Detection of Helicobacter pylori resistance to clarithromycin and fluoroquinolones in Brazil: A national survey.

AIM: To evaluate bacterial resistance to clarithromycin and fluoroquinolones in Brazil using molecular methods. METHODS: The primary antibiotic resistance rates of Helicobacter pylori (H. pylori) were determined from November 2012 to March 2015 in the Southern, South-Eastern, Northern, North-Eastern, and Central-Western regions of Brazil. Four hundred ninety H. pylori patients [66% female, mean age 43 years (range: 18-79)] who had never been previously treated for this infection were enrolled. All patients underwent gastroscopy with antrum and corpus biopsies and molecular testing using GenoType HelicoDR (Hain Life Science, Germany). This test was performed to detect the presence of H. pylori and to identify point mutations in the genes responsible for clarithromycin and fluoroquinolone resistance. The molecular procedure was divided into three steps: DNA extraction from the biopsies, multiplex amplification, and reverse hybridization. RESULTS: Clarithromycin resistance was found in 83 (16.9%) patients, and fluoroquinolone resistance was found in 66 (13.5%) patients. There was no statistical difference in resistance to either clarithromycin or fluoroquinolones (P = 0.55 and P = 0.06, respectively) among the different regions of Brazil. Dual resistance to clarithromycin and fluoroquinolones was found in 4.3% (21/490) of patients. The A2147G mutation was present in 90.4% (75/83), A2146G in 16.9% (14/83) and A2146C in 3.6% (3/83) of clarithromycin-resistant patients. In 10.8% (9/83) of clarithromycin-resistant samples, more than 01 mutation in the 23S rRNA gene was noticed. In fluoroquinolone-resistant samples, 37.9% (25/66) showed mutations not specified by the GenoType HelicoDR test. D91N mutation was observed in 34.8% (23/66), D91G in 18.1% (12/66), N87K in 16.6% (11/66) and D91Y in 13.6% (9/66) of cases. Among fluoroquinolone-resistant samples, 37.9% (25/66) showed mutations not specified by the GenoType HelicoDR test. CONCLUSION: The H. pylori clarithromycin resistance rate in Brazil is at the borderline (15%-20%) for applying the standard triple therapy. The fluoroquinolone resistance rate (13.5%) is equally concerning.

Clinical efficacy of dexmedetomidine alone is less than propofol for conscious sedation during ERCP.

BACKGROUND: Propofol is an accepted method of sedation for an ERCP and generally achieves deep sedation rather than conscious sedation, and dexmedetomidine has sedative properties of equivalent efficacy. OBJECTIVE: To examine the hypothesis that dexmedetomidine is as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. DESIGN AND SETTING: Randomized, blind, double-dummy clinical trial. PATIENTS: Twenty-six adults, American Society of Anesthesiologists status I to III, underwent an ERCP. INTERVENTIONS: Patients were randomized to receive either propofol (n = 14) (target plasma concentration range 2-4 microg/mL) combined with fentanyl 1 microg/kg, or dexmedetomidine (n = 12) 1 microg/kg for 10 minutes, followed by 0.2 to 0.5 microg/kg/min. Additional sedatives were used if adequate sedation was not achieved at the maximum dose allowed. MAIN OUTCOMES MEASUREMENTS: The sedation level was assessed by the Richmond alertness-sedation scale and the demand for additional sedatives. Furthermore, heart rate, blood pressure, oxygen saturation, and respiratory rate were continuously assessed. RESULTS: The relative risk (RR) was 2.71 (95% CI, 1.31-5.61) and the number of patients that needed to be treated (NNT) was 1.85 (95% CI, 1.19-4.21) to observe one additional patient with drowsiness 15 minutes after sedation in the dexmedetomidine group. Also, the RR was 9.42 (95% CI, 1.41-62.80), and the NNT was 1.42 (95% CI, 1.0-2.29) to require additional analgesic. However, there was also a greater reduction in blood pressure, a lower heart rate, and greater sedation after the procedure. CONCLUSIONS: Dexmedetomidine alone was not as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. Furthermore, dexmedetomidine was associated with greater hemodynamic instability and a prolonged recovery.

Acalasia na doença de Chagas é diferente de acalasia idiopática? Experiência do Hospital de Clínicas de Porto Alegre / Is achalasia in Chagas'disease different from idiopathic achalasia? Experience of the Hospital de Clínicas de Porto Alegre

O presente trabalho tem como objetivo avaliar as diferenças entre a acalasia chagásica e a idiopática em pacientes do Hospital de Clínicas de Porto Alegre, através da análise de achados epidemiológicos, clínicos, radiológicos e manométricos. Foram estudados pacientes encaminhados ao Hospital de Clínicas de Porto Alegre, entre novembro de 1996 e dezembro de 2001, com suspeita de acalasia, posteriormente, confirmada por manometria esofágica. Além das características manométricas e radiológicas, os pacientes foram avaliados quanto a idade, sexo, sintomas e tempo de evolução. Entre 51 pacientes, nove (18 por cento) tiveram sorologia positiva para doença de Chagas e 42 (82 por cento) sorologia negativa. Indivíduos com sorologia negativa foram considerados portadores de acalasia idiopática. Pacientes com acalasia chagásica tinham média de idade de 62 mais ou menos 15 anos e os com idiopática 43 mais ou menos 18 anos (P<0,02). O período de evolução dos sintomas em pacientes com acalasia chagásica foi de 74 mais ou menos 47 meses e nos idiopáticos 49 mais ou menos 35 meses (P<0,05). Disfagia, regurgitação, dor torácica e emagrecimento, valores do esfíncter esofágico inferior (pressão basal, pressão e duração de relaxamento pós-deglutição e comprimento total) e do corpo esofágico (amplitude e duração das ondas pós-deglutição) foram similares em ambos os grupos). As únicas diferenças estatisticamente significativas encontradas entre os dois grupos foram a média de idade e o período de evolução dos sintomas, maiores nos pacientes chagásicos. Esses dados permitem especular sobre uma maior tolerância aos sintomas nos pacientes com idade mais avançada.

Síndrome de Caroli e carcinomatose peritoneal / Caroli's syndrome and peritoneal carcinomatosis

A Síndrome de Caroli é uma entidade incomum caracterizada pela presença de dilatações císticas da árvore biliar intra-hepática e fibrose hepática congênita. Pode comportar-se como condição pré-maligna, evoluindo em alguns casos para colangiocarcinoma. Relatamos um caso diagnosticado em paciente do sexo masculino, 37 anos, complicado por carcinomatose peritoneal de sítio desconhecido, fazendo também revisão da literatura