Colangiopancreatografia retrógrada endoscópica versus ultrassom endoscópico no diagnóstico histológico da estenose biliar maligna: revisão sistemática e metanálise

Introdução: O diagnóstico histológico das estenoses biliares é fundamental na definição da terapêutica a ser empregada, devido à heterogeneidade dos resultados dos estudos comparando o uso do escovado citológico e da biópsia transpapilar na colangiopancreatografia retrógada endoscópica (CPRE) com a punção aspirativa ecoguiada com agulha fina (ECO-PAAF) no diagnóstico histológico da estenose biliar maligna, e o fato de não existirem revisões sistemáticas e metanálises comparando esses métodos, este estudo propõe comparar esses dois métodos no diagnóstico histológico da estenose biliar maligna, através de revisão sistemática e metanálise da literatura. Métodos: Utilizando as bases de dados eletrônicas Medline, Embase, Cochrane, LILACS, CINAHL, e Scopus foram pesquisados estudos datados anteriormente a novembro de 2014. De um total de 1009 estudos publicados, foram selecionados três estudos prospectivos comparando ECO-PAAF e CPRE no diagnóstico histológico da estenose biliar maligna e cinco estudos transversais comparando ECO-PAAF com o mesmo padrão-ouro dos outros três estudos comparativos. Todos os pacientes foram submetidos ao mesmo padrão-ouro. Foram calculadas as variáveis do estudo (prevalência, sensibilidade, especificidade, valores preditivos positivos e negativos e acurácia) e realizada a metanálise utilizando os softwares Rev Man 5 e Meta-DiSc 1.4. Resultados: Um total de 294 pacientes foi incluído na análise. A probabilidade pré-teste para estenose biliar maligna foi de 76,66%. As sensibilidades médias da CPRE e da ECO-PAAF para o diagnóstico histológico da estenose biliar maligna foram de 49% e 76,5%, respectivamente; especificidades foram de 96,33% e 100%, respectivamente. As probabilidades pós-teste também foram determinadas: valores preditivos positivos de 98,33% e 100%, respectivamente, e valores preditivos negativos de 34% e 58,87%. As acurácias foram 60,66% e 82,25%, respectivamente. Conclusão: A ECO-PAAF é superior a CPRE com escovado citológico e/ou biópsia transpapilar no diagnóstico histológico da estenose biliar maligna. No entanto, um teste de ECO-PAAF ou CPRE com amostra histológica negativa não pode excluir a estenose biliar maligna, pois ambos os testes apresentam baixo valor preditivo negativo

Comparação entre prótese plástica e metálica na paliação endoscópica da obstrução maligna da via biliar: revisão sistemática e metanálise baseadas em estudos randomizados

INTRODUÇÃO: A prótese biliar endoscópica é aceita em todo o mundo como a primeira escolha de tratamento paliativo na obstrução biliar maligna. Atualmente ainda persistem dois tipos de materiais utilizados em sua confecção: plástico e metal. Consequentemente, muitas dúvidas surgem quanto a qual deles é o mais benéfico para o paciente. Esta revisão reúne as informações disponíveis da mais alta qualidade sobre estes dois tipos de prótese, fornecendo informações em relação à disfunção, complicação, taxas de reintervenção, custos, sobrevida e tempo de permeabilidade; e pretende ajudar a lidar com a prática clínica nos dias de hoje. OBJETIVO: Analisar, através de metanálise, os benefícios de dois tipos de próteses na obstrução biliar maligna inoperável. MÉTODOS: Uma revisão sistemática de ensaios clínicos randomizados (RCT) foi conduzida, com a última atualização em março de 2015, utilizando EMBASE, CINAHL (EBSCO), Medline, Lilacs / Centro (BVS), Scopus, o CAPES (Brasil), e literatura cinzenta. As informações dos estudos selecionados foram extraídas tendo em vista seis desfechos: primariamente disfunção, taxas de reintervenção e complicações; e, secundariamente, custos, sobrevivência e tempo de permeabilidade. Os dados sobre as características dos participantes do RCT, critérios de inclusão e exclusão e tipos de próteses também foram extraídos. Os vieses foram avaliados principalmente através da escala de Jadad. Esta metanálise foi registrada no banco de dados PROSPERO pelo número CRD42014015078. A análise do risco absoluto dos resultados foi realizada utilizando o software RevMan 5, calculando as diferenças de risco (RD) de variáveis dicotômicas e média das diferenças (MD) de variáveis contínuas. Os dados sobre a RD e MD para cada desfecho primário foram calculados utilizando o teste de Mantel-Haenszel e a inconsistência foi avaliada com o teste Qui-quadrado (Chi2) e o método de Higgins (I2). A análise de sensibilidade foi realizada com a retirada de estudos discrepantes e a utilização do efeito aleatório. O teste t de Student foi utilizado para a comparação das médias aritméticas ponderadas, em relação aos desfechos secundários. RESULTADOS: Inicialmente foram identificados 3660 estudos; 3539 foram excluídos por título ou resumo, enquanto 121 estudos foram totalmente avaliados e foram excluídos, principalmente por não comparar próteses metálicas (SEMS) e próteses plásticas (PS), levando a treze RCT selecionados e 1133 indivíduos metanálise. A média de idade foi de 69,5 anos, e o câncer mais comum foi de via biliar (proximal) e pancreático (distal). O diâmetro de SEMS mais utilizado foi de 10 mm (30 Fr) e o diâmetro de PS mais utilizado foi de 10 Fr. Na metanálise, SEMS tiveram menor disfunção global em comparação com PS (21,6% versus 46,8% p < 0,00001) e menos reintervenções (21,6% versus 56,6% p < 0,00001), sem diferença nas complicações (13,7% versus 15,9% p = 0,16). Na análise secundária, a taxa média de sobrevida foi maior no grupo SEMS (182 contra 150 dias - p < 0,0001), com um período maior de permeabilidade (250 contra 124 dias - p < 0,0001) e um custo semelhante por paciente, embora menor no grupo SEMS (4.193,98 contra 4.728,65 Euros - p < 0,0985). CONCLUSÃO: SEMS estão associados com menor disfunção, menores taxas de reintervenção, melhor sobrevida e maior tempo de permeabilidade. Complicações e custos não apresentaram diferença

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

Portal cavernoma cholangiopathy : case report and systematic review

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Quistos aracnoideus : quais as indicações cirúrgicas?

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Colite microscópica : uma causa rara de diarreia crónica em pediatria

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Groove pancreatitis a propósito de um caso clínico

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Pólipos hiperplásicos da junção gastro-esofágica em idade pediátrica

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Tratamento endoscópico endonasal de tumores nasossinusais malignos : resseção e reconstrução

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Tratamento da ruptura de varizes esofágicas em doentes com cirrose

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Atresia das choanas bilateral no recém nascido : revisão a propósito de 2 casos clínicos

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Second St. Gallen European Organisation for Research and Treatment of Cancer Gastrointestinal Cancer Conference: consensus recommendations on controversial issues in the primary treatment of rectal cancer

Primary treatment of rectal cancer was the focus of the second St. Gallen European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Cancer Conference. In the context of the conference, a multidisciplinary international expert panel discussed and voted on controversial issues which could not be easily answered using published evidence. Main topics included optimal pretherapeutic imaging, indication and type of neoadjuvant treatment, and the treatment strategies in advanced tumours. Here we report the key recommendations and summarise the related evidence. The treatment strategy for localised rectal cancer varies from local excision in early tumours to neoadjuvant radiochemotherapy (RCT) in combination with extended surgery in locally advanced disease. Optimal pretherapeutic staging is a key to any treatment decision. The panel recommended magnetic resonance imaging (MRI) or MRI + endoscopic ultrasonography (EUS) as mandatory staging modalities, except for early T1 cancers with an option for local excision, where EUS in addition to MRI was considered to be most important because of its superior near-field resolution. Primary surgery with total mesorectal excision was recommended by most panellists for some early tumours with limited risk of recurrence (i.e. cT1-2 or cT3a N0 with clear mesorectal fascia on MRI and clearly above the levator muscles), whereas all other stages were considered for multimodal treatment. The consensus panel recommended long-course RCT over short-course radiotherapy for most clinical situations where neoadjuvant treatment is indicated, with the exception of T3a/b N0 tumours where short-course radiotherapy or even no neoadjuvant therapy were regarded to be an option. In patients with potentially resectable tumours and synchronous liver metastases, most panel members did not see an indication to start with classical fluoropyrimidine-based RCT but rather favoured preoperative short-course radiotherapy with systemic combination chemotherapy or alternatively a liver-first resection approach in resectable metastases, which both allow optimal systemic therapy for the metastatic disease. In general, proper patient selection and discussion in an experienced multidisciplinary team was considered as crucial component of care.

A new eosinophilic esophagitis (EoE)-like disease without tissue eosinophilia found in EoE Families

BACKGROUND Eosinophilic esophagitis (EoE) is a rapidly emerging, chronic inflammatory, genetically impacted disease of the esophagus, defined clinically by symptoms of esophageal dysfunction and, pathologically, by an eosinophil-predominant tissue infiltration. However, in four EoE-families, we have identified patients presenting with EoE-typical and corticosteroid-responsive symptoms, but without tissue eosinophilia. It was the aim of this study to clinically and immunologically characterize these patients with EoE-like disease. METHODS Five patients suffering from an EoE-like disease were evaluated with endoscopic, histologic, functional and quantitative immunohistologic examinations, and mRNA expression determination. RESULTS The frequency of first generation offspring of EoE-like disease patients affected by EoE or EoE-like disease was 40%. Immunofluorescence analysis confirmed an almost complete absence of eosinophils in the esophageal tissues of patients with EoE-like disease, but revealed a considerable T cell infiltration, comparable to EoE. In contrast to EoE, eotaxin-3 mRNA and protein were markedly reduced in EoE-like disease (P < 0.05). The mRNA expression levels of three selected EoE genes (eotaxin-3, MUC4 and CDH26) allowed to discriminate between EoE-like disease, EoE and normal epithelium. CONCLUSIONS Patients suffering from "EoE without eosinophilia" do not fulfill formally the diagnostic criteria for EoE. However, their clinical manifestation, immunohistology and gene-expression pattern, plus the fact that they bequeath EoE to their offspring, suggest a uniform underlying pathogenesis. Conventional EoE, with its prominent eosinophilia, therefore appears to be only one phenotype of a broader "inflammatory dysphagia syndrome" spectrum. In this light, the role of the eosinophils, the definition of EoE, and its diagnostic criteria must likely be reconsidered. This article is protected by copyright. All rights reserved.

Geochemistry of ODP Hole 128-798B

The capability of determining elemental concentrations through geochemical logging has recently been established. However, the quality of these data obtained in some environments has yet to be quantified. We assess the quality of geochemical logs compared with XRF results from a suite of core samples from Hole 798B. The resulting core/log correlations are only fair, because the tool has been adversely affected by the very high porosity of the formation. The results, however, do fall within the statistical uncertainties predicted by the processing. The recent application of a modified boron sleeve to the Ocean Drilling Program's geochemical logging tool is shown to reduce interference of borehole chlorine on the resultant chemistry.

Students crossing State St. in front of Michigan Union. Taken for the Michigan Alumnus, April, 1947

On negative sleeve: A suggestion of warmer days ahead for winter-weary Michiganders is contained in this early spring picture, taken from the Michigan Union looking across to Alumni Memorial Hall just as students leave classes at the noon hour