Major adverse events related to endoscopic or laparoscopic procedures in achalasia. A systematic review and meta-analysis.

INTRODUCTION AND AIMS: Surgical or endoscopic treatments play an essential role in the management of achalasia. The probability of adverse events in the performance of said treatments is a relevant aspect, when establishing the risk-benefit balance. The present study aimed to establish the association between serious adverse events and the performance of those procedures, in adult patients with achalasia. MATERIALS AND METHODS: A systemic search of randomized and nonrandomized clinical trials, retrospective cohorts, and cases series on adult patients with achalasia that underwent laparoscopic Heller myotomy (LHM), peroral endoscopic myotomy (POEM), or endoscopic balloon dilation, that reported serious adverse events, was carried out on the Medline, CENTRAL, and EBSCO databases. Serious adverse events were defined as: death at 30 days, Clavien-Dindo grade III or higher classification, esophageal or gastric perforation, pneumothorax, mucosal tear, leakage, emphysema, pneumonia, and chest pain. The methodology included the PRISMA guidelines for reporting systematic reviews. RESULTS: Thirty-five studies were found that reported information on 1,276 patients that underwent POEM, 5,492 that underwent LHM, and 10,346 that underwent endoscopic balloon dilation. The proportions of adverse events for the three techniques were 3.6, 4.9, and 3.1%, respectively. DISCUSSION AND CONCLUSIONS: The 3 therapeutic interventions evaluated had similar proportions of adverse events. There were few reports of death at 30 days as an outcome and the lack of standardization in reporting adverse events in the studies analyzed was prominent.

Uso práctico de inhibidores de bomba de protones / Practical use of proton pump inhibitors / Uso prático de inibidores da bomba de prótons

Los inhibidores de la bomba de protones (IBP) se encuentran entre los medicamentos más utilizados en el mundo por su bajo costo, extensa prescripción y efectividad. Sin embargo, su uso a largo plazo no es inocuo y aún hay vacíos en el conocimiento del empleo adecuado de estos medicamentos. Por lo tanto, en esta revisión se expone, además de sus propiedades generales, sus verdaderas indicaciones, el uso recomendado a largo plazo y las estrategias para lograr la deprescripción, con el fin de evitar el uso indiscriminado.

Proton pump inhibitors (PPIs) are among the most widely used drugs in the world, due to their low cost, extensive prescription and effectiveness. However, its long-term use is not safe and there are still certain gaps in the knowledge of the proper use of these drugs. Therefore, this review aims to expose their general properties as well as their true indications, the appropriate long-term use and strategies to achieve adequate deprescription of these drugs, seeking to avoid indiscriminate use.

Os inibidores da bomba de prótons (IBP) se encontram entre os medicamentos mais utilizados no mundo pelo seu baixo custo, extensa prescrição e efetividade. Embora, seu uso a longo prazo não é inócuo e ainda há vazios no conhecimento do uso adequado destes medicamentos. Por tanto, nesta revisão se expõe, além das suas propriedades gerais, suas verdadeiras indicações, o uso recomendado ao longo prazo e as estratégias para conseguir a deprescrição, com o fim de evitar o uso indiscriminado.

Reducing the heterogeneity in hepatocellular carcinoma. A cluster analysis based on clinical variables in patients treated at a quaternary care hospital.

INTRODUCTION AND AIMS: Even though the term hepatocellular carcinoma designates the most common type of primary liver cancer, the disease has a high level of heterogeneity due to its etiology, geographic variation, behavior, and association with specific genetic alterations. The aim of the present study was to establish, through a cluster analysis, the clinical characteristics that enable homogeneous conglomerates to be defined. MATERIALS AND METHODS: An exploratory cluster analysis was developed utilizing the K-means method for sub-classifying 119 cases of patients with hepatocellular carcinoma. Sixty-two of those patients met the inclusion criteria, as well as none of the exclusion criteria. For the cluster analysis, an n-dimensional space was defined, in which n was equal to the number of variables included in the study (n = 17). The spatial coordinates corresponded to any possible magnitude between the minimum and maximum values of the variables analyzed (age, sex, tumor volume, AFP, AST, DB, Alb, Na, INR, Cr, HBV, HCV, OH, NASH, cirrhosis, multiple tumors, and neotumor). RESULTS: Four patterns with homogeneous clinical characteristics were identified, in which age at presentation, history of hepatitis B virus infection, altered liver profile with cholestatic dominance, and low albumin levels were associated with an apparently worse outcome. CONCLUSIONS: How heterogeneity in hepatocellular carcinoma could be reduced was shown through utilizing an unsupervised learning method to define specific subgroups, in whom known pathophysiologic mechanisms could better explain tumor behavior and define the determining prognostic factors related to the subgroups.

Reducing the heterogeneity in hepatocellular carcinoma. A cluster analysis based on clinical variables in patients treated at a quaternary care hospital. / Disminuyendo la heterogeneidad en hepatocarcinoma. Análisis de clúster por variables clínicas en pacientes atendidos en una institución de cuarto nivel de complejidad.

INTRODUCTION AND OBJECTIVE: Even though the term hepatocellular carcinoma designates the most common type of primary liver cancer, the disease has a high level of heterogeneity due to its etiology, geographic variation, behavior, and association with specific genetic alterations. The aim of the present study was to establish, through a cluster analysis, the clinical characteristics that enable homogeneous conglomerates to be defined. MATERIALS AND METHODS: An exploratory cluster analysis was developed utilizing the K-means method for sub-classifying 119 cases of patients with hepatocellular carcinoma. Sixty-two of those patients met the inclusion criteria, as well as none of the exclusion criteria. For the cluster analysis, an n-dimensional space was defined, in which n was equal to the number of variables included in the study (n = 17). The spatial coordinates corresponded to any possible magnitude between the minimum and maximum values of the variables analyzed (age, sex, tumor volume, AFP, AST, DB, Alb, Na, INR, Cr, HBV, HCV, OH, NASH, cirrhosis, multiple tumors, and neotumor). RESULTS: Four patterns with homogeneous clinical characteristics were identified, in which age at presentation, history of hepatitis B virus infection, altered liver profile with cholestatic dominance, and low albumin levels were associated with an apparently worse outcome. CONCLUSION: How heterogeneity in hepatocellular carcinoma could be reduced was shown through utilizing an unsupervised learning method to define specific subgroups, in whom known pathophysiologic mechanisms could better explain tumor behavior and define the determining prognostic factors related to the subgroups.

Handedness in native Amazonians.

A sample of 65 Tucano adolescents living in the Amazon region of Colombia were administered a 26-item handedness questionnaire. All subjects were right-handed. A factor analysis of the data indicated a factor structure rather different from that seen in North Americans, although both skilled and unskilled handedness factors were seen. Other factors related to specific tool use and to strength. These data indicate that positive reinforcement for right-hand use can modify patterns of handedness, and may well alter the relations among different items. The data suggest that hand preference can be modified through positive reinforcement at an appropriate age, and that hand preference is the precursor of skill differences rather than vice versa.

Effects of cultural background and education on handedness.

A 5-item handedness questionnaire was given to 317 subjects in four different groups: (1) 51 Tucano (Amazonian jungle) adolescents (36 male, 15 female); (2) 66 Spanish-speaking adolescents (43 male, 23 female) with similar age and educational background to the Tucano group; (3) 100 urban subjects (50 male, 50 female) with a low educational level; and (4) 100 urban subjects (50 male, 50 female) with a high level of education. Hand preference scores were not affected by sex or educational level. The incidence of left-handedness was lower in the Tucano group than in the other groups, despite the fact that the Tucano culture is a highly permissive one. The two rural groups showed less extreme hand preferences than the urban groups, and the Tucano in particular were less likely to indicate extreme hand preferences on any of the items. These results indicate significant effects of culture and environment on declared hand preference, and may be pertinent to recent discussions of cerebral organization in illiterates.