Nontumoral portal vein thrombosis in patients with and without cirrhosis : clinical significance, natural history of varices and efficacy of anticoagulation

A cirrose caracteriza-se por um estado de hipercoagulabilidade. A incidência de trombose da veia porta (TVP) aumenta na cirrose avançada. O impacto da TVP na história natural de cirrose não é claro. A segurança de anticoagulação na cirrose avançada e TVP não é clara e o seu impacto na sobrevida livre de transplante hepático ortotopico (THO) na cirrose avançada e TVP é controverso. Em doentes com trombose da veia porta não-cirrótica e não-tumoral (TVPNCNT) crónica, existe escassa evidência sobre a história natural de varizes esófagogastricas que são habitualmente manejadas como na cirrose. Não existe evidência relativa à eficácia desta estratégia. No primeiro estudo desta tese, uma coorte de 241 doentes com cirrose sem TVP foi seguida prospectivamente e verificamos que a descompensação prévia de cirrose e trombocitopenia foram factores independentes predizentes de desenvolvimento de TVP. A TVP não foi factor predizente independente de descompensações de cirrose ou de sobrevida livre de THO. No segundo estudo, uma análise retrospectiva duma coorte prospectiva de 178 doentes com TVPNCNT crónica, verificamos que o curso natural de varizes esofagogástricas é semelhante ao de doentes com cirrose. No terceiro estudo, uma análise retrospectiva de 80 doentes com cirrose e TVP não-tumoral, constatamos que a anticoagulação, embora não melhorasse a sobrevida global livre de THO, associou-se a melhoria de sobrevida apenas em doentes com cirrose avançada. A anticoagulação aumentou significativamente a recanalização da TVP e deverá ser mantida para prevenir a retrombose. Em conclusão, a descompensação prévia de cirrose e trombocitopenia predizem independentemente, maior risco de desenvolvimento de TVP. A TVP não influenciou independentemente, descompensações de cirrose ou a sobrevida livre de THO. A anticoagulação foi segura e aparenta melhorar a sobrevida livre de THO na cirrose avançada. Na TVPNCNT crónica a mesma estratégia terapêutica como na cirrose associou-se a um baixo risco de hemorragia e mortalidade.Cirrhosis is considered a hipercoagulable state and there is strong evidence that the incidence of nontumoral portal vein thrombosis (PVT) increases in advanced cirrhosis. There is conflicting data regarding the impact of PVT on the natural history of cirrhosis. The safety of anticoagulation especially in patients with advanced cirrhosis and PVT is unclear. The impact of anticoagulation in patients with cirrhosis and PVT on orthotopic liver transplant (OLT) free survival is controversial. There is scant data regarding natural history of gastroesophageal varices in patients with chronic noncirrhotic nontumoral PVT (NCNTPVT), which are usually managed as in cirrhosis. There is no evidence regarding efficacy of this policy. In the first study of this thesis, a cohort of 241 patients with cirrhosis without PVT at study inclusion were evaluated prospectively and we found that prior decompensation of cirrhosis and thrombocytopenia independently predicted development of PVT. PVT did not independently predict higher risk of cirrhosis decompensations and lower OLT free survival. In the second study, a retrospective analysis of a prospective cohort of 178 patients with chronic NCNTPVT, we found that the course of esophagogastric varices appears to be similar to that in cirrhosis. In the third study, a retrospective analysis of 80 patients with cirrhosis with nontumoral PVT, although anticoagulation did not improve OLT free survival of the entire study cohort, it was associated with significantly higher survival in advanced cirrhosis. Anticoagulation was safe, significantly increased PVT recanalization and should be maintained to avoid rethrombosis. In conclusion, prior decompensation of cirrhosis and thrombocytopenia predicted higher risk of developing PVT. PVT did not independently influence cirrhosis decompensations or OLT free survival. Anticoagulation appears to improve OLT free survival only in advanced cirrhosis. In chronic NCNTPVT using the same therapeutic approach as for cirrhosis was associated with a low risk of bleeding and death

Detection and Characterization of Early Gastric Cancer

In this review, we would like to focus on risk stratification and quality indicators of diagnostic upper gastrointestinal endoscopy in the detection and characterization of early gastric cancer. Preparation of the upper gastrointestinal tract with mucolytic agents or simethicone is often overlooked in the west, and this inexpensive step prior to endoscopy can greatly improve the quality of imaging of the upper digestive tract. Risk stratification based on epidemiological features including family history, Helicobacter pylori infection status, and tobacco smoking is often overlooked but may be useful to identify a subgroup of patients at higher risk of developing gastric cancer. Quality indicators of diagnostic upper gastrointestinal endoscopy are now well defined and include: minimal inspection time of 3 min, adequate photographic documentation of upper gastrointestinal landmarks, utilization of advanced endoscopic imaging technology including narrow band imaging and blue laser imaging to detect intestinal metaplasia and characterize early gastric cancer; and standardized biopsy protocols allow for histological evaluation of gastric mucosa and detection of atrophic gastritis and intestinal metaplasia. Finally, endoscopic and histologic classifications such as the Kimura–Takemoto Classification of atrophic gastritis and the OLGA–OLGIM classifications may help stratify patients at a higher risk of developing early gastric cancer

SUCESSO NO TRATAMENTO ENDOSCÓPICO DE PERFURAÇÃO CÓLICA COM OVER-THE-SCOPE CLIP

Colonoscopic perforation is a rare adverse event and it’s incidence increases as more procedures are performed. Therapy may include closure with clip devices with acceptable results. This case-report demonstrates the efficacy and safety of the over-the-scope clip application in an iatrogenic colonic perforation. A perfuração durante colonoscopia é uma complicação rara, cuja incidência aumenta com a realização de procedimentos. O tratamento pode incluir o encerramento com recurso a clip, com resultado satisfatório. Este caso-clínico demonstra a eficácia e segurança da aplicação do over-the-scope clip no tratatamento de perfurações iatrogénicas do cólon.&nbsp

Study of the incidence of dialysis in São Paulo, the largest Brazilian city

OBJECTIVES: Chronic kidney disease is a major public health problem worldwide. In Brazil, approximately 100,000 patients (January 2012) receive renal replacement therapy. Nevertheless, data on dialysis incidence in the Brazilian population are scarce. This study aims to analyze the incidence of patients starting dialysis therapy in São Paulo City, the largest Brazilian metropolis. METHOD: This cohort study analyzed data from 9,994 patients starting hemodialysis or peritoneal dialysis funded by the Brazilian Public Health System during a 5-year period (2007-2011). Patient data for this study (recorded as electronic files) were obtained from the São Paulo City's Dialysis Regulatory Bureau, which regulates the allocation of patients requiring dialytic therapy. RESULTS: The dialysis incidence rates were 178, 174, 170, 185 and 188 per million population for the years 2007, 2008, 2009, 2010 and 2011, respectively. The incidence rates increased with age. Hypertension and diabetes were the main etiologies diagnosed. Hemodialysis was the chosen dialysis modality in the majority of patients (92.6%), whereas the percentage of patients referred for peritoneal dialysis decreased from 10.1% to 5.5%. CONCLUSION: The incidence of patients starting renal replacement therapy from 2007-2011 in São Paulo was stable but higher than the projected incidence for the entire country. The authors emphasize the need for further studies of the incidence of dialysis in the Brazilian population and for the creation of a Brazilian registry of dialysis patients, which would be a valuable tool for developing healthcare policies and renal replacement therapy strategies

Characterization of novel calcium hydroxide- mediated highly porous chitosan- calcium scaffolds for potential application in dentin tissue engineering

The aim of this study was to develop a highly porous calcium- containing chitosan scaffold suitable for dentin regeneration. A calcium hydroxide (Ca[OH]2) suspension was used to modulate the degree of porosity and chemical composition of chitosan scaffolds. The chitosan solution concentration and freezing protocol were adjusted to optimize the porous architecture using the phase- separation technique. Scanning electron microscopy/energy- dispersive spectroscopy demonstrated the fabrication of a highly porous calcium- linked chitosan scaffold (CH- Ca), with a well- organized and interconnected porous network. Scaffolds were cross- linked on glutaraldehyde (GA) vapor. Following a 28- day incubation in water, cross- linked CH scaffold had no changes on humid mass, and CH- Ca featured a controlled degradability profile since the significant humid mass loss was observed only after 21 (26.0%) and 28- days (42.2%). Fourier- transform infrared spectroscopy indicated the establishment of Schiff base on cross- linked scaffolds, along with calcium complexation for CH- Ca. Cross- linked CH- Ca scaffold featured a sustained Ca2+ release up to 21- days in a humid environment. This porous and stable architecture allowed for human dental pulp cells (HDPCs) to spread throughout the scaffold, with cells exhibiting a widely stretched cytoplasm; whereas, the cells seeded onto CH scaffold were organized in clusters. HDPCs seeded onto CH- Ca featured significantly higher ALP activity, and gene expressions for ALP, Col1, DMP- 1, and DSPP in comparison to CH, leading to a significant 3.5 times increase in calcium- rich matrix deposition. In sum, our findings suggest that CH- Ca scaffolds are attractive candidates for creating a highly porous and bioactive substrate for dentin tissue engineering.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/155906/1/jbmb34586.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/155906/2/jbmb34586_am.pd

Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas

Background and Aims: Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas. Methods: This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence. Results: The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4–145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1–10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15–72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50–205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence. Conclusions: A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically. Key Messages: Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically

Zeolites: A Theoretical and Practical Approach with Uses in (Bio)Chemical Processes

This review provides a state-of-the-art summary of distributed zeolite technology, as well as identifying strategies to further promote the absorption of these materials in various areas of study. Zeolites are materials that can be synthesized or found in natural rock deposits a with a basic composition consisting in Al, Si, and O. Zeolite’s consideration as a future material is due to many facile synthesis methods to obtain different structures with variations in pore size, surface area, pore volume and physical properties. These methods are developed using the control of relevant synthesis parameters that influences structure formation, such as crystallization temperature, time of aging and/or crystallization, stoichiometric relationships between components of synthesis gel, pH of the medium, and in some cases the type of structure-directing agent. Each method will lead to geometric changes in the framework formation, making possible the formation of typical chemical bonds that are the fingerprint of any zeolitic structure (O-Si-O and Al-O-Si), forming typical acid sites that give specificity in zeolite and allows it to act as a nanoreactor. The specificity is a characteristic that in some cases depends on selectivity, a fundamental property derived of the porosity, mostly in processes that occur inside the zeolite. In processes outside the structure, the surface area is the main factor influencing this property. Moreover, there are many natural sources with adequate chemical composition to be used as precursors. Some of these sources are waste, minimizing the deposition of potential hazardous materials that can be recalcitrant pollutants depending on the environment. Besides its uses as a catalyst, zeolite serves as a support for many bioprocesses; therefore, this review aims to explain relevant aspects in chemical nature, physical properties, main methods of synthesis, main precursors used for synthesis, and relevant applications of zeolites in chemical catalysis and biological processes

Use of albumin infusion for cirrhosis-related complications: An international position statement

BACKGROUND & AIMS: Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. METHODS: Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. RESULTS: Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. CONCLUSIONS: Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. IMPACT AND IMPLICATIONS: Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion