Plano de eliminação da Hepatite C da RAM

conhecimento de saúde e sensibilização para a problemática ... número de rastreios e diagnósticos ... referenciação para as consultas de especialidade hospitalar ... número de tratamentos ativos ... prevenção de descompensação da doença hepática crónica, CHC e mortalidade ... prevenção de novas infeções e reinfeçõesinfo:eu-repo/semantics/updatedVersio

ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI

Question: A 57-year old woman with a previous history of contrast-related anaphylaxis was referred to the gastroenterology department with worsening liver function tests. She developed recurrent abdominal pain, diarrhea, significant weight loss, pruriginous generalized skin rash, and increased abdominal volume over 1 year. Physical examination revealed generalized small reddish monomorphic macules on the trunk and thighs (Figure A), hepatosplenomegaly, peripheral lymphadenopathy, and ascites. Blood tests showed normocytic normochromic anemia (hemoglobin 9.4 g/dL), monocytosis (1.3 103/mL), thrombocytopenia (97 103/mL), slight international normalized ratio prolongation, and a marked elevation of cholestasis parameters without jaundice (aspartate aminotransferase, 60 U/L; alanine aminotransferase, 56 U/L; gamma-glutamyl transferase, 324 U/L; and alkaline phosphatase, 1277 U/L). Abdominal Doppler ultrasound examination and a computed tomography scan revealed homogeneous hepatosplenomegaly (without signs of chronic liver disease), signs of portal hypertension without thrombosis of the splenoportal axis, moderate ascites, and intra-abdominal, axillary, and inguinal lymphadenopathies. Upper endoscopy showedesophageal varices and portal hypertensive gastropathy.Laboratory studies for chronic hepatopathy, infectious agents, and angiotensin-converting enzyme were negative. Bone marrow biopsy revealed granulomatous myelitis, and both lymphadenopathy and skin biopsies showed increased mononuclear cells.info:eu-repo/semantics/publishedVersio

Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy

Background: For many years, ERCP was avoided in pregnancy given the concerns regarding the adverse effects that, with special focus on radiation, could occur in the developing fetus. However, the postponement or rejection of ERCP in pregnant women, may lead to a higher risk for mother and fetus, especially when the indication is unequivocal, namely cholangitis, biliary pancreatitis and symptomatic choledocholithiasis. Summary and key messages: This review aims to summarize the scarce literature on the subject in order to plan ERCP in pregnancy with the highest safety. The use of techniques that reduce radiation and increase the protection of pregnant women allow radiation levels far below the safety limits. We also discuss the various alternatives of ERCP without radiation. EUS can eliminate the need for ERCP with doubtful choledocholithiasis and plan the best approach in those with previous evidence. The possibility of performing “ERCP” with a linear echoendoscope uniquely under ultrasound control has been described. Conversely, the two-step strategy (initial sphincterotomy with stent placement without fluoroscopy and after delivery, ERCP with lithiasis extraction) proved to be safe obviating fluoroscopy. In conclusion, ERCP can be performed in pregnancy safely and effectively with minimal radiation or even no-radiation at all.info:eu-repo/semantics/publishedVersio

Infliximab-Induced Lupus: A Case Report

We report the case of a 48-year-old, leukodermic female diagnosed with ulcerative proctitis for 4 years and latent tuberculosis. She was allergic to salicylates and had a minor allergic reaction to infliximab (rash, vertigo, and headache). Thereafter, she started azathioprine (2.5 mg/kg/day). She maintained intravenous infliximab, together with prophylaxis with clemastine and hydrocortisone, due to the steroid-dependent proctitis. The therapy was continued every 8 weeks with anti-tumor necrosis factor for about 3 years. The analytical evaluation when she was diagnosed with ulcerative proctitis (February 2011) showed negative antinuclear antibodies (ANA), double-stranded-DNA antibodies (anti-dsDNA), antineutrophil cytoplasmic antibodies and anti-Saccharomyces cerevisiae antibodies, and a positive outer membrane protein antibody. About 2 years and 6 months after starting infliximab (November 2013), the patient complained of inflammatory symmetrical polyarthralgia (knee, shoulder, elbow, and wrist) without synovitis, which started every week before the administration of infliximab. Resolution of symptoms was observed after each infliximab infusion. In July 2014, the autoantibody re-evaluation showed positive ANA with a homogeneous pattern with a titer of 1:640, weak positive anti-dsDNA (30.2), and positive anti-histone with C3 decreased (80.3). She was then diagnosed with lupus induced by infliximab and initiated hydroxychloroquine 400 mg. Infliximab was suspended. On re-evaluation, the erythrocyte sedimentation rate was 25 mm/h (1st hour), C-reactive protein 0.5 mg/dL (previously erythrocyte sedimentation rate 15 mm/h and C-reactive protein 1.2 mg/dL), and endoscopically, the mucosa was scarred, with some atrophy and scarce mucus in the lower rectum. About 10 months after discontinuation of infliximab, repeated autoantibodies proved all negative, keeping only low C3 (87). The patient also reported complete resolution of the arthralgia.Relato do caso de uma mulher, 48 anos, leucodérmica, com o diagnóstico de proctite ulcerosa com 4 anos de evolução e tuberculose latente. Alérgica aos salicilatos e com reacção alérgica minor ao infliximab (rash, cefaleia e vertigem), iniciou azatioprina (2,5 mg/kg/dia) apenas após a reacção alérgica. Manteve infliximab com profilaxia endovenosa com clemastina e hidrocortisona dada a cortico-depedência da proctite. A terapêutica com antiTNF foi mantida de 8 em 8 semanas durante cerca de 3 anos. Na avaliação analítica aquando o diagnóstico da doença inflamatória intestinal (Fev 2011) apresentava ANA, anti-dsDNA, ANCAs e ASCA negativos com antiOMP positivo. Cerca de 2 anos e meio após o início de infliximab (Nov 2013), iniciou quadro de poliartralgia inflamatória simétrica (joelhos, ombros, cotovelos e punhos) sem sinovite com início regular na semana prévia à admnistração programada de infliximab e resolução após a infusão endovenosa. Em Julho de 2014, apresenta ANA positivos com padrão homogéneo com título de 1/640, anti-dsDNA equívoco (30.2), anti-histonas positivo com C3 diminuído (80.3). Foi diagnosticada com lupus eritematoso sistémico induzido por infliximab e iniciou hidroxicloroquina 400 mg. O infliximab foi suspenso. Na reavaliação da doença, destaca-se VS 25 mm/h (1ª hora), PCR 0,5 mg/dL (previamente VS 15 e PCR 0.6) e endoscopicamente mucosa cicatrizada, com alguma atrofia e escasso muco no recto baixo. Cerca de 10 meses após a suspensão do infliximab, repetiu auto-anticorpos que se revelaram todos negativos, mantendo apenas o C3 baixo (87). Verificou-se ainda resolução completa das queixas articulares.info:eu-repo/semantics/publishedVersio

Portal Cavernoma Cholangiopathy Secondary to Polycythemia Vera: Case Report and Echoendoscopic Findings

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Pancreatite Aguda e Síndrome de Encefalopatia Posterior Reversível: Relato de um Caso

The posterior reversible encephalopathy syndrome is a neurological syndrome characterized by headache, confusion, visual disturbances and seizures associated with identifiable areas of cerebral edema on imaging studies. The authors report the case of a man, 33 years-old, leukodermic with a history of chronic alcohol and tobacco consumption, who is admitted to the emergency department for epigastric pain radiating to the back and vomiting with about six hours of evolution and an intense holocranial headache for two hours. His physical examination was remarkable for a blood pressure of 190/100 mmHg and tenderness in epigastrium. His analytical results revealed emphasis on amylase 193 U/L and lipase 934 U/L. During the observation in the emergency department, he presented a generalized tonic-clonic seizure. Abdominal ultrasonography was performed and suggestive of pancreatitis without gallstones signals. Head computed tomography showed subarachnoid haemorrhage and a small right frontal cortical haemorrhage. The brain magnetic resonance imaging done one week after admission showed areas of a bilateral and symmetrical T2 / FLAIR hyperintensities in the subcortical white matter of the parietal and superior frontal regions, suggesting a diagnosis of posterior reversible encephalopathy syndrome. Abdominal computed tomography (10 days after admission) demonstrated a thickened pancreas in connection with inflammation and two small hypodense foci in the anterior part of the pancreas body, translating small foci of necrosis. The investigation of a thrombophilic defect revealed a heterozygous G20210A prothrombin gene mutation. The patient was discharged without neurological sequelae and asymptomatic. The follow-up brain magnetic resonance imaging confirmed the reversal of the lesions, confirming the diagnosis.A síndrome de enfalopatia posterior reversível é uma síndrome neurológica caracterizada por cefaleias, confusão, alterações visuais e convulsões associada a áreas de edema cerebral identificável em exames de neuroimagem. Os autores relatam o caso de um homem, 33 anos, leucodérmico, com história de alcoolismo e tabagismo crónico, que recorre ao serviço de urgência por epigastralgia em cinturão e vómitos com cerca de seis horas de evolução e cefaleia holocraneana intensa há duas horas. Ao exame objectivo, apresentava tensão arterial de 190/100 mmHg e empastamento no epigastro. Analiticamente, amilase 193 U/L e lipase 934 U/L. Durante a observação no serviço de urgência, apresentou uma crise tónico-clónica generalizada. A ecografia abdominal realizada foi sugestiva de pancreatite, sem sinais de litíase biliar. A tomografia computorizada crânio-encefálica demonstrou hemorragia subaracnoideia e pequena hemorragia cortical frontal direita. A ressonância magnética nuclear crânio-encefálica realizada uma semana após a admissão revelou áreas de hipersinal T2/FLAIR bilaterais e simétricas na substância branca subcortical das regiões parietais e frontais superiores, sugerindo o diagnóstico de síndrome de enfalopatia posterior reversível. Na tomografia computorizada abdominal (10 dias após a admissão) visualizou-se pâncreas espessado, em relação com processo inflamatório e dois pequenos focos hipodensos na parte anterior do corpo, traduzindo pequenos focos de necrose. A investigação de defeitos trombofílicos revelou uma mutação do gene G20210A da protrombina em heterozigotia. O doente teve alta sem sequelas neurológicas, e assintomático. A ressonância magnética nuclear crânio-encefálica de controlo confirmou a reversão das lesões, confirmando o diagnóstico.info:eu-repo/semantics/publishedVersio

Hepatosplenic T-Cell Lymphoma: A Rare Complication of Monotherapy with Thiopurines in Crohn’s Disease

Hepatosplenic T-cell lymphoma (HSTCL) is an extremely rare and aggressive form of non-Hodgkin lymphoma associated with poor response to treatment and high mortality. There is an increased incidence among patients with inflammatory bowel disease, especially young male patients under 35 years old and on combination therapy (thiopurine and anti-TNF-α). We describe a case of HSTCL in a young male patient with stenosing ileal Crohn’s disease on azathioprine monotherapy for 4.8 years admitted to our hospital with intra- abdominal sepsis. Despite chemotherapy, the patient eventually died 1 month after the diagnosis. Through a literature review, we identified 18 additional cases of HSTCL in Crohn’s disease patients that had only been treated with thiopurine monotherapy. The authors intend to highlight the rarity of this diagnosis especially with azathioprine monotherapy and the diagnostic challenge in a case that presented with intra-abdominal sepsis

Increasing and sustaining blood-borne virus screening in Spain and Portugal throughout the COVID-19 pandemic: a multi-center quality improvement intervention

BackgroundAround 57,000 people in Spain and Portugal currently living with HIV or chronic hepatitis C are unaware of their infection. The COVID-19 pandemic severely disrupted screening efforts for these infections. We designed an intervention to increase and sustain opportunistic blood-borne virus (BBV) screening and linkage to care (SLTC) by implementing the TEST model.MethodsThe Plan Do Study Act (PDSA) method of quality improvement (QI) was implemented in 8 healthcare organizations (HCOs), including four hospitals, two clusters of community health centers, and two community-based organizations (CBOs). Baseline assessment included a review of BBV SLTC practices, testing volume, and results 12 months before the intervention. Changes in BBV testing rates over time were measured before, during, and after the COVID-19 lockdowns in 2020. A mixed ANOVA model was used to analyze the possible effect on testing volumes among HCOs over the three study periods.InterventionBBV testing was integrated into normal clinical flow in all HCOs using existing clinical infrastructure and staff. Electronic health record (EHR) systems were modified whenever possible to streamline screening processes, implement systemic institutional policy changes, and promote QI.ResultsTwo years after the launch of the intervention in screening practices, testing volumes increased by 116%, with formal healthcare settings recording larger increases than CBOs. The start of the COVID-19 lockdowns was accompanied by a global 60% decrease in testing in all HCOs. Screening emergency department patients or using EHR systems to automate screening showed the highest resilience and lowest reduction in testing. HCOs recovered 77% of their testing volume once the lockdowns were lifted, with CBOs making the fullest recovery. Globally, enhanced screening techniques enabled HCOs to diagnose a total of 1,860 individuals over the research period.ConclusionsImplementation of the TEST model enabled HCOs to increase and sustain BBV screening, even during COVID-19 lockdowns. Although improvement in screening was noted in all HCOs, additional work is needed to develop strong patient linkage to care models in challenging times, such as global pandemics

Role of alpha-1 antitrypsin genotypes in the progression of adult liver disease

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Risk Predictive Values of ACG Classification in a Cohort of Colon Ischemia: Redefining the Definition of Mild disease

Introduction: Although most cases of colon ischemia (CI) are mild and self-limiting, when severe it implies high mortality rates. We aimed to evaluate the risk predictive value of the classi!cation proposed by American College of Gastroenterology (ACG) guidelines (2015), created to provide a management algorithm.info:eu-repo/semantics/publishedVersio