Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding?

BACKGROUND: in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. AIMS: evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS: we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. RESULTS: with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy´s lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. CONCLUSIONS: intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable.

Effect of portal hypertension in the small bowel: an endoscopic approach

BACKGROUND AND AIM: The effects of portal hypertension in the small bowel are largely unknown. The aim of the study was to prospectively assess portal hypertension manifestations in the small bowel. METHODS: We compared, by performing enteroscopy with capsule endoscopy, the endoscopic findings of 36 patients with portal hypertension, 25 cirrhotic and 11 non-cirrhotic, with 30 controls. RESULTS: Varices, defined as distended, tortuous, or saccular veins, and areas of mucosa with a reticulate pattern were significantly more frequent in patients with PTH. These two findings were detected in 26 of the 66 patients (39%), 25 from the group with PTH (69%) and one from the control group (3%) (P < 0.0001). Among the 25 patients with PTH exhibiting these patterns, 17 were cirrhotic and 8 were non-cirrhotic (P = 0.551). The presence of these endoscopic changes was not related to age, gender, presence of cirrhosis, esophageal or gastric varices, portal hypertensive gastropathy, portal hypertensive colopathy, prior esophageal endoscopic treatment, current administration of beta-blockers, or Child-Pugh Class C. More patients with these endoscopic patterns had a previous history of acute digestive bleeding (72% vs. 36%) (P = 0.05). Active bleeding was found in two patients (5.5%). CONCLUSIONS: The presence of varices or areas of mucosa with a reticulate pattern are manifestations of portal hypertension in the small bowel, found in both cirrhotic and non-cirrhotic patients. The clinical implications of these findings, as regards digestive bleeding, are uncertain, although we documented acute bleeding from the small bowel in two patients (5.5%).

Assessments of body composition and bone parameters of lactating rats treated with diet containing flaxseed meal (Linum usitatissinum) during post-weaning period

Introduction: There are few studies on body composition and the effects of diet on weight postpartum women. The aim was to evaluate the body composition and bone parameters in lactating rats treated with diet containing flaxseed flour during postweaning period. Methods: After weaning, the lactating rat were divided in control (n = 6) and experimental (F, n = 6) group, treated with 25% flaxseed flour diet. After 30 days, body composition by dual-energy X-ray absorptiometry, serum analysis, organs and intra-abdominal fat mass, femur and lumbar vertebra parameters were determined. Results: The groups showed similar food intake, body mass and bone parameters. While F group showed the following: lower body (-5%), gonadal (-17%), mesenteric (-23%) and intra-abdominal (-6%) fat mass. Increase of HDL-cholesterol (+10%) and lower glucose (-15%), triglycerides (P < 0.05, -37%) and cholesterol (P < 0.05, -21%). Conclusions: The findings highlight the effects of flaxseed for control of adiposity and to maintain a healthy biochemical profile during the postnatal period.

Descrição do ciclo gametogênico do ouriço-branco, Tripneustes ventricosus (Lamarck, 1816), no Arquipélago de Fernando de Noronha PE, Brasil

Sea urchins are common benthic organisms on coastal ecosystems of tropical and temperate shallow waters. The impact of sea urchins populations in shore communities is density-dependent, and therefore, knowledge of the life history of these animals is important to understand these interactions. Between 2000 and 2005 a population boom of Tripneustes ventricosus was observed in the Fernando de Noronha Archipelago. In 2004 a research program was started to monitor the population dynamics of T. ventricosus in the archipelago, when it noted a lack of basic information on the biology and reproduction of this species, despite its broad geographic distribution and economic importance in parts of its occurrence. In this context, this work focuses on the reproductive biology of T. ventricosus with emphasis on the description of the gametogenic stages. Between December 2006 and July 2007, ten urchins were collected by snorkeling in two sites of the archipelago, totaling 120 individuals. Gametogenic stages were described for both sexes through microscopic analysis, and were defined as: Recovery, Growing, Premature, Mature and Spawning. Results showed increasing in Gonad index throughout of months of sampling and suggest that the reproductive cycle of the species in the archipelago is annual

Dieta do ouriço-branco, Tripneustes ventricosus (Lamarck, 1816), no Arquipélago de Fernando de Noronha, PE

Sea urchins are benthic macroinvertebrates that inhabit shallow coastal waters in tropical and temperate zones. Urchins are usually classified as generalists or omnivores as they can adjust their diet according to the food resources available in the environment. Due to the strong grazing pressure they may exert, urchins have an important role in marine ecosystems, occupying different trophic levels and stimulating the intensification of the dynamics of communities where they occur. In 2004, a monitoring program focused on the population dynamics of the white sea urchin, Tripneustes ventricosus, has been initiated in the Fernando de Noronha Archipelago. At the same time, a surprisingly lack of information on the species biology has been noted, despite their wide geographical distribution and economic importance in many parts of its range. Hence, this work was developed to provide information on the feeding habits of T. ventricosus in the archipelago. Ten specimens were collected between December 2006 and July 2007 at two sites of the archipelago, Air France and Sueste Bay for biometrics and analysis of gut contents. Test diameters ranged from 9.19 cm (± 1.1) to 10.08 cm (± 0.58). Calculated stomach repletion index (IRE) was higher (p <0.05) in the Air France site and also during January and July. The IRE was not correlated to the gonad index. Fifteen different species of algae were detected in a total of 120 stomachs examined: 4 Chlorophytas, 4 Phaeophytas and 6 Rhodophytas. Food diversity (p <0.05) was higher in December 2006 and January 2007. Although several items had a high frequency of occurrence, they were low represented in terms of weight, and consequently, had a low level of relative importance. The brown algae Dictyopteris spp and Dictyota spp, followed by the green algae Caulerpa verticillata accounted for the greatest importance in T. ventricosus diet, comprising about 90% of the consumed items

Ecologia alimentar e reprodutiva da piaba-do-rabo-amarelo, Astyanax cf. lacustris (Reinhardt, 1874) (Osteichthyes: Characidae) na Lagoa do Piató, Assu, Rio Grande do Norte, Brasil

The feeding habits and biological aspects of the reproductive cycle of two-spot astyanax, Astyanax cf. lacustris (Reinhardt, 1874) were investigated. Fish samples were captured on a monthly basis, using gillnets of 4 cm mesh size, from the Piató Lake, Assu, Rio Grande do Norte, during the period of September, 2006 to August, 2007. Physico-chemical parameters, such as, temperature, electrical conductivity and dissolved oxygen of the lake were registered. The monthly values of rainfall also were obtained. The 360 individuals captured, were measured, weighed, dissected, and stomach weight and the stage of gonadal maturity were registered. The stomach contents analyses were carried out based on volumetric method, points, frequency of occurrence and applying the Index of Relative Importance. The degrees of repletion of the stomachs were determined besides the Index of Repletion relating to feeding activity variations and frequency of ingestion with limnological parameters and rainfall. The food items identified were separated into distinct groups according to their origin. Sex ratio and Gonadosomatic Relation of females were verified to determine the spawning period and fecundity. The physico-chemical parameters presented the following annual mean values: temperature = 28.8ºC, electrical conductivity = 992.5 µS.cm-1; dissolved oxygen = 4.9 mg.L-1 during the study period. The annual mean of the rainfall was 63.5 mm. The results indicate that this species present an omnivorous feeding habit with a tendency towards insectivory, with an increase in feeding activity during the dry season. The aquatic oxygen to interfere very importance in the feeding activity than the others factors physico-chemicals of water and rainfall. There was a predominance of females, with a sex proportion of 1M:7F. The macroscopic characteristics of the ovaries and testicles revealed four stages of gonadal development: immature, maturing, mature and spent. A temporal variation was observed for the gonadal development of males and females. There was reproductive activity through out the year, with peaks in the months of February, April and June to correspond with the rain of precipitation of the region. The mean fecundity was 7.681 mature oocytes, varying from 4.476 to 12.036, with mean of 7.681. There was positive relation between fecundity and body mass. Condition Factor is not an efficient indicator of the reproductive period of this species. The species A. cf. lacustris is an opportunist and is well adapted to the conditions of the semi-arid Caatinga Biome

Ecologia reprodutiva do peixe-donzela, Stegastes fuscus cuvier, 1830 (osteichthyes: pomacentridae) em arrecifes rochosos da praia de Búzios, Rio Grande do Norte, Brasil

The reproductive ecology of fish plays a key role both for rational exploitation methods and for protective measures of natural stocks. The purpose of this study was to analyze the reproductive aspects of the damsel-fish, Stegastes fuscus, during October 2004 to September 2005, in the coastal rocky reefs of Búzios Beach, Nísia Floresta, RN. Fish were captured using hooks and hand nets, during low tide. Reproduction was determined using sexual ratio, mean length of first maturation (L50), absolute fecundity and macroscopic characteristics of gonads. The following parameters were related to gonadosomatic index (GSI): condition factor (CF), hepatosomatic index (HSI), rain fall and temperature. In relation to sex distribution, it was observed that 78% were females and 22% were males. The L50 was 6.2 cm for females and 7.0 for males. Average fecundity was 6832 oocytes. Results showed that S. fuscus had better body condition in the months prior to spawning, particularly during initial and intermediate stages of maturation. Five stages of gonadal maturation were identified through macroscopic analysis: immature, in maturation, mature, spent and resting. The HSI was inversely related to the GSI. This was possibly due to the reproductive cycle of this species which was associated to the dry period of this region. During this period, low rain fall and high temperatures provide an propitious reproductive condition for the study species

Analysis of sexually dimorphic growth in captive reared cobia (Rachycentron canadum) and the occurrence of intersex individuals

The growth of three cohorts of captive reared cobia, grown in a combination of flow-though and recirculating aquaculture systems, was progressively measured to determine the existence and extent of sexually dimorphic growth in cobia. Approximately 100 fish from each cohort were individually identified and regularly weighed until the average weight of the fish was approximately 5 kg. The sex of individuals was determined through gonadal observations at the conclusion of each trial and the gender fitted retrospectively to the growth data set. Intersex gonads were observed in the first two cohorts of cobia, with 16.9% incidence in cohort 1 and 6.8% in cohort 2. Cobia is considered a gonochoristic species. This was the first reported observation of intersex gonads in cobia and the first reported occurrence of intersex gonads from a gonochoristic fish species from Australian waters. Only one fish out of the 182 examined in the third cohort was identified as intersex. There was no sexually dimorphic growth in cobia when there was a relatively high incidence of the intersex anomaly, as seen in the first two cohorts of fish. In the relative absence of the intersex condition, female cobia was significantly larger than males from 2 kg onwards. The weight of female cobia was almost 30% more than that of males at 17 months of age when average weight of the cohort was 4.6 kg. It is likely that the first two cobia cohorts were exposed to endocrine disruption in some form, and the possible sources are discussed. Statement of relevance This study demonstrated that female cobia grow significantly faster than male fish and that investigations into monosex culture could lead to significant productivity gains for cobia aquaculture. It also demonstrated that cohorts containing intersex fish did not exhibit sexually dimorphic growth. It is likely that the reproductive anomaly is the result of disruption to the endocrine system.

Identifying Robust Proxies of Gonad Maturation for the Protandrous Hermaphrodite Tridacna maxima (Röding, 1798, Bivalvia) from Individual to Population Scale

Monitoring gonadmaturation for protandrous and functional hermaphrodite species such as the giant clamTridacna maxima is difficult due to the juxtaposition and relative proportion ofmale and female tissues in the gonad [gonadal sex ratio (GSR)]. Here, the relevance of the widely used gonadosomatic index (GSI) as proxy of giant clam gonad maturation is tested with a large dataset (n = 265). Gonadosomatic index is compared with other indices, namely the proportion of the male part harboring spermatozoids, the proportion of empty oocyte follicles, the mean oocyte diameter, and the oocyte elongation. At gonad scale, high index variability highlighted partial spawning. At individual scale, male and female maturation proxies were contrasted, showing either asynchronous emissions of male and female gametes or contrasted spermatogenesis and oogenesis duration. The GSI was mostly driven by the number and diameter of oocytes and therefore it is recommended here as primary proxy for female maturity. Except for the oocyte elongation, all indices were affected by the GSR, which ruled out drawing conclusions at population scale. These results highlight the need for maturation stage proxies that are optimized for functional hermaphrodite species.

Impact of radiofrequency ablation for patients with varicose veins on the budget of the German statutory health insurance system

Objectives: In contrast to other countries, surgery still represents the common invasive treatment for varicose veins in Germany. However, radiofrequency ablation, e.g. ClosureFast, becomes more and more popular in other countries due to potential better results and reduced side effects. This treatment option may cause less follow-up costs and is a more convenient procedure for patients, which could justify an introduction in the statutory benefits catalogue. Therefore, we aim at calculating the budget impact of a general reimbursement of ClosureFast in Germany. Methods: To assess the budget impact of including ClosureFast in the German statutory benefits catalogue, we developed a multi-cohort Markov model and compared the costs of a “World with ClosureFast” with a “World without ClosureFast” over a time horizon of five years. To address the uncertainty of input parameters, we conducted three different types of sensitivity analysis (one-way, scenario, probabilistic). Results: In the Base Case scenario, the introduction of the ClosureFast system for the treatment of varicose veins saves costs of about 19.1 Mio. € over a time horizon of five years in Germany. However, the results scatter in the sensitivity analyses due to limited evidence of some key input parameters. Conclusions: Results of the budget impact analysis indicate that a general reimbursement of ClosureFast has the potential to be cost-saving in the German Statutory Health Insurance.

Determinantes das perturbações musculoesqueléticas nos trabalhadores de cuidados pessoais em residências de apoio ao idoso

Introdução: O enfermeiro especialista em reabilitação é o profissional com competências e conhecimentos para, após o diagnóstico, implementar e monitorizar os resultados dos programas de redução do risco das perturbações musculosqueléticas relacionadas com o trabalho (PME), junto dos trabalhadores de cuidados pessoais em residências de apoio ao idoso, avaliando e introduzindo no processo de prestação de cuidados os necessários ajustamentos, promovendo assim, práticas mais seguras e eficazes. Assim, o presente estudo centrou-se em identificar os determinantes das PME nestes trabalhadores e suas repercussões na saúde. Métodos: Estudo de natureza quantitativa, de tipologia transversal e descritivocorrelacional, com recurso a uma amostra não probabilística por conveniência, constituída por 120 indivíduos, na sua maioria do género feminino (95,8%) e com uma média de idades de 43,21 anos (Dp=10,812 anos). Como instrumento de colheita de dados utilizou-se o inquérito de saúde e trabalho (INSAT), aferido para este domínio de investigação. Resultados: Estes cuidadores formais manifestam défices de saúde com principal relevância para os relacionados com a mobilidade física e dor, quer pela existência de constrangimentos de natureza física e biomecânica, organizacional e psicossocial, bem como de natureza individual. Os problemas de saúde identificados por estes trabalhadores, resultantes das condições e características do trabalho foram: dores de costas (90,8%), dores musculares e articulares (82,5%), varizes (64,2%), dores de cabeça (49,2%) e ansiedade ou irritabilidade (47,5%). Ser do género feminino, ter idade entre os 49-58 anos, ser viúvo ou divorciado, ter doenças crónicas, tomar medicação e efetuar horário diurno, revelaram-se como determinantes percursores das PME assim como, a nível laboral, as características e os constrangimentos organizacionais e relacionais relacionados com o esforço físico, a intensidade e tempo de trabalho, as exigências emocionais, a insuficiência de autonomia e a má qualidade das relações sociais. Conclusão: Estes resultados apontam para a necessidade de desenvolvimento de estratégias preventivas das PME neste grupo profissional, onde é fundamental a intervenção do enfermeiro de reabilitação na implementação de programas de promoção da saúde, gestão do stresse e riscos psicossociais e formação profissional. Palavras-chave: Doenças musculosqueléticas; Enfermagem de Reabilitação; Saúde Ocupacional.

Identification and expression analysis of two Wnt4 genes in the spotted scat ( Scatophagus argus )

Background: WNT4 is a protein that plays a crucial role in ovarian differentiation and development in mammals, with a relatively well understood function in mammalian gonadal differentiation. The role of Wnt4 in teleost fish; however, remains unclear. In the present study, cDNAs of Wnt4a and Wnt4b were cloned and characterized in the spotted scat. The expression patterns of two Wnt4 genes in the gonads at different stages of development and in fish after treatment with 17α-methyltestosterone (MT) were investigated. Results: The tissue distribution showed that Wnt4a was expressed in various tissues, including the gonads, gills, spleen, brain, and fin. Interestingly, Wnt4b not only was expressed in the gills, brain, and spleen, but also was obviously expressed in the ovary. During gonad development, Wnt4a was highly expressed in the testis at stage I and Wnt4b was mainly expressed in the ovary at stages II–III. After MT treatment, the mRNA expression of Wnt4a increased significantly up to 40 d, and the transcript level of Wnt4b decreased at 20 d. Conclusions: These results suggest that Wnt4a may be involved in gonad development and plays a role in the process of spermatogonial proliferation. Our results also demonstrate that Wnt4b is not only expressed in the nervous system, but also in the ovary and it may be involved in ovary development of the spotted scat.

Endoscopic capacity in West Africa.

Background: Levels of endoscopic demand and capacity in West Africa are unclear. Objectives: This paper aims to: 1. describe the current labor and endoscopic capacity, 2. quantify the impact of a mixed-methods endoscopy course on healthcare professionals in West Africa, and 3. quantify the types of diagnoses encountered. Methods: In a three-day course, healthcare professionals were surveyed on endoscopic resources and capacity and were taught through active observation of live cases, case discussion, simulator experience and didactics. Before and after didactics, multiplechoice exams as well as questionnaires were administered to assess for course efficacy. Also, a case series of 23 patients needing upper GI endoscopy was done. Results: In surveying physicians, less than half had resources to perform an EGD and none could perform an ERCP, while waiting time for emergency endoscopy in urban populations was at least one day. In assessing improvement in medical knowledge among participants after didactics, objective data paired with subjective responses was more useful than either alone. Of 23 patients who received endoscopy, 7 required endoscopic intervention with 6 having gastric or esophageal varices. Currently the endoscopic capacity in West Africa is not sufficient. A formal GI course with simulation and didactics improves gastrointestinal knowledge amongst participants.

Multicenter prospective validation of the Baveno IV and Baveno II/III criteria in cirrhosis patients with variceal bleeding

International audience

Insuficiencia venosa crónica en trabajadores sin factores de riesgo que permanecen horas prolongadas en bipedestación

La insuficiencia venosa crónica (IVC) es una patología prevalente en la sociedad actual. Los problemas derivados de ella, son una causa importante de gasto económico y absentismo laboral. Las condiciones laborales actuales, como jornadas de larga duración, con largas horas en bipedestación, inadecuada carga de pesos y malas condiciones de humedad y temperatura, contribuyen al desarrollo de esta patología. En este trabajo se ha realizado una revisión sistemática de la bibliografía existente en relación a la insuficiencia venosa crónica y el tiempo en bipedestación de las jornadas laborales. Para determinar el nivel de evidencia de los estudios evaluados, se han seguido los criterios del Scottish Intercollegiate Guidelines Network (SIGN). En particular, se ha concluido que existe una asociación significativamente positiva entre el tiempo prolongado en bipedestación y el riesgo de padecer insuficiencia venosa crónica. Sin embargo, la literatura actual no permite establecer un umbral que determine el número de horas considerado como bipedestación prolongada. Para poder valorar si la insuficiencia venosa crónica debería considerarse una enfermedad profesional, es necesario diseñar y llevar a cabo nuevos estudios de investigación en esta dirección. Estos estudios son necesarios para poder establecer evidencias de cara a concienciar a la sociedad y generar campañas de prevención y promoción de la salud que disminuyan los costes económicos y mejoren la calidad de vida de la población.