"Downhill" varices. A rare cause of esophageal hemorrhage

"Downhill" varices or upper esophageal varices are a rare cause of proximal digestive tract hemorrhage with only 16 cases described in the literature. In our series, hemorrhage due to "downhill" varices represents 0.1% of all acute esophageal variceal bleeding. Their etiology differs from that of the usual "uphill" varices secondary to portal hypertension, and the clinical management should be directed to vascular obstruction if present. We report a case of an 89-year-old male with hemorrhagic "downhill" varices not associated, as usually, with superior vena cava obstruction or compression, but with severe pulmonary hypertension and drug-related hemorrhagic risk factors, whose removal proved sufficient to prevent rebleeding

Contributos da epistemologia sistémica na investigação com famílias

Considerando a importância dos estudos científicos com famílias e o crescente interesse dos investigadores por esta temática, tanto nas ciências psicológicas como noutras (e.g., educação), esta reflexão foca a utilização de uma abordagem teórica e metodológica, fundamentada na epistemologia sistémica, no desenvolvimento da investigação com famílias. Para o efeito, apresentam-se exemplos de diferentes investigações, baseadas nesta epistemologia, e evidenciam-se as diferenças entre o paradigma “tradicional” (e.g., Descartes) e o paradigma sistémico: simplicidade versus complexidade; estabilidade versus instabilidade; objetividade versus intersubjetividade. Pensar e investigar sistemicamente as famílias implica: cruzar fontes e níveis de informação, focar a análise na relação, contextualizar social, cultural e historicamente, considerar o fator tempo e a perspetiva longitudinal, e, finalmente, recorrer à triangulação metodológica. Resumindo, estudar as famílias, através de uma perspetiva sistémica, requer uma atitude de contextualização e de reconhecimento da causalidade recursiva, o que pode ser favorecido pela combinação de diferentes estratégias e instrumentos metodológicos.Considering the importance of scientific studies with families and the growing interest of researchers in this subject, in psychological and in other sciences (e.g., education), this work focus on the use of a theoretical and methodological approach, based on systemic epistemology, within the development in families’ research. Therefore, different research’ examples are presented, according to that epistemology, and the differences between the “traditional” (e.g., Descartes) and systemic paradigms are evidenced: simplicity versus complexity; stability versus instability; objectivity versus intersubjetivity. Thinking and researching families in a systemic way implies: crossing sources and informative levels, focusing the analysis on relation, considering the social, cultural and historical context, as well as the time factor and a longitudinal perspective and, finally, using methodological triangulation. In summary, studying families, through a systemic perspective, requires an attitude of contextualization and recursive causality awareness, which could be improved by the combination of different methodological strategies and instruments.info:eu-repo/semantics/publishedVersio

Cell sheet engineering for reproducing the bone marrow hematopoietic stem cell niche

Hematopoietic stem and progenitor cells (HSPC) are multipotent cells responsible for the maintenance and renewal of the hematopoietic lineage in the adult body. The fate of these stem cells is closely regulated by their surrounding microenvironment, or niche. The importance of the microenvironment for HSPC function has been long recognized by researchers that more than 30 years ago attempted to emulate it in 2D using a layer of bone marrow stromal cells to culture hematopoietic cells for long time periods (Dexter-type cultures). However, all the models based on feeder layers are less than perfect in recreating the hematopoietic microenvironment. The use of growth factor cocktails provided some promising results concerning the maintenance and proliferation of some cell populations but still struggle to deliver the correct microenvironment for the maintenance of suitable HSPC populations. Part of the problem of the current systems lies on the lack of the third dimension. At the same time, the proposed three-dimensional methodologies using scaffolds to engineer the bone marrow (BM) microenvironment present very limited results probably due to the scaffolding matrices’ intrinsic limitations. Therefore, an engineered BM microenvironment capable of acting as a functional HSPC niche would provide a tremendous tool for the study of hematopoiesis as well as for obtaining and maintaining HSPC. Using osteogenic cell sheets, we have previously demonstrated that it was possible to induce the ectopic formation of mature bone tissue with a clear bone marrow, avoiding the use of scaffolds. In the present work, we studied the potential of using osteogenic cell sheets to build in vitro, a 3D microenvironment capable of providing HSPC a suitable niche for their survival and proliferation. For this, we used bone marrow stromal cells and adipose-derived stem cells to produce the osteogenic cell sheets and human umbilical cord blood as a source of hematopoietic stem cells

A multicenter validation of an endoscopic classification with narrow band imaging for gastric precancerous and cancerous lesions

BACKGROUND AND STUDY AIM: The reliability and external validity of narrow band imaging (NBI) in the stomach have not been described consistently. The aim of the current study was to describe and estimate the accuracy and reliability of a simplified classification system for NBI in the diagnosis of gastric lesions. METHODS: Consecutive patients undergoing NBI endoscopy at two reference centers (n=85, 33% with dysplasia) were included in two studies. In total, 224 different areas were biopsied and recorded onto video. In the derivation study, previously described NBI features were analyzed in order to develop a simplified classification. In the validation study the accuracy and reliability of this classification were estimated among three groups of endoscopists with different levels of expertise in NBI. .RESULTS: The reliability/accuracy results from the derivation study allowed the creation of a simplified NBI classification. In the validation study, "regular vessels with circular mucosa" (pattern A) was associated with normal histology (accuracy 83%; 95% confidence interval [CI] 75?%-90%); "tubulo-villous mucosa" (pattern B) was associated with intestinal metaplasia (accuracy 84%; 95CI 77%-91%; positive likelihood ratio [LR+]=4.75); and "irregular vessels and mucosa" (pattern C) was associated with dysplasia (accuracy 95%; 95CI 90%-99%; LR+=44.33). The reproducibility of these patterns was high (k=0.62). "Light-blue crest" was moderately reliable (k=0.49) but specific (87%) for intestinal metaplasia. A variable vascular density (additional pattern+) was the best feature for Helicobacter pylori gastritis (accuracy 70%; 95CI 59%-80%) but showed only fair reliability (k=0.38). Non-experienced endoscopists presented lower agreement (k=0.6 vs. k=0.75) and accuracy (74% vs. 86%) than international experts/experienced endoscopists. CONCLUSION: A simplified NBI classification is accurate and reliable for the diagnosis of intestinal metaplasia and dysplasia. The classification should be further assessed and validated on a per-patient assessment of NBI, and by comparing NBI with other imaging technologies.This study was supported by a grant for medical investigation from the Portuguese Digestive Endoscopy Society (SPED 2009 Investigation Grant)

Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019

Patients with chronic atrophic gastritis or intestinal metaplasia (IM) are at risk for gastric adenocarcinoma. This underscores the importance of diagnosis and risk stratification for these patients. High definition endoscopy with chromoendoscopy (CE) is better than high definition white-light endoscopy alone for this purpose. Virtual CE can guide biopsies for staging atrophic and metaplastic changes and can target neoplastic lesions. Biopsies should be taken from at least two topographic sites (antrum and corpus) and labelled in two separate vials. For patients with mild to moderate atrophy restricted to the antrum there is no evidence to recommend surveillance. In patients with IM at a single location but with a family history of gastric cancer, incomplete IM, or persistent Helicobacter pylori gastritis, endoscopic surveillance with CE and guided biopsies may be considered in 3 years. Patients with advanced stages of atrophic gastritis should be followed up with a high quality endoscopy every 3 years. In patients with dysplasia, in the absence of an endoscopically defined lesion, immediate high quality endoscopic reassessment with CE is recommended. Patients with an endoscopically visible lesion harboring low or high grade dysplasia or carcinoma should undergo staging and treatment. H. pylori eradication heals nonatrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions, and it is recommended. H. pylori eradication is also recommended for patients with neoplasia after endoscopic therapy. In intermediate to high risk regions, identification and surveillance of patients with precancerous gastric conditions is cost-effective.info:eu-repo/semantics/publishedVersio

Health-related quality of life and utilities in gastric premalignant conditions and malignant lesions: a multicentre study in a high prevalence country

BACKGROUND AND AIMS: A recent review of economic studies relating to gastric cancer revealed that authors use different tests to estimate utilities in patients with and without gastric cancer. Our aim was to determine the utilities of gastric premalignant conditions and adenocarcinoma with a single standardized health measure instrument. METHODS: Cross-sectional nationwide study of patients undergoing upper endoscopy (n=1,434) using the EQ-5D-5L quality of life (QoL) questionnaire. RESULTS: According to EQ-5D-5L, utilities in individuals without gastric lesions were 0.78 (95% confidence interval: 0.76-0.80), with gastric premalignant conditions 0.79 (0.77-0.81), previously treated for gastric cancer 0.77 (0.73-0.81) and with present cancer 0.68 (0.55-0.81). Self-reported QoL according to the visual analogue scale (VAS) for the same groups were 0.67 (0.66-0.69), 0.67 (0.66-0.69), 0.62 (0.59-0.65) and 0.62 (0.54-0.70) respectively. Utilities were consistently lower in women versus men (no lesions 0.71 vs. 0.78; premalignant conditions 0.70 vs. 0.82; treated for cancer 0.72 vs. 0.78 and present cancer 0.66 vs. 0.70). CONCLUSION: The health-related QoL utilities of patients with premalignant conditions are similar to those without gastric diseases whereas patients with present cancer show decreased utilities. Moreover, women had consistently lower utilities than men. These results confirm that the use of a single standardized instrument such as the EQ-5D-5L for all stages of the gastric carcinogenesis cascade is feasible and that it captures differences between conditions and gender dissimilarities, being relevant information for authors pretending to conduct further cost-utility analysis