Diagnosis and management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals. OBJECTIVE: To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it. METHOD: The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication. RESULTS: Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications. CONCLUSION: GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic methods. The clinical treatment is useful in controlling the symptoms; however, the great problem is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who required continued drug use, intolerant to the drugs and with complicated forms of GERD.

“Species Pollution” in Florida: A Cross-Section of Invasive Vertebrate Issues and Management Responses

The state of Florida as among the two worst invasive species problems in the USA. Besides the sheer numbers of established exotic species in Florida, many present novel difficulties for management, or have other characteristics making effective management extremely challenging. Moreover, initiation of management action requires more than recognition by experts that a potentially harmful species has become established. It also requires the political will along with concomitant resources and appropriate personnel to develop effective methods and apply them. We illustrate various aspects of the situation in Florida with examples of invasive vertebrates, the problems they pose(d), and management approaches to the problems.

Ecology, stable isotopes, and management of grassland songbirds at National Park Service properties on the Great Plains

Grassland ecosystems have been severely reduced and grassland bird populations have experienced consistent declines. National Park Service (NPS) properties on the Great Plains provide breeding habitat for grassland songbirds, though little is known about the quality of this habitat. A short-term study on songbirds at three NPS properties complemented current monitoring, providing an among park comparison addressing grassland bird productivity and fidelity relative to NPS property size. During 2008-2009, I assessed avian species richness, and estimated bird density and grassland songbird nest success. Bird species richness was greatest at small and medium sites, while number of nesting obligate species was greatest at the large site. Species-specific densities varied among sites, with few grassland obligates occurring at all three sites. Nest success estimates for grassland obligates were highest at the small site and lower at the large site. Another method to quantify habitat quality is assessment of breeding site fidelity. Current extrinsic markers used in monitoring site fidelity are inadequate for small birds; stable isotope analyses provide an alternative. I compared two techniques for assigning stable isotope tissue origin and measured grassland songbird site fidelity. My method of assigning origin provided site-specific variances of expected stable isotope values, an improvement over the most commonly used method. Fidelity tended to be higher at the large site, which may indicate a more robust breeding community of grassland birds. The small size of two of my sites precluded large sample sizes and made strong inferences difficult. To quantify how scientists cope with weak inference, I conducted a literature review. Strong inference was rarely observed, and most authors of weak-inference papers provided specific management recommendations. I suggest that adaptive management is an ideal method to resolve uncertainty from weak inference. Managers should consider my results within the context of regional and global management and the extent to which their unit might aide songbird conservation.

Therapeutic Project at Extra-Hospital Mental Health Services: a critical reflection on the elaboration and management of services' therapeutic projects

Based on a study conducted in Ribeirao Preto, SP, Brazil in extra-hospital mental health services that addressed the organization of these services, therapeutic projects and the inclusion of psychosocial rehabilitation in health actions available, a theoretical-critical reflection concerning the development process of the therapeutic projects by the services' teams is presented. The qualitative study was conducted in an outpatient clinic and a Psychosocial Care Center. Data were collected through semi-structured interviews and focal groups. Data analysis was based on the hermeneutic dialectic philosophy of Jurgen Habermas according to the techniques of reconstruction and interpretation. Data analysis revealed that professionals have difficulty developing and managing therapeutic projects. Health actions are made available without being concretely supported by a proposal guiding the service's practical activities. The therapeutic projects are referred by professionals as the result of guidelines provided by management levels or technical orientations inherent to each profession but not as an activity that represents a philosophy of work of the health team. When the therapeutic project is focused on as a type of consensus that results from a communicative action directed to a mutual and intersubjective understanding among the members of the mental health extra-hospital team, the difficulties of the services' team dialogically organizing themselves to collectively construct the therapeutic project is evidenced.

Lithiasis in 1,313 Kidney Transplants: Incidence, Diagnosis, and Management

Background. Renal transplantation remains the optimal treatment of patients with end-stage renal disease. Urinary lithiasis represents an unusual urologic complication in renal transplantation, with an incidence of <1%. Today, recipients of kidneys from deceased donors are more likely to receive grafts with undiagnosed lithiasis, which does not occur in patients from living donors, owing to screening with computerized tomography. Objective. The aim of this study was to evaluate the incidence, diagnosis, and therapeutic management of renal lithiasis in transplanted kidneys at a single institution. Methods. We reviewed the medical records for 1,313 patients who underwent kidney transplantation from February 1968 to February 2011. Results. Among the grafts, 17 patients (1.29%) had nephrolithiasis: 9 women and 8 men. Ages ranged from 32 to 63 years (mean = 45.6 years). Fifteen patients received kidneys from cadaveric and only 2 from living related donors. Two stones, both located inside the ureter, were identified during transplant surgery (11.7%). Three instances of lithiasis were incidentally diagnosed by ultrasound during graft evaluation, within 7 days after surgery (17.6%); all 3 were in the calyces. The 12 remaining patients had the stones diagnosed later (70.58%): 6 in the calyces, 3 in the renal pelvis, and 3 inside the ureter. Conclusions. Urinary lithiasis is a rare complication in renal transplantation. In most patients the condition occurs without pain. The diagnosis and treatment options for graft urolithiasis are similar to those patients with nephrofithiasis in the general population. Extracorporeal shock wave lithotripsy (ESWL) was the most common treatment method.

Acute heat stress impairs performance parameters and induces mild intestinal enteritis in broiler chickens: Role of acute hypothalamic-pituitary-adrenal axis activation

Studies on the environmental consequences of stress are relevant for economic and animal welfare reasons. We recently reported that long-term heat stressors (31 +/- 1 degrees C and 36 +/- 1 degrees C for 10 h/d) applied to broiler chickens (Gallus gallus domesticus) from d 35 to 42 of life increased serum corticosterone concentrations, decreased performance variables and the macrophage oxidative burst, and produced mild, multifocal acute enteritis. Being cognizant of the relevance of acute heat stress on tropical and subtropical poultry production, we designed the current experiment to analyze, from a neuroimmune perspective, the effects of an acute heat stress (31 +/- 1 degrees C for 10 h on d 35 of life) on serum corticosterone, performance variables, intestinal histology, and peritoneal macrophage activity in chickens. We demonstrated that the acute heat stress increased serum corticosterone concentrations and mortality and decreased food intake, BW gain, and feed conversion (P < 0.05). We did not find changes in the relative weights of the spleen, thymus, and bursa of Fabricius (P > 0.05). Increases in the basal and the Staphylococcus aureus-induced macrophage oxidative bursts and a decrease in the percentage of macrophages performing phagocytosis were also observed. Finally, mild, multifocal acute enteritis, characterized by the increased presence of lymphocytes and plasmocytes within the lamina propria of the jejunum, was also observed. We found that the stress-induced hypothalamic-pituitary-adrenal axis activation was responsible for the negative effects observed on chicken performance and immune function as well as for the changes in the intestinal mucosa. The data presented here corroborate with those presented in other studies in the field of neuroimmunomodulation and open new avenues for the improvement of broiler chicken welfare and production performance.

Assessment and management of oral health in liver transplant candidates

Liver transplantation has become a standard treatment for end-stage liver disease and the number of recipients has grown rapidly in the last few years. Dental care during pre-transplant workup is important to reduce potential sources of infection in the drug-induced immunosuppression phase of liver transplantation. Objectives: The objectives of this study were to document the prevalence of oral abnormalities in patients on a liver transplant waiting list presenting to an urban dental school clinic, discuss the appropriate dental treatment according their systemic conditions and compare their oral manifestations with those of healthy individuals. Material and Methods: A pilot study was conducted involving 16 end-stage liver disease individuals (study group- SG) attending the Special Care Dentistry Center of the University of So Paulo and 16 control individuals (control group- CG) with no liver diseases, receiving dental care at the Dental School of the University of So Paulo. These individuals were assessed for their dental status (presence of oral disease or abnormalities), coagulation status, and dental treatment indications. Results: The patients from SG exhibited a greater incidence of oral manifestations compared with CG (p=0.0327) and were diagnosed with at least one oral disease or condition that required treatment. Coagulation abnormalities reflecting an increased risk of bleeding were found in 93.75% of the patients. However, no bleeding complications occurred after dental treatment. Conclusions: The patients with chronic liver diseases evaluated in this study exhibited a higher incidence of oral manifestations compared with the control group and had at least one oral disease or abnormality which required dental treatment prior to liver transplantation. Careful oral examination and evaluation of the patient, including laboratory tests, will ensure correct oral preparation and control of oral disease prior to liver transplantation.

Pain in photodynamic therapy: mechanism of action and management strategies

Photodynamic therapy involves administration of a photosensitizing drug and its subsequent activation by irradiation with a light source at wavelengths matching the absorption spectrum of the photosensitizer. In many countries around the world, topical photodynamic therapy has been approved for treatment of cutaneous oncologic conditions such as actinic keratosis, Bowen's disease, and superficial basal cell carcinoma. Multicenter, randomized, controlled studies have confirmed its efficacy and superior cosmetic outcomes compared to conventional therapies. Nevertheless, this therapeutic method presents some adverse effects, such as erythema, edema, pigmentation, pustules, and pain. There is no doubt that pain is the most severe of the adverse effects, being sometimes responsible for definitive treatment interruption. The pain mechanism has not yet been fully understood, which makes complete pain control a challenge to be conquered. In spite of that, this literature review presents some useful pain management strategies as well as the most important pain-related factors in photodynamic therapy.

Bilateral mesiodens in monozygotic twins: 3D diagnostic and management

Mesiodens is the most frequent type of supernumerary tooth and may occur in several forms, causing different local disorders, such as impaction of the anterior permanent teeth. High-resolution three-dimensional (3D) images have improved the diagnosis and treatment plan of patients with impacted and supernumerary teeth. The purpose of this paper was to report a case of two mesiodens in monozygotic twin boys with appropriate 3D diagnostic and treatment plan

Pediatric pain: prevalence, assessment, and management in a teaching hospital

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients’ pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child’s pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.

Measurement and model calculation of the temperature dependence of ligand-to-metal energy transfer rates in lanthanide complexes

Temperature dependent transient curves of excited levels of a model Eu3+ complex have been measured for the first time. A coincidence between the temperature dependent rise time of the 5D0 emitting level and decay time of the 5D1 excited level in the [Eu(tta)3(H2O)2] complex has been found, which unambiguously proves the T1→5D1→5D0 sensitization pathway. A theoretical approach for the temperature dependent energy transfer rates has been successfully applied to the rationalization of the experimental data.

Portal hypertension: a comparison between portal-venous pressure measurement and ARFI measurement of liver and spleen stiffness

PURPOSE. Portal pressure is measured invasively as Hepatic Venous Pressure Gradient (HVPG) in the angiography room. Liver stiffness measured by Fibroscan was shown to correlate with HVPG values below 12 mmHg. This is not surprising, since in cirrhosis the increase of portal pressure is not directly linked with liver fibrosis and consequently to liver stiffness. We hypothesized that, given the spleen’s privileged location upstream to the whole portal system, splenic stiffness could provide relevant information about portal pressure. Aim of the study was to assess the relationship between liver and spleen stiffness measured by Virtual Touch™ (ARFI) and HVPG in cirrhotic patients. METHODS. 40 consecutive patients (30 males, mean age 62y, mean BMI=26, mean Child-Pugh A6, mean platelet count=92.000/mmc, 19 HCV+, 7 with ascites) underwent to ARFI stiffness measurement (10 valid measurements in right liver lobe both surface and centre, left lobe and 20 in the spleen) and HPVG, blindly to each other. Median ARFI values of 10 samplings on every liver area and of 20 samplings on spleen were calculated. RESULTS. Stiffness could be easily measured in all patients with ARFI, resulting a mean of 2,61±0,76, 2,5±0,62 and 2,55±0,66 m/sec in the liver areas and 3.3±0,5 m/s in the spleen. Median HPVG was 14 mmHg (range 5-27); 28 patients showed values ≥10 mmHg. A positive significant correlation was found between spleen stiffness and HPVG values (r=0.744, p<0.001). No significant correlation was found between all liver stiffness and HVPG (p>0,05). AUROC was calculated to test spleen stiffness ability in discriminating patients with HVPG ≥10. AUROC = 0.911 was obtained, with sensitivity of 69% and specificity of 91% at a cut-off of 3.26 m/s. CONCLUSION. Spleen stiffness measurement with ARFI correlates with HVPG in patients with cirrhosis, with a potential of identifying patients with clinically significant portal hypertension.

Measurement and modeling of cloud condensation nuclei in continental air

Atmospheric aerosol particles serving as cloud condensation nuclei (CCN) are key elements of the hydrological cycle and climate. Knowledge of the spatial and temporal distribution of CCN in the atmosphere is essential to understand and describe the effects of aerosols in meteorological models. In this study, CCN properties were measured in polluted and pristine air of different continental regions, and the results were parameterized for efficient prediction of CCN concentrations.The continuous-flow CCN counter used for size-resolved measurements of CCN efficiency spectra (activation curves) was calibrated with ammonium sulfate and sodium chloride aerosols for a wide range of water vapor supersaturations (S=0.068% to 1.27%). A comprehensive uncertainty analysis showed that the instrument calibration depends strongly on the applied particle generation techniques, Köhler model calculations, and water activity parameterizations (relative deviations in S up to 25%). Laboratory experiments and a comparison with other CCN instruments confirmed the high accuracy and precision of the calibration and measurement procedures developed and applied in this study.The mean CCN number concentrations (NCCN,S) observed in polluted mega-city air and biomass burning smoke (Beijing and Pearl River Delta, China) ranged from 1000 cm−3 at S=0.068% to 16 000 cm−3 at S=1.27%, which is about two orders of magnitude higher than in pristine air at remote continental sites (Swiss Alps, Amazonian rainforest). Effective average hygroscopicity parameters, κ, describing the influence of chemical composition on the CCN activity of aerosol particles were derived from the measurement data. They varied in the range of 0.3±0.2, were size-dependent, and could be parameterized as a function of organic and inorganic aerosol mass fraction. At low S (≤0.27%), substantial portions of externally mixed CCN-inactive particles with much lower hygroscopicity were observed in polluted air (fresh soot particles with κ≈0.01). Thus, the aerosol particle mixing state needs to be known for highly accurate predictions of NCCN,S. Nevertheless, the observed CCN number concentrations could be efficiently approximated using measured aerosol particle number size distributions and a simple κ-Köhler model with a single proxy for the effective average particle hygroscopicity. The relative deviations between observations and model predictions were on average less than 20% when a constant average value of κ=0.3 was used in conjunction with variable size distribution data. With a constant average size distribution, however, the deviations increased up to 100% and more. The measurement and model results demonstrate that the aerosol particle number and size are the major predictors for the variability of the CCN concentration in continental boundary layer air, followed by particle composition and hygroscopicity as relatively minor modulators. Depending on the required and applicable level of detail, the measurement results and parameterizations presented in this study can be directly implemented in detailed process models as well as in large-scale atmospheric and climate models for efficient description of the CCN activity of atmospheric aerosols.

Stream sediments analysis for geochemical mapping of Romagna Apennines (Northern Italy): monitoring and management tool of environmental resources at various scales

Geochemical mapping is a valuable tool for the control of territory that can be used not only in the identification of mineral resources and geological, agricultural and forestry studies but also in the monitoring of natural resources by giving solutions to environmental and economic problems. Stream sediments are widely used in the sampling campaigns carried out by the world's governments and research groups for their characteristics of broad representativeness of rocks and soils, for ease of sampling and for the possibility to conduct very detailed sampling In this context, the environmental role of stream sediments provides a good basis for the implementation of environmental management measures, in fact the composition of river sediments is an important factor in understanding the complex dynamics that develop within catchment basins therefore they represent a critical environmental compartment: they can persistently incorporate pollutants after a process of contamination and release into the biosphere if the environmental conditions change. It is essential to determine whether the concentrations of certain elements, in particular heavy metals, can be the result of natural erosion of rocks containing high concentrations of specific elements or are generated as residues of human activities related to a certain study area. This PhD thesis aims to extract from an extensive database on stream sediments of the Romagna rivers the widest spectrum of informations. The study involved low and high order stream in the mountain and hilly area, but also the sediments of the floodplain area, where intensive agriculture is active. The geochemical signals recorded by the stream sediments will be interpreted in order to reconstruct the natural variability related to bedrock and soil contribution, the effects of the river dynamics, the anomalous sites, and with the calculation of background values be able to evaluate their level of degradation and predict the environmental risk.