Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes.

INTRODUCTION: Although different scores have been suggested to predict outcomes in the setting of upper gastrointestinal bleeding (UGIB), few comparative studies between simplified versions of older scores and recent scores have been published. We aimed to evaluate the accuracy of pre- (PreRS) and postendoscopic Rockall scores (PostRS), the Glasgow-Blatchford score (GBS) and its simplified version (sGBS), as well as the AIMS65 score in predicting different clinical outcomes. METHODS: In this retrospective study, PreRS, PostRS, GBS, sGBS, and AIMS65 score were calculated, and then, areas under the receiver operating characteristic curve were used to evaluate the performance of each score to predict blood transfusion, endoscopic therapy, surgery, admission to intensive/intermediate care unit, length of hospital stay, as well as 30-day rebleeding or mortality. RESULTS: PreRS, PostRS, GBS, and sGBS were calculated for all the 433 included patients, but AIMS65 calculation was only possible for 315 patients. Only the PreRS and PostRS were able to fairly predict 30-day mortality. The GBS and sGBS were good in predicting blood transfusion and reasonable in predicting surgery. None of the studied scores were good in predicting the need for endoscopic therapy, admission to intensive/intermediate care unit, length of hospital stay, and 30-day rebleeding. CONCLUSIONS: Owing to the identified limitations, none of the 5 studied scores could be singly used to predict all the clinically relevant outcomes in the setting of UGIB. The sGBS was as precise as the GBS in predicting blood transfusion and surgery. The PreRS and PostRS were the only scores that could predict 30-day mortality. An algorithm using the PreRS and the sGBS as an initial approach to patients with UGIB is presented and suggested.

INTRODUÇÃO: Apesar dos vários scores propostos para pre-ver os diferentes outcomes no contexto de hemorragia di-gestiva alta (HDA), poucos estudos se debruçaram sobre a comparação entre eles. Este estudo avaliou o desem-penho dos scores de Rockall pré- (PreRS) e pós-endoscópi-co (PosRS), Glasgow-Blatchford (GBS) e a sua versão sim-plificada (sGBS), bem como o score AIMS65 na previsão de diferentes outcomes clínicos. MÉTODOS: Neste estudo ret-rospetivo, foram calculados os scores PreRS, PosRS, GBS, sGBS e AIMS65 e posteriormente as respectivas áreas sob as curvas de ROC para avaliar a capacidade de cada score em predizer necessidade de suporte transfusional, tera-pêutica endoscópica, cirurgia, admissão em unidade de cuidados intensivos/intermédios, tempo de internamen-to, bem como recidiva hemorrágica ou morte aos 30 dias. RESULTADOS: Em todos os 433 doentes incluídos foram cal-culados os scores PreRS, PosRS, GBS, sGBS, mas o cálculo do score AIMS65 apenas foi possível em 315 doentes. Ape-nas o PreRS e o PosRS foram capazes de prever de forma aceitável a mortalidade aos 30 dias. O GBS e o sGBS apre-sentaram uma boa capacidade de prever necessidade de transfusão e razoável capacidade para prever cirurgia. Ne-nhum dos cinco scores foi bom a predizer a necessidade de tratamento endoscópico, internamento em unidade de cuidados intensivos/intermédios, tempo de interna-mento ou recidiva hemorrágica aos 30 dias. CONCLUSÕES: Devido às limitações identificadas, nenhum dos scores pode ser usado isoladamente na previsão dos diferentes outcomes no contexto de HDA. O sGBS é tão preciso como o GBS na previsão da necessidade de transfusão ou cirur-gia. Apenas os scores PreRS e PosRS são capazes de prever mortalidade aos 30 dias. É sugerido um algoritmo para a abordagem inicial de doentes com HDA usando os scores PreRS e sGBS.

Fecal Calprotectin as a Selection Tool for Small Bowel Capsule Endoscopy in Suspected Crohn's Disease.

BACKGROUND: Small bowel capsule endoscopy (SBCE) is a firstline examination in patients with suspected Crohn's disease (CD) after negative ileocolonoscopy. Fecal calprotectin (FC) is a noninvasive marker of intestinal inflammation. The aim of this study was to evaluate the predictive value of FC in inflammatory activity detected by SBCE in patients with suspected CD. METHODS: This is a retrospective study including patients who underwent SBCE for suspected CD between March 2015 and October 2016. FC was measured within 1 week of SBCE. Inflammatory activity at SBCE was considered significant when the Lewis score (LS) was ≥135. FC correlation with LS was assessed using the Spearman correlation. The diagnostic accuracy of FC for significant inflammatory activity at SBCE was calculated by the area under the receiver operating characteristic curve (AUC). RESULTS: Seventy-five patients were included: 52 females (69.3%), with a mean age of 37 years. SBCE detected significant inflammatory activity (LS ≥ 135) in 42 patients (56%), and FC was positively correlated to LS (rank correlation = 0.56; P < 0.001). The AUC of FC was 0.854 for significant inflammatory activity (LS ≥ 135). For values of FC ≥100 µg/g, an LS ≥135 was found in 33 of 37 patients (89.2%, P < 0.001), corresponding to a sensitivity, specificity, positive predictive value, and negative predictive value of 78.6%, 87.9%, 89.2%, and 76.3%, respectively. CONCLUSIONS: FC has shown a good ability to predict significant inflammatory activity in SBCE in patients with suspected CD. Thus, FC proved to be a useful tool to select patients with suspected CD for SBCE.

Percutaneous endoscopic gastrostomy: confirming the clinical benefits far beyond anthropometry.

OBJECTIVES: The real benefit of gastrostomy is still a matter of debate. We aimed to prospectively evaluate the global impact of percutaneous endoscopic gastrostomy (PEG) in patients followed at a specialized multidisciplinary clinic, namely, the impact on the need for healthcare resources, anthropometric measures, pressure ulcers prevention and healing, and nutritional and hydration status. PATIENTS AND METHODS: From the 201 patients who underwent PEG between May 2011 and September 2014, 60 were included in a prospective study. Anthropometric, clinical, and laboratorial variables were collected and compared before and after PEG. Follow-up duration, mortality, and number of emergency department visits or hospital admissions were also assessed. RESULTS: Thirty-three (55.0%) patients were women and the median age was 79 years. The main indications for PEG were dementia (43.3%) and poststroke dysphagia (30.0%). Four months following PEG, significant decreases in the tricipital skinfold (P=0.002) and brachial perimeter (P=0.003) were found. A decrease in the mean number of hospitalizations (1.4 vs. 0.3; P<0.001) and visits to emergency department (2.2 vs. 1.1; P=0.003) was noted in the next 6 months after PEG compared with the previous semester. In 53.8% of patients with pressure ulcers, complete healing was observed after PEG. PEG was associated with increases in hemoglobin (P=0.024), lymphocytes (P=0.041), cholesterol (P=0.008), transferrin (P<0.001), albumin (P<0.001), and total proteins (P<0.001), and a decrease in serum sodium (P=0.001). CONCLUSION: Anthropometric values may not translate the early benefits of a gastrostomy. PEG decreases the need for hospital health care, facilitates healing of pressure ulcers, and induces biochemical changes that may reflect better nutrition and hydration.

Osteonecrosis of both knees in a woman with Crohn's disease.

Osteonecrosis is a very rare complication of Crohn's disease (CD). It is not clear if it is related to corticosteroid therapy or if it occurs as an extraintestinal manifestation of inflammatory bowel disease. We present the case of a patient with CD who presented with osteonecrosis of both knees. A 22 years old woman was diagnosed with CD in April 2012 (Montreal Classification A2L1 + L4B3p). She was started on prednisolone (40 mg/d), azathioprine (100 mg/d) and messalazine (3 g/d). In July 2012, due to active perianal disease, infliximab therapy was initiated. In September 2012, she had a pelvic abscess complicated by peritonitis and an ileal segmental resection and right hemicolectomy were performed. In December 2012 she was diagnosed with bilateral septic arthritis of both knees with walking impairment. She was treated with amoxicillin-clavulanic acid, started a physical rehabilitation program and progressively improved. However, then, bilateral knee pain exacerbated by movement developed. Magnetic resonance imaging showed multiple osseous medullary infarcts in the distal extremity of the femurs, proximal extremity of the tibiae and patellas and no signs of subchondral collapse, which is consistent with osteonecrosis. The patient recovered completely and maintains therapy with azathioprine and messalazine. A review of the literature is also done.

Uncovering the uncertainty: Risk factors and clinical relevance of P1 lesions on small bowel capsule endoscopy of anemic patients.

AIM: To identify risk factors for P1 lesions on small bowel capsule endoscopy (SBCE) and to describe the natural history of anemic patients with such type of lesions. METHODS: One hundred patients were consecutively selected for a case-control analysis performed between 37 cases with P1 lesions and 63 controls with negative SBCE. Age, gender, comorbidities and regular medication were collected. Rebleeding, further investigational studies and death were also analyzed during the follow-up. RESULTS: No significant differences on gender, median age or Charlson index were found between groups. Although no differences were found on the use of proton pump inhibitors, acetylsalicylic acid, anticoagulants or antiplatelet agents, the use of non-steroidal anti-inflammatory drugs (NSAID) was associated with a higher risk of P1 lesions (OR = 12.00, 95%CI: 1.38-104.1). From the 87 patients followed at our center, 39 were submitted to additional studies for investigation of iron-deficiency anemia (IDA), and this was significantly more common in those patients with no findings on SBCE (53.7% vs 30.3%, P = 0.033). A total of 29 patients had at least one rebleeding or IDA recurrence episode and 9 patients died of non-anemia related causes but no differences were found between cases and controls. CONCLUSION: P1 lesions are commonly found in patients with IDA submitted to SBCE. The use of NSAID seems to be a risk factor for P1 lesions. The outcomes of patients with P1 lesions do not differ significantly from those with P0 lesions or normal SBCE.

O retrato dos eventos adversos em uma clínica médica: análise de uma década / The portrait adverse events in a medical clinic: analysis of a decade / Descripción de eventos adversos en un servicio de clínica médica: análisis de una década

Estudo observacional do tipo descritivo transversal que teve como objetivo analisar os eventos adversos ocorridos em unidade de clínica médica de um hospital de Goiás. A coleta de dados foi realizada a partir da leitura de 12 livros de registros de enfermagem preenchidos de janeiro de 2005 a dezembro de 2014. Foram encontrados 1360 eventos adversos, dos quais 408 (30%) se referiam a retiradas acidentais de sondas, cateteres e cânulas; 288 (21,2%) erros de medicação; 157 (11,5%) erros envolvendo acesso vascular; 134 (9,8%) casos de infecção relacionada à assistência à saúde; 115 (8,4%) processos alérgicos; 91 (6,7%) quedas de pacientes; 72 (5,3%) úlceras por pressão; 56 (4,1%) episódios de falta de hemoderivados e 39 (2,9%) evasões. O estudo aponta o aumento dos registros dos eventos adversos ao longo da década, indicando a necessidade de adoção de medidas de prevenção e maior conscientização da enfermagem quanto à importância do relato desse incidente (AU).

This was a cross-sectional descriptive observational study aimed at analyzing adverse events in a medical clinic unit of a hospital in Goiás. Data were collected from the reading of 12 nursing registry books completed from January 2005 to December 2014. The analysis found 1,360 adverse events, of which 408 (30%) referred to accidental removal of probes, catheters, and cannulas; 288 (21.2%) to medication errors; 157 (11.5%) to errors involving vascular access; 134 (9.8%) to cases of healthcare-associated infections; 115 (8.4%) to allergic processes; 91 (6.7%) to patient falls; 72 (5.3%) to pressure ulcers; 56 (4.1%) to episodes of lack of blood derivatives; and 39 (2.9%) to evasions. The study shows an increase in the registry of adverse events over the decade, pointing out the need to adopt preventive measures and raising nursing personnel's awareness about the importance of reporting these incidents (AU).

Estudio observacional de tipo descriptivo transversal objetivando analizar los eventos adversos ocurridos en unidad de clínica médica de un hospital de Goiás. Datos recolectados a partir de lectura de 12 libros de registros de enfermería completados entre enero de 2005 y diciembre de 2014. Fueron hallados 1360 eventos adversos, de los cuales 408 (30%) hacían referencia a retiros accidentales de sondas, catéteres y cánulas; 288 (21,2%) errores de medicación; 157 (11,5%) errores involucrando acceso vascular; 134 (9,8%) casos de infección relacionada a atención de salud; 115 (8,4%) procesos alérgicos; 91 (6,7%) caídas de pacientes; 72 (5,3%) úlceras por presión; 56 (4,1%) episodios de falta de hemoderivados y 39 (2,9%) evasiones. El estudio expresa el aumento de registros de eventos adversos a lo largo de la década, indicando necesidad de adopción de medidas preventivas y mayor concientización de los enfermeros respecto de la importancia de informar estos incidentes (AU).

Cirrhotic cardiomyopathy: Isn't stress evaluation always required for the diagnosis?

AIM: To describe the proportion of patients with cirrhotic cardiomyopathy (CCM) evaluated by stress echocardiography and investigating its association with the severity of liver disease. METHODS: A cross-sectional study was conducted. Cirrhotic patients without risk factors for cardiovascular disease were included. Data regarding etiology and severity of liver disease (Child-Pugh score and model for end-stage liver disease), presence of ascites and gastroesophageal varices, pro-brain natriuretic peptide (pro-BNP) and corrected QT (QTc) interval were collected. Dobutamine stress echocardiography (conventional and tissue Doppler imaging) was performed. CCM was considered present when diastolic and/or systolic dysfunction was diagnosed at rest or after pharmacological stress. Therapy interfering with cardiovascular system was suspended 24 h before the examination. RESULTS: Twenty-six patients were analyzed, 17 (65.4%) Child-Pugh A, mean model for end-stage liver disease (MELD) score of 8.7. The global proportion of patients with CCM was 61.5%. At rest, only 2 (7.7%) patients had diastolic dysfunction and none of the patients had systolic dysfunction. Dobutamine stress echocardiography revealed the presence of diastolic dysfunction in more 6 (23.1%) patients and of systolic dysfunction in 10 (38.5%) patients. QTc interval prolongation was observed in 68.8% of the patients and increased pro-BNP levels in 31.2% of them. There was no association between the presence of CCM and liver impairment assessed by Child-Pugh score or MELD (P = 0.775, P = 0.532, respectively). Patients with QTc interval prolongation had a significant higher rate of gastroesophageal varices comparing with those without QTc interval prolongation (95.0% vs 50.0%, P = 0.028). CONCLUSION: CCM is a frequent complication of cirrhosis that is independent of liver impairment. Stress evaluation should always be performed, otherwise it will remain an underdiagnosed condition.

Predictive factors of early mortality after percutaneous endoscopic gastrostomy placement: The importance of C-reactive protein.

INTRODUCTION AND AIMS: Percutaneous endoscopic gastrostomy (PEG) is considered one of the preferred routes for long-term enteral feeding. However, early mortality after PEG placement is high. We aimed at analyzing overall and early mortality in patients who underwent PEG insertion and at identifying risk factors of increased mortality after the procedure. METHODS: Retrospective study which included patients who had a PEG insertion at our department between May 2007 and January 2013. Variables analyzed: demographic, Charlson's co-morbidity index, past aspiration pneumonia, indication for PEG, hemogram, ionogram, urea, creatinine, albumin and C-reactive protein (CRP). OUTCOME: death. Kaplan-Meier survival analysis was used to calculate mortality after PEG placement. Predictive factors of overall mortality were identified by univariate and multivariate analysis and of 30-day, 90-day and 180-day mortality by logistic regression. The AUROC analysis for CRP levels was performed. RESULTS: Inclusion of 135 patients: 51.9% female, mean age of 73 ± 17 years, 90.4% with neurological dysphagia and 9.6% with tumors compromising oral intake. The median survival time was 272 days. The 30-day, 90-day and 180-day mortality was 0.14 ± 0.06 (95% CI 0.08-0.20), 0.29 ± 0.08 (95% CI 0.21-0.37) and 0.43 ± 0.08 (95% CI 0.35-0.51), respectively. Patients with higher levels CPR (hazard ratio (HR) 1.009 95% CI 1.002-1.160, p = 0.012) and higher levels of urea (HR 1.009 95% CI 1.002-1.160, p = 0.012) had worse outcome and those with higher sodium levels (HR 0.945 95% CI 0.908-0.983, p = 0.005) had better prognosis. Higher CRP levels was the only independent predictive factor for 30-day mortality (odds ratio (OR) 1.008 95% CI 1.001-1.014, p = 0.029), and was also a risk factor for 90-day and 180-day mortality (OR 1.013 95% CI 1.005-1.021, p = 0.002 and OR 1.009 95% CI 1.001-1.018, p = 0.026, respectively). CRP levels ≥35.9 mg/dL could predict death at 30 days with a sensitivity of 0.810 and a specificity of 0.614. CONCLUSIONS: The early mortality after PEG placement is high. CRP, an indicator of acute illness, is a useful parameter at identifying patients with increased probability of dying after PEG insertion. High CRP levels should be considered in the decision making process.

Minimal Hepatic Encephalopathy: The Reality Beyond Our Eyes.

INTRODUCTION: Minimal hepatic encephalopathy refers to a mild neurocognitive impairment not detectable by clinical examination that can be present in cirrhotic patients. AIM: To determine the prevalence of minimal hepatic encephalopathy in a secondary healthcare center in Northern Portugal. MATERIAL AND METHODS: A cross-sectional study was conducted. Cirrhotic outpatients were included. EXCLUSION CRITERIA: overt hepatic encephalopathy, illiteracy, active alcohol consumption, psychotropic drug use and therapy with lactulose. The presence of minimal hepatic encephalopathy was defined as a value ≥ -4 on the Psychometric Hepatic Encephalopathy Score, calculated according to the Portuguese norms. Variables analyzed: etiology and severity of liver disease and venous blood ammonia concentration. p values < 0.05 were considered significant. RESULTS: From the 102 patients who were evaluated, 41 were included: 31 males, mean age 57 ± 10 years, mean education 5 ± 2 years, 31 in Child-Pugh class A, mean MELD score 6 ± 3. Minimal hepatic encephalopathy was diagnosed in 14 (34%) patients. The presence of minimal hepatic encephalopathy was unrelated to severity of liver disease. Despite being more elevated, the mean venous ammonia concentration in minimal hepatic encephalopathy patients was not statistically different from the mean venous ammonia concentration in non-minimal hepatic encephalopathy patients (48.5 ± 13.3 vs. 45.6 ± 15.6 µmol/L, p = 0.555). DISCUSSION: The prevalence of minimal hepatic encephalopathy reported is in accordance with the international published data. CONCLUSION: Minimal hepatic encephalopathy is a frequent condition that is present early in the course of cirrhosis, even in compensated cirrhotic patients. Therefore, this hidden entity should be actively pursued and managed properly.

Introdução: A encefalopatia hepática mínima define-se como um défice neurocognitivo ligeiro, não detectável ao exame clínico, que pode estar presente nos doentes cirróticos. Objectivo: Determinar a prevalência da encefalopatia hepática mínima num hospital prestador de cuidados de saúde secundários no Norte de Portugal. Material e Métodos: Realizou-se um estudo transversal em que foram incluídos os doentes cirróticos seguidos na consulta externa. Critérios de exclusão: encefalopatia hepática clínica, iliteracia, consumo activo de álcool e terapêutica com fármacos psicotrópicos ou lactulose. A presença de encefalopatia hepática mínima foi definida como um valor ≥ -4 na Pontuação Psicométrica da Encefalopatia Hepática, calculado de acordo com as normas portuguesas. Analisaram-se as variáveis: etiologia e gravidade da doença hepática e concentração da amónia sanguínea venosa. Considerou-se o valor de p < 0,05 como significativo. Resultados: Dos 102 doentes avaliados, 41 foram incluídos: 31 homens, idade média de 57 ± 10 anos, escolaridade média de 5 ± 2 anos, 31 Child-Pugh classe A, score MELD médio de 6 ± 3. Foi diagnosticada encefalopatia hepática mínima em 14 (34%) doentes. A presença de encefalopatia hepática mínima não se relacionou com a gravidade da doença hepática. Apesar de mais elevado, o valor médio da concentração da amónia venosa nos doentes com encefalopatia hepática mínima não foi significativamente diferente do valor médio da concentração da amónia venosa nos doentes sem encefalopatia hepática mínima (48,5 ± 13,3 vs. 45,6 ± 15,6 µmol/L, p = 0,555). Discussão: A prevalência da encefalopatia hepática mínima descrita está de acordo com os dados internacionais. Conclusão: A encefalopatia hepática mínima é uma entidade frequente que está presente precocemente na história natural da cirrose, mesmo em doentes compensados. Consequentemente, esta condição escondida deve ser activamente procurada e os doentes devidamente orientados após o diagnóstico.

Oesophageal lymphangioma: an exceedingly rare tumour.

An asymptomatic 57-year-old man was referred for evaluation of a 10 mm pale pink subepithelial polypoid lesion of the distal oesophagus; the lesion was found incidentally during an upper gastrointestinal endoscopy. The endoscopic ultrasound (EUS) revealed a heterogeneous, although primarily hypoechogenic, well-circumscribed lesion, located in the submucosa. Owing to the absence of endosonographic features, which would have allowed for a precise diagnosis, EUS-guided fine-needle aspiration was performed; however, the cytology was inconclusive because of the lack of cellular representation. We chose to remove it by cap-assisted endoscopic mucosal resection. However, due to its shape and deep location, complete removal was not achieved. A macrobiopsy was taken, and histological examination, of all oesophageal layers except the adventitia, revealed many irregularly dilated lymphatic vessels, beneath normal squamous epithelium. These findings are consistent with the diagnosis of lymphangioma. A follow-up EUS did not reveal any changes. The patient is currently asymptomatic and is under surveillance.

Virtual chromoendoscopy in small bowel capsule endoscopy: New light or a cast of shadow?

AIM: To evaluate whether virtual chromoendoscopy can improve the delineation of small bowel lesions previously detected by conventional white light small bowel capsule endoscopy (SBCE). METHODS: Retrospective single center study. One hundred lesions selected from forty-nine consecutive conventional white light SBCE (SBCE-WL) examinations were included. Lesions were reviewed at three Flexible Spectral Imaging Color Enhancement (FICE) settings and Blue Filter (BF) by two gastroenterologists with experience in SBCE, blinded to each other's findings, who ranked the quality of delineation as better, equivalent or worse than conventional SBCE-WL. Inter-observer percentage of agreement was determined and analyzed with Fleiss Kappa (κ) coefficient. Lesions selected for the study included angioectasias (n = 39), ulcers/erosions (n = 49) and villous edema/atrophy (n = 12). RESULTS: Overall, the delineation of lesions was improved in 77% of cases with FICE 1, 74% with FICE 2, 41% with FICE 3 and 39% with the BF, with a percentage of agreement between investigators of 89% (κ = 0.833), 85% (κ = 0.764), 66% (κ = 0.486) and 79% (κ = 0.593), respectively. FICE 1 improved the delineation of 97.4% of angioectasias, 63.3% of ulcers/erosions and 66.7% of villous edema/atrophy with a percentage of agreement of 97.4% (κ = 0.910), 81.6% (κ = 0.714) and 91.7% (κ = 0.815), respectively. FICE 2 improved the delineation of 97.4% of angioectasias, 57.1% of ulcers/erosions and 66.7% of villous edema/atrophy, with a percentage of agreement of 89.7% (κ = 0.802), 79,6% (κ = 0.703) and 91.7% (κ = 0.815), respectively. FICE 3 improved the delineation of 46.2% of angioectasias, 24.5% of ulcers/erosions and none of the cases of villous edema/atrophy, with a percentage of agreement of 53.8% [κ = not available (NA)], 75.5% (κ = NA) and 66.7% (κ = 0.304), respectively. The BF improved the delineation of 15.4% of angioectasias, 61.2% of ulcers/erosions and 25% of villous edema/atrophy, with a percentage of agreement of 76.9% (κ = 0.558), 81.6% (κ = 0.570) and 25.0% (κ = NA), respectively. CONCLUSION: Virtual chromoendoscopy can improve the delineation of angioectasias, ulcers/erosions and villous edema/atrophy detected by SBCE, with almost perfect interobserver agreement for FICE 1.

Reflexão em torno da adesão ao tratamento em pacientes recebidos através do Centro de Atendimento Psicanalítico da SBPdePA / Reflection about the adhesion to treatment in patients received via the Center of Psychoanalytical Treatment of the SBPdePA / Reflexión sobre la adhesión al tratamiento en pacientes recibidos a través de la Clínica de Tratamiento Psicoanalítico de la SBPdePA

Os analistas participantes do Centro de Atendimento Psicanalítico da Sociedade Brasileira de Psicanálise de Porto Alegre deparam-se, frequentemente, com a questão de por que alguns pacientes aderem ao tratamento psicanalítico e muitos outros, não. Neste trabalho, é feita uma reflexão em torno de alguns fatores do paciente e do analista que possam estar implicados nessa questão, envolvendo vicissitudes da transferência e da contratransferência. Os dados levantados em relação à adesão ao tratamento referem-se ao período de janeiro de 2012 a janeiro de 2013.

The analysts participating in the Center of Psychoanalytical Treatment of the Brazilian Society of Psychoanalysis of Porto Alegre frequently face the problem of why some patients adhere to the psychoanalytical treatment and many do not. In this paper, a reflection is made about some factors regarding both the patient and the analyst; these factors may be implicated in this matter, involving vicissitudes of transference and countertransference. The data collected in relation to the adhesion to the treatment refers to the period from January 2012 to January 2013.

Los analistas participantes en la Clínica de Tratamiento Psicoanalítico de la Sociedad Brasilera de Psicoanálisis de Porto Alegre enfrentan la cuestión de por qué algunos pacientes adhieren al tratamiento psicoanalítico y muchos, en cambio, no. En este trabajo, se hace una reflexión sobre algunos factores del paciente y del analista que puedan estar relacionados a esta cuestión, involucrando vicisitudes de la transferencia y de la contratransferencia. Los datos obtenidos en relación a la adhesión al tratamiento se refieren al período de enero de 2012 a enero de 2013.

Oral purgative and simethicone before small bowel capsule endoscopy.

AIM: To evaluate small bowel cleansing quality, diagnostic yield and transit time, comparing three cleansing protocols prior to capsule endoscopy. METHODS: Sixty patients were prospectively enrolled and randomized to one of the following cleansing protocols: patients in Group A underwent a 24 h liquid diet and overnight fasting; patients in Group B followed protocol A and subsequently were administered 2 L of polyethylene glycol (PEG) the evening before the procedure; patients in Group C followed protocol B and were additionally administered 100 mg of simethicone 30 min prior to capsule ingestion. Small bowel cleansing was independently assessed by two experienced endoscopists and classified as poor, fair, good or excellent according to the proportion of small bowel mucosa under perfect conditions for visualization. When there was no agreement between the two endoscopists, the images were reviewed and discussed until a consensus was reached. The preparation was considered acceptable if > 50% or adequate if > 75% of the mucosa was in perfect cleansing condition. The amount of bubbles was assessed independently and it was considered significant if it prevented a correct interpretation of the images. Positive endoscopic findings, gastric emptying time (GET) and small bowel transit time (SBTT) were recorded for each examination. RESULTS: There was a trend favoring Group B in achieving an acceptable (including fair, good or excellent) level of cleansing (Group A: 65%; Group B: 83.3%; Group C: 68.4%) [P = not significant (NS)] and favoring Group C in attaining an excellent level of cleansing (Group A: 10%; Group B: 16.7%; Group C: 21.1%) (P = NS). The number of patients with an adequate cleansing of the small bowel, corresponding to an excellent or good classification, was 5 (25%) in Group A, 5 (27.8%) in Group B and 4 (21.1%) in Group C (P = 0.892). Conversely, 7 patients (35%) in Group A, 3 patients (16.7%) in Group B and 6 patients (31.6%) in Group C were considered to have poor small bowel cleansing (P = 0.417), with significant fluid or debris such that the examination was unreliable. The proportion of patients with a significant amount of bubbles was 50% in Group A, 27.8% in Group B and 15.8% in Group C (P = 0.065). This was significantly lower in Group C when compared to Group A (P = 0.026). The mean GET was 27.8 min for Group A, 27.2 min for Group B and 40.7 min for Group C (P = 0.381). The mean SBTT was 256.4 min for Group A, 256.1 min for Group B and 258.1 min for Group C (P = 0.998). Regarding to the rate of complete examinations, the capsule reached the cecum in 20 patients (100%) in Group A, 16 patients (88.9%) in Group B and 17 patients (89.5%) in Group C (P = 0.312). A definite diagnosis based on relevant small bowel endoscopic lesions was established in 60% of the patients in Group A (12 patients), 44.4% in Group B (8 patients) and 57.8% in Group C (11 patients) (P = 0.587). CONCLUSION: Preparation with 2 L of PEG before small bowel capsule endoscopy (SBCE) may improve small bowel cleansing and the quality of visualization. Simethicone may further reduce intraluminal bubbles. No significant differences were found regarding GET, SBTT and the proportion of complete exploration or diagnostic yield among the three different cleansing protocols.

Os gambás (Didelphis sp) e a cana-de-açúcar (Saccharum spp) na possível transmissão oral do Trypanosoma cruzi: revisão da literatura / Opossums (Didelphis sp) and sugar cane (Saccharum spp) in the possible oral transmission of Trypanosoma cruzi: literature review

Os surtos da doença de Chagas por ingestão de alimentos contaminados, como o caldo de cana-de-açúcar (Saccharum spp), adquiriram importância mais recentemente, embora não se possa descartar a possibilidade de contaminação de reservatórios silvestres do Trypanosoma cruzi, como os gambás (Didelphis sp). Conduziu-se revisão sistemática da literatura analisando-se artigos científicos disponíveis na Biblioteca Cochrane, LILACS, MEDLINE e SciELO acerca da contaminação da cana-de-açúcar e/ou gambás por T. cruzi, publicados no continente americano entre 1909 e outubro de 2008. Após leitura e discussão da literatura escolhida, selecionaram-se os artigos científicos integrantes desta revisão, que corroboram a importância dos gambás e da cana-de-açúcar na epidemiologia da doença de Chagas. Entretanto, apenas um estudo aborda diretamente o objeto desta pesquisa, enquanto os demais descrevem contaminações experimentais de Didelphis sp com diferentes cepas de T. cruzi. Os resultados encontrados destacam a importância da cana-de-açúcar e Didelphis sp na transmissão oral da doença de Chagas, sugerindo a condução de estudos adicionais sobre a temática.

Chagas disease outbreaks through ingestion of contaminated food, such as sugar cane (Saccharum spp) juice, have kept attention recently, although the possibility of contamination of wild reservoirs with Trypanosoma cruzi, such as opossums (Didelphis sp), cannot be overlooked. A systematic literature review was carried out through the analysis of scientific articles available at Cochrane Library, LILACS, MEDLINE, and SciELO about contamination of sugar cane and/or opossum by T. cruzi. These papers were published in America from 1909 to October, 2008. After reading and discussing the chosen literature, we selected the scientific articles presented in this research, which corroborate the importance of opossums and sugar cane in Chagas disease epidemiology. Nevertheless, only one study approaches directly the object of this research, whereas the others describe experimental contamination of Didelphis sp with different strains of T. cruzi. The results show the importance of sugar cane and Didelphis sp in the oral transmission of Chagas disease, suggesting, thus, further research on this topic.