Characterization of digestive involvement in patients with chronic T. cruzi infection in Barcelona, Spain

Background: Digestive damage due to Chagas disease (CD) occurs in 15-20% of patients diagnosed as a result of peristaltic dysfunction in some endemic areas. The symptoms of chronic digestive CD are non-specific, and there are numerous confounders. Diagnosis of CD may easily be missed if symptoms are not evaluated by a well trained physician. Regular tests, as barium contrast examinations, probably lack the necessary sensitivity to detect early digestive damage. Methods: 71 individuals with T. cruzi infection (G1) and 18 without (G2) coming from Latin American countries were analyzed. They were asked for clinical and epidemiological data, changes in dietary habits, and history targeting digestive and cardiac CD symptoms. Serological tests for T. cruzi, barium swallow, barium enema, an urea breath test, and esophageal manometry were requested for all patients. Principal findings: G1 and G2 patients did not show differences in lifestyle and past history. Fifteen (21.1%) of G1 had digestive involvement. Following Rezende criteria, esophagopathy was observed in 8 patients in G1 (11.3%) and in none of those in G2. Manometry disorders were recorded in 34 G1 patients and in six in G2. Isolated hypotensive lower esophageal sphincter (LES) was found in sixteen G1 patients (23.9%) and four G2 patients (28.8%). Achalasia was observed in two G1 patients. Among G1 patients, ineffective esophageal motility was seen in six (five with symptoms), diffuse esophageal spasm in two (one with dysphagia and regurgitation), and nutcracker esophagus in three (all with symptoms). There were six patients with hypertonic upper esophageal sphincter (UES) among G1. Following Ximenes criteria, megacolon was found in ten G1 patients (13.9%), and in none of the G2 patients. Conclusions: The prevalence of digestive chronic CD in our series was 21.1%. Dysphagia is a non-pathognomonic symptom of CD, but a good marker of early esophageal involvement. Manometry could be a useful diagnostic test in selected cases, mainly in patients with T. cruzi infection and dysphagia in whose situation barium swallow does not evidence alterations. Constipation is a common but non-specific symptom that can be easily managed. Testing for CD is mandatory in a patient from Latin America with constipation or dysphagia, and if diagnosis is confirmed, megacolon and esophageal involvement should be investigated

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

La defecografía en el estudio del compartimento posterior del suelo de la pelvis en mujeres con prolapso genital

[spa] La defecografía es una exploración que realizada con la preparación y la técnica adecuadas, de forma cuidadosa y con las máximas medidas de higiene y privacidad, no provoca molestias significativas siendo aceptada sin problemas por las pacientes. La técnica de la defecografía debe realizarse con la paciente sentada en una silla radiotransparente, el contraste rectal ha de ser pasta de bario densa en cantidad no inferior a los 300 ml, la opacificación por vía oral del intestino delgado con la ingesta previa de 400 ml de bario líquido es obligatoria y resulta imprescindible la realización de proyecciones con esfuerzo al final de la evacuación del contraste rectal. La línea pubococcígea y la línea de las tuberosidades isquiáticas son de difícil valoración y la determinación de los ángulos anorrectales en reposo y durante la defecación carece de interés por su falta de relevancia en el diagnóstico del prolapso. El rectocele y el enterocele se identifican sin dificultad durante el desarrollo de la defecografía. La valoración precisa de ambas alteraciones, muchas veces sincrónicas, permite la elección de la técnica quirúrgica adecuada. La intususcepción rectal que puede acompañar al rectocele y que debe persistir durante la evacuación del contraste nos parece una alteración funcional no obstructiva que influye en la sensación de defecación incompleta cuya causa principal es la existencia de residuo en la porción vaginal del rectocele al final de la evacuación. El estudio de la incontinencia fecal en la mujer debe comprender la ecografía endoanal para valoración de los esfínteres y la defecografía para descartar las alteraciones asociadas que pueden favorecer su aparición. La defecografía es útil en el estudio del estreñimiento sobre todo si muestra la existencia de rectocele y/o sigmoidocele en pacientes con clínica de "obstrucción distal" (outlet obstruction) y debe unirse al enema opaco y a la determinación del tiempo de tránsito colónico con marcadores. En la valoración del anismo, la defecografía confirma el diagnóstico obtenido con la manometría anorrectal. Los términos "perineo descendido" y "descenso del suelo de la pelvis" deberían sustituirse por el concepto "combinación de patologías del suelo de la pelvis" que define de una manera más clara la existencia de alteraciones sincrónicas del mismo compartimento (rectocele y enterocele) o la combinación de patologías de los compartimentos urinario, ginecológico y digestivo. La RM pelviana se ha revelado como una técnica de gran utilidad en el diagnóstico de las alteraciones del suelo de la pelvis. Permite las reconstrucciones multiplanares, la valoración de los músculos y el diagnóstico del peritoneocele. No comporta radiación pero puede estar contraindicada si existen clips metálicos y/o claustrofobia. Salvo en RM abiertas en las que es posible la posición sentada, la exploración se realiza en decúbito supino, posición que limita el descenso de las vísceras pelvianas y dificulta las maniobras de esfuerzo realizadas por la paciente.[eng] SUMMARY When perfomed gently with the convenient preparation, technique and maximum measures of hygiene and privacy, defecography may cause no significant inconveniences and therefore is a procedure that is easily accepted by the patients. Defecography's technique requires the patient to be seated on a radiotransparent commode, the rectum to be filled with thick barium paste in a quantity not under 300 ml, small bowel opacification with 400 ml of previously taken liquid barium is a must and is essential to take images at the end of the contrast evacuation as the patient squeezes. Rectocele and enterocele are easily demonstrated during the procedure. Precise evaluation of both disorders, very often sincronic, allows choosing convenient surgery. We consider rectal intussuceptium that may appear retocele and which must last contrast evacuation long as a non obstructive functional disorder that contributes to incomplete defecation sensation, which is primarily due to the existence of a remnant in the vafginal portion of rectocele at the end of the evacuation. Faecal incontinence imaging in woman must include both endoanal ultrasound to asses sphincters and defecography to rule out associated abnormalities that may ease its presence. Defecography plays a role in constipation evaluation specially if it demonstrates rectocele and/or sigmoidocele in patients with clinical outlet obstruction and must be associated with barium enema and time of transist determination with markers. In anism evaluation defecography confirms diagnosis. The terms "descending perineum" and "pelvic floor descent" should be substituted by "combination of pelvis floor disorders" concept which better defines the presence on sincronic alterations of the same compartement (rectocele and enterocele) or the combination of urinary, gynaecologic and digestive compartements disorders

Characterization of digestive involvement in patients with chronic T. cruzi infection in Barcelona, Spain.

Digestive damage due to Chagas disease (CD) occurs in 15-20% of patients diagnosed as a result of peristaltic dysfunction in some endemic areas. The symptoms of chronic digestive CD are non-specific, and there are numerous confounders. Diagnosis of CD may easily be missed if symptoms are not evaluated by a well trained physician. Regular tests, as barium contrast examinations, probably lack the necessary sensitivity to detect early digestive damage.71 individuals with T. cruzi infection (G1) and 18 without (G2) coming from Latin American countries were analyzed. They were asked for clinical and epidemiological data, changes in dietary habits, and history targeting digestive and cardiac CD symptoms. Serological tests for T. cruzi, barium swallow, barium enema, an urea breath test, and esophageal manometry were requested for all patients.G1 and G2 patients did not show differences in lifestyle and past history. Fifteen (21.1%) of G1 had digestive involvement. Following Rezende criteria, esophagopathy was observed in 8 patients in G1 (11.3%) and in none of those in G2. Manometry disorders were recorded in 34 G1 patients and in six in G2. Isolated hypotensive lower esophageal sphincter (LES) was found in sixteen G1 patients (23.9%) and four G2 patients (28.8%). Achalasia was observed in two G1 patients. Among G1 patients, ineffective esophageal motility was seen in six (five with symptoms), diffuse esophageal spasm in two (one with dysphagia and regurgitation), and nutcracker esophagus in three (all with symptoms). There were six patients with hypertonic upper esophageal sphincter (UES) among G1. Following Ximenes criteria, megacolon was found in ten G1 patients (13.9%), and in none of the G2 patients.The prevalence of digestive chronic CD in our series was 21.1%. Dysphagia is a non-pathognomonic symptom of CD, but a good marker of early esophageal involvement. Manometry could be a useful diagnostic test in selected cases, mainly in patients with T. cruzi infection and dysphagia in whose situation barium swallow does not evidence alterations. Constipation is a common but non-specific symptom that can be easily managed. Testing for CD is mandatory in a patient from Latin America with constipation or dysphagia, and if diagnosis is confirmed, megacolon and esophageal involvement should be investigated

Characterization of digestive involvement in patients with chronic T. cruzi infection in Barcelona, Spain

Background: Digestive damage due to Chagas disease (CD) occurs in 15-20% of patients diagnosed as a result of peristaltic dysfunction in some endemic areas. The symptoms of chronic digestive CD are non-specific, and there are numerous confounders. Diagnosis of CD may easily be missed if symptoms are not evaluated by a well trained physician. Regular tests, as barium contrast examinations, probably lack the necessary sensitivity to detect early digestive damage. Methods: 71 individuals with T. cruzi infection (G1) and 18 without (G2) coming from Latin American countries were analyzed. They were asked for clinical and epidemiological data, changes in dietary habits, and history targeting digestive and cardiac CD symptoms. Serological tests for T. cruzi, barium swallow, barium enema, an urea breath test, and esophageal manometry were requested for all patients. Principal findings: G1 and G2 patients did not show differences in lifestyle and past history. Fifteen (21.1%) of G1 had digestive involvement. Following Rezende criteria, esophagopathy was observed in 8 patients in G1 (11.3%) and in none of those in G2. Manometry disorders were recorded in 34 G1 patients and in six in G2. Isolated hypotensive lower esophageal sphincter (LES) was found in sixteen G1 patients (23.9%) and four G2 patients (28.8%). Achalasia was observed in two G1 patients. Among G1 patients, ineffective esophageal motility was seen in six (five with symptoms), diffuse esophageal spasm in two (one with dysphagia and regurgitation), and nutcracker esophagus in three (all with symptoms). There were six patients with hypertonic upper esophageal sphincter (UES) among G1. Following Ximenes criteria, megacolon was found in ten G1 patients (13.9%), and in none of the G2 patients. Conclusions: The prevalence of digestive chronic CD in our series was 21.1%. Dysphagia is a non-pathognomonic symptom of CD, but a good marker of early esophageal involvement. Manometry could be a useful diagnostic test in selected cases, mainly in patients with T. cruzi infection and dysphagia in whose situation barium swallow does not evidence alterations. Constipation is a common but non-specific symptom that can be easily managed. Testing for CD is mandatory in a patient from Latin America with constipation or dysphagia, and if diagnosis is confirmed, megacolon and esophageal involvement should be investigated

Narrow band imaging and white light endoscopy in the characterization of a polypectomy scar: A single-blind observational study

AIM: To assess the incremental benefit of narrow band imaging (NBI) and white light endoscopy (WLE), randomizing the initial technique for the detection of residual neoplasia at the polypectomy scar after an endoscopic piecemeal mucosal resection (EPMR). METHODS: We conducted an observational study in an academic center to assess the incremental benefit of NBI and WLE randomly applied 1:1 (NBI-WLE or WLE-NBI) in the follow-up of a post-EPMR scar by the same endoscopist. RESULTS: A total of 112 EPMR scars were included. The median baseline polyp size was 20 mm (interquartile range: 14-30). At first review, NBI and WLE showed good sensitivity (85.0% vs 78.9%), specificity (77.1% vs 84.2%) and overall accuracy (80.0% vs 82.5%). NBI after WLE (WLE-NBI group) improved accuracy, but this difference was not statistically significant [area under the curve (AUC): 86.8% vs 81.6%, P = 0.15]. WLE after NBI (NBI-WLE group) did not improve accuracy (AUC: 81.4% vs 81.1%, P = 0.9). Overall, recurrence was found in 39/112 (34.8%) lesions. CONCLUSION: Although no statistically significant differences were found between the two techniques at the first post-EPMR assessment, the use of NBI after WLE may improve residual neoplasia detection. Nevertheless, biopsy is still required in the first scar review

Baseline characteristics of patients, including past gastrointestinal history.

1<p>Alcohol intake was reported as occasional in all cases.</p>2<p>Presence of symptoms considered as originating in the gastroduodenal region, in the absence of any organic, systemic, or metabolic disease that is likely to explain the symptoms (Roma III criteria).</p>3<p>One patient presented in her past history pyloric stenosis surgery, showing normal esophagogram and barium enema.</p>4<p>Five patients presented partial colectomy previously of being admitted in the international health centre. After the surgery, one of them presented megasigma, and another one dolichomegacolon. The other three presented dolichocolon. All of them did not showed alterations in esophagogram.</p

Manometric patterns and association with symptoms.

<p><b>Abbreviation: LES:</b> lower esophageal sphincter.</p

Colonopathy: Clinical findings and barium enema results.

<p>Colonopathy: Clinical findings and barium enema results.</p

Signs and symptoms of esophagopathy and association with esophagogram findings.

<p><b>Abbreviations: LES:</b> lower esophageal sphincter; <b>L:</b> in relation to liquids; <b>S:</b> in relation to solids.</p>1<p>More than one symptom in some patients.</p