in a female patient with pure autonomic failure

We report the case of a 72-year-old female with pure autonomic failure, a rare entity, whose diagnosis of autonomic dysfunction was determined with a series of complementary tests. For approximately 2 years, the patient has been experiencing dizziness and a tendency to fall, a significant weight loss, generalized weakness, dysphagia, intestinal constipation, blurred vision, dry mouth, and changes in her voice. She underwent clinical assessment and laboratory tests (biochemical tests, chest X-ray, digestive endoscopy, colonoscopy, chest computed tomography, abdomen and pelvis computed tomography, abdominal ultrasound, and ambulatory blood pressure monitoring). Measurements of catecholamine and plasmatic renin activity were performed at rest and after physical exercise. Finally the patient underwent physiological and pharmacological autonomic tests that better diagnosed dysautonomia.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry - CENIC

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Intracoronary brachytherapy in the treatment of in-stent restenosis. Initial experience in Brazil

Intracoronary brachytherapy using beta or gamma radiation is currently the most efficient type of therapy for preventing the recurrence of coronary in-stent restenosis. Its implementation depends on the interaction among interventionists, radiotherapists, and physicists to assure the safety and quality of the method. The authors report the pioneering experience in Brazil of the treatment of 2 patients with coronary in-stent restenosis, in whom beta radiation was used as part of the international multicenter randomized PREVENT study (Proliferation REduction with Vascular ENergy Trial). The procedures were performed rapidly and did not require significant modifications in the traditional techniques used for conventional angioplasty. Alteration in the radiological protection devices of the hemodynamic laboratory were also not required, showing that intracoronary brachytherapy using beta radiation can be incorporated into the interventional tools of cardiology in our environment.

Predictive factors of complications after coronary stent implantation

OBJECTIVE: To analyze the predictive factors of complications after implantation of coronary stents in a consecutive cohort study. METHODS: Clinical and angiographic characteristics related to the procedure were analyzed, and the incidence of major cardiovascular complications (myocardial infarction, urgent surgery, new angioplasty, death) in the in-hospital phase were recorded. Data were stored in an Access database and analyzed by using the SPSS 6.0 statistical program and a stepwise backwards multiple logistic regression model. RESULTS: One thousand eighteen (mean age of 61±11 years, 29% females) patients underwent 1,070 stent implantations. The rate of angiographic success was 96.8%, the rate of clinical success was 91%, and the incidence of major cardiovascular complications was 7.9%. The variables independently associated with major cardiovascular complications, with their respective odds ratio (OR) were: rescue stent, OR = 5.1 (2.7-9.6); filamentary stent, OR = 4.5 (2.2-9.1); first-generation tubular stent, OR = 2.4 (1.2-4.6); multiple stents, OR = 3 (1.6-5.6); complexity of the lesion, OR = 2.4 (1.1-5.1); thrombus, OR = 2 (1.1-3.5). CONCLUSION: The results stress the importance of angiographic variables and techniques in the risk of complications and draw attention to the influence of the stent's design on the result of the procedure.

Short- and midterm follow-up results of valvuloplasty with balloon catheter for congenital aortic stenosis

OBJECTIVE: To report short and midtem follow-up results of balloon aortic valvuloplasty to treat congenital aortic stenosis. METHODS: Seventy-five patients (median age: 8 years) underwent the procedure through the retrograde femoral or carotid route. RESULTS: The procedure was completed in 74 patients (98.6%). The peak-to-peak systolic gradient dropped from 79.6±27.7 to 22.3±17.8 mmHg (P<0.001), the left ventricular systolic pressure dropped from 164±39.1 to 110±24.8 mmHg (P<0.001), and the left ventricular end diastolic pressure dropped from 13.3±5.5 to 8.5±8.3 mmHg (P< 0.01). Four patients (5.3%) died due to the procedure. Aortic regurgitation (AoR) appeared or worsened in 27/71 (38%) patients, and no immediate surgical intervention was required. A mean follow-up of 50±38 months was obtained in 37 patients. Restenosis and significant AoR were observed in 16.6% of the patients. The estimates for being restenosis-free and for having significant AoR in 90 months were 60% and 50%, respectively. CONCLUSION: Aortic valvuloplasty was considered the initial palliative method of choice in managing congenital aortic stenosis, with satisfactory short- and midterm results.

Efficacy and Safety of Drug-Eluting Stents in the Real World: 8-Year Follow-Up

Background: Drug-eluting stents have been used in daily practice since 2002, with the clear advantages of reducing the risk of target vessel revascularization and an impressive reduction in restenosis rate by 50%-70%. However, the occurrence of a late thrombosis can compromise long-term results, particularly if the risks of this event were sustained. In this context, a registry of clinical cases gains special value. Objective: To evaluate the efficacy and safety of drug-eluting stents in the real world. Methods: We report on the clinical findings and 8-year follow-up parameters of all patients that underwent percutaneous coronary intervention with a drug-eluting stent from January 2002 to April 2007. Drug-eluting stents were used in accordance with the clinical and interventional cardiologist decision and availability of the stent. Results: A total of 611 patients were included, and clinical follow-up of up to 8 years was obtained for 96.2% of the patients. Total mortality was 8.7% and nonfatal infarctions occurred in 4.3% of the cases. Target vessel revascularization occurred in 12.4% of the cases, and target lesion revascularization occurred in 8% of the cases. The rate of stent thrombosis was 2.1%. There were no new episodes of stent thrombosis after the fifth year of follow-up. Comparative subanalysis showed no outcome differences between the different types of stents used, including Cypher®, Taxus®, and Endeavor®. Conclusion: These findings indicate that drug-eluting stents remain safe and effective at very long-term follow-up. Patients in the "real world" may benefit from drug-eluting stenting with excellent, long-term results.

Influence of Spironolactone on Matrix Metalloproteinase-2 in Acute Decompensated Heart Failure

Background: Matrix metalloproteinases (MMPs) are a family of enzymes important for the resorption of extracellular matrices, control of vascular remodeling and repair. Increased activity of MMP2 has been demonstrated in heart failure, and in acutely decompensated heart failure (ADHF) a decrease in circulating MMPs has been demonstrated along with successful treatment. Objective: Our aim was to test the influence of spironolactone in MMP2 levels. Methods: Secondary analysis of a prospective, interventional study including 100 patients with ADHF. Fifty patients were non-randomly assigned to spironolactone (100 mg/day) plus standard ADHF therapy (spironolactone group) or standard ADHF therapy alone (control group). Results: Spironolactone group patients were younger and had lower creatinine and urea levels (all p < 0.05). Baseline MMP2, NT-pro BNP and weight did not differ between spironolactone and control groups. A trend towards a more pronounced decrease in MMP2 from baseline to day 3 was observed in the spironolactone group (-21 [-50 to 19] vs 1.5 [-26 to 38] ng/mL, p = 0.06). NT-pro BNP and weight also had a greater decrease in the spironolactone group. The proportion of patients with a decrease in MMP2 levels from baseline to day 3 was also likely to be greater in the spironolactone group (50% vs 66.7%), but without statistical significance. Correlations between MMP2, NT-pro BNP and weight variation were not statistically significant. Conclusion: MMP2 levels are increased in ADHF. Patients treated with spironolactone may have a greater reduction in MMP2 levels.

Acute Coronary Syndrome Treatment Costs from the Perspective of the Supplementary Health System

AbstractBackground:Acute coronary syndrome (ACS) is defined as a “group of clinical symptoms compatible with acute myocardial ischemia”, representing the leading cause of death worldwide, with a high clinical and financial impact. In this sense, the development of economic studies assessing the costs related to the treatment of ACS should be considered.Objective:To evaluate costs and length of hospital stay between groups of patients treated for ACS undergoing angioplasty with or without stent implantation (stent+ / stent-), coronary artery bypass surgery (CABG) and treated only clinically (Clinical) from the perspective of the Brazilian Supplementary Health System (SHS).Methods:A retrospective analysis of medical claims of beneficiaries of health plans was performed considering hospitalization costs and length of hospital stay for management of patients undergoing different types of treatment for ACS, between Jan/2010 and Jun/2012.Results:The average costs per patient were R$ 18,261.77, R$ 30,611.07, R$ 37,454.94 and R$ 40,883.37 in the following groups: Clinical, stent-, stent+ and CABG, respectively. The average costs per day of hospitalization were R$ 1,987.03, R$ 4,024.72, R$ 6,033.40 and R$ 2,663.82, respectively. The average results for length of stay were 9.19 days, 7.61 days, 6.19 days and 15.20 days in these same groups. The differences were significant between all groups except Clinical and stent- and between stent + and CABG groups for cost analysis.Conclusion:Hospitalization costs of SCA are high in the Brazilian SHS, being significantly higher when interventional procedures are required.

Sommes-nous prêts à prescrire une polypill à nos patients [Are we ready to prescribe a polypill to our patients?].

The all-in-one pill combination (Polypill) of several active components used in primary prevention of cardiovascular disease was a decade ago purposed to reduce the cardiovascular burden by more than 80%. This Polypill could be approved before 2013 in United States. Although controversed, it could answer to the worried situation even observed in Switzerland: the adherence to secondary prevention treatments is clearly insufficient and the cardiovascular events remain in the first row of death's causes. This abstract summarize the results from interventional studies who tried to valid this concept as well as the main stakes to be assessed on the medical side before to consider such a similar approach in Switzerland.

Endoscopic mucosal resection in the esophagus with a new rigide device : an animal study

Résumé: Introduction : L'utilisation de méthodes endoscopiques peu invasives est en constante augmentation pour le traitement des lésions tumorales précoces de l'oesophage. Le but du traitement comprend l'éradication complète de tous les foyers de dysplasie ou de carcinome in situ, notamment dans les métaplasies intestinales de l'oesophage de Barrett, qui peuvent dégénérer en adénocarcinome. Plusieurs techniques d'ablation de la muqueuse oesophagienne (laser, argon plasma, electrocoagulation, photothérapie dynamique, résection endoscopique) ont été utilisées jusqu'à présent, mais aucune n'a vraiment donné entière satisfaction. Les techniques actuelles de résections endoscopiques par fibroscopie sont entre autres limitées par le grand nombre de séances nécessaires à l'éradication complète de la lésion et par la petite taille des fragments de muqueuse obtenus, ce qui rend l'analyse histologique difficile. Dans notre étude animale, nous avons évalué la faisabilité, l'efficacité et la sécurité d'une méthode de résection endoscopique à l'aide d'un nouvel oesophagoscope rigide. Matériel et méthode : Le résectoscope est formé d'un oesophagoscope rigide avec une fenêtre distale transparente à travers laquelle la muqueuse et une partie de la sous-muqueuse sont aspirées et ensuite réséquées avec une anse thermique. Les diverses fenêtres utilisées ont une taille comprise entre 2.2 et 4.4 cm. Le mouton a été choisi en raison de la ressemblance de son oesophage avec celui de l'humain en ce qui concerne l'épaisseur de son oesophage et sa structure histologique. Nous avons effectué 55 résections hémi-circonférentielles sur 21 animaux et 11 résections circonférentielles sur 11 autres. La Mitomycine-C, une substance qui inhibe la prolifération fibroblastique, a été utilisée dans 8 résections circonférentielles à différents intervalles de temps afin d'empêcher la survenue de sténoses oesophagiennes. Résultats : Toutes les résections hémi-circonférentielles ont permis d'obtenir des fragments compacts de tissu avec des bords nets, ce qui permet une excellente étude histologique. La surface du tissu prélevé était en corrélation avec la taille de la fenêtre du resectoscope. Nous avons ainsi pu obtenir des fragments avec des dimensions comprises entre 6 et 12 cm2. Pour les résections circonférentielles, les tissus étaient obtenus en 2 parties, en inversant de 180° la position de l'appareil. La profondeur de la résection a été optimale dans 58 cas sur 65 avec une découpe précise au niveau de la sous-muqueuse sans lésion de la couche musculaire sous- jacente. Il n'y a pas eu de complications après les résections hémi-circonférentielles. Les complications engendrées par les résections circonférentielles (sténose, perforation) n'ont plus été rencontrées après application locale de Mitomycine-C administrée à des intervalles de temps bien précis. Conclusion : Notre méthode de résection endoscopique de la muqueuse oesophagienne offre une nouvelle approche très prometteuse par rapport aux options déjà disponibles. Elle apparaît supérieure en ce qui concerne la taille de tissu prélevé, la précision et régularité de la profondeur de résection, ainsi que la facilité et sûreté du diagnostic histologique et des marges de sécurité. Les résections hémi-circonférentielles se sont révélées sûres chez le modèle animal. Cette nouvelle technique mérite de plus amples investigations pour les résections circonférentielles avant son utilisation chez l'humain. Abstract: Background and Study Aims: We undertook this retrospective study to evaluate the frequency and prognosis of endoscopic treatment of laterally spreading tumors (LSTs) in the rectum. The recurrence rate for lesions of the lower rectum was compared with that of the upper rectum. Patients and Methods: During the period from July 1989 to June 2002, a total of 1237 rectal tumors were detected. LSTs accounted for 6.9% (85/1237) of all rectal tumors. A total of 224 tumors of the lower rectum were detected among the 1237 rectal tumors. LSTs accounted for 16.1 % (36/224) of all the lower rectal tumors. From 85 LST lesions, 67 were evaluated for their prognosis after endoscopic mucosal resection (EMR). Patients whose LSTs had been resected were followed up by endoscopy at the following frequencies: once 15 (22.4%); twice (more than 1 year), 20 (29.9%); three times (more than 3 years), 21(31.3%); and four times or more (more than 5 years), 11 (16.4%). Results: A total of 67 patients with endoscopically treated LSTs were followed up by endoscopy. We observed recurrences in two lesions of the upper rectum (2/38, 5.3%) and five lesions of the lower rectum (5/29, 17.2%) (P = 0.2364); all seven lesions were resected piecemeal. LSTs whose horizontal margin reached the pectinate line frequently recurred in the lower rectum, at a rate of 80% (4/5). However, all patients were completely cured by additional endoscopic resections, the greatest number of treatments being four. Conclusion: For early detection of recurrence and successful endoscopic cure, further colonoscopic examination within a few months after the first treatment is necessary.

Age, smoking and overweight contribute to the development of intestinal metaplasia of the cardia.

AIM: To assess the role of Helicobacter pylori (H. pylori), gastroesophageal reflux disease (GERD), age, smoking and body weight on the development of intestinal metaplasia of the gastric cardia (IMC).¦METHODS: Two hundred and seventeen patients scheduled for esophagogastroduodenoscopy were enrolled in this study. Endoscopic biopsies from the esophagus, gastroesophageal junction and stomach were evaluated for inflammation, the presence of H. pylori and intestinal metaplasia. The correlation of these factors with the presence of IMC was assessed using logistic regression.¦RESULTS: IMC was observed in 42% of the patients. Patient age, smoking habit and body mass index (BMI) were found as potential contributors to IMC. The risk of developing IMC can be predicted in theory by combining these factors according to the following formula: Risk of IMC = a + s - 2B where a = 2,...6 decade of age, s = 0 for non-smokers or ex-smokers, 1 for < 10 cigarettes/d, 2 for > 10 cigarettes/d and B = 0 for BMI < 25 kg/m² (BMI < 27 kg/m² in females), 1 for BMI > 25 kg/m² (BMI > 27 kg/m² in females). Among potential factors associated with IMC, H. pylori had borderline significance (P = 0.07), while GERD showed no significance.¦CONCLUSION: Age, smoking and BMI are potential factors associated with IMC, while H. pylori and GERD show no significant association. IMC can be predicted in theory by logistic regression analysis.