Risk factors for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis: a prospective, single-center study.

BACKGROUND AND STUDY AIMS: To determine the clinical features associated with advanced duodenal and ampullary adenomas in familial adenomatous polyposis. Secondarily, we describe the prevalence and clinical significance of jejunal polyposis. PATIENTS AND METHODS: This is a single center, prospective study of 62 patients with familial adenomatous polyposis. Duodenal polyposis was classified according to Spigelman and ampullary adenomas were identified. Patients with Spigelman III and IV duodenal polyposis underwent balloon assisted enteroscopy. Predefined groups according to Spigelman and presence or not of ampullary adenomas were related to the clinical variables: gender, age, family history of familial adenomatous polyposis, type of colorectal surgery, and type of colorectal polyposis. RESULTS: Advanced duodenal polyposis was present in 13 patients (21 %; 9 male) at a mean age of 37.61 ±â€Š13.9 years. There was a statistically significant association between family history of the disease and groups according to Spigelman ( P  = 0.03). Seven unrelated patients (6 male) presented ampullary adenomas at a mean age of 36.14 ±â€Š14.2 years. The association between ampullary adenomas and extraintestinal manifestations was statistically significant in multivariate analysis ( P  = 0.009). Five endoscopic types of non-ampullary adenoma were identified, showing that lesions larger than 10 mm or with a central depression presented foci of high grade dysplasia. Among 28 patients in 12 different families, a similar Spigelman score was identified; 10/12 patients (83.3 %) who underwent enteroscopy presented small tubular adenomas with low grade dysplasia in the proximal jejunum. CONCLUSIONS: Advanced duodenal polyposis phenotype may be predictable from disease severity in a first-degree relative. Ampullary adenomas were independently associated with the presence of extraintestinal manifestations.

[Hyperplastic polyp with neoplastic transformation in a patient with atrophic gastritis and multiple gastric neuroendocrine tumors]. / Pólipo hiperplásico con transformación neoplásica en paciente con gastritis atrófica y múltiples tumores neuroendocrinos.

Hyperplastic gastric polyps are often found at GI endoscopy and are not considered premalignant lesions, although some cases of malignancy have been reported. Neuroendocrine tumors, conversely, are rare and account for approximately 1% to 2% of gastric polyps. Both hyperplastic gastric polyps and neuroendocrine tumors are related to gastric atrophy. The case of a hyperplastic polyp with multifocal areas of adenocarcinoma within the polyp associated to multiple gastric neuroendocrine tumors is reported.

Use of multiple channel pH monitoring for evaluation of ultra-distal reflux in patients after fundoplication for treatment of Barrett's esophagus.

Dysplasia and esophageal adenocarcinoma may arise in patients with Barrett's esophagus after fundoplication esophageal pH monitoring showing no acid in esophagus. This suggests the need to develop methodology to evaluate the occurrence of ultra-distal reflux (1cm above the LES). The objective of the study was to compare acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the LES and in the intrasphincteric region. Eleven patients with Barrett's esophagus after Nissen fundoplication with no clinical, endoscopic and radiologic evidence of reflux were selected. Four-channel pH monitoring took place: channel A, 5cm above the upper border of the LES; channel B, 1cm above the LES; channel C, intrasphincteric; channel D, intragastric. The results of channels A, B and C were compared. There was significant increase in number of reflux episodes and a higher fraction of time with pH <4.0 in channel B compared to channel A. There was significant decrease in fraction of time with pH <4.0 in channel B compared to channel C. Two cases of esophageal adenocarcinoma were diagnosed in the studied patients. The region 1cm above the upper border of the LES is more exposed to acid than the region 5cm above the upper border of the LES, although this exposure occurred in reduced levels. The region 1cm above the upper border of the LES is less exposed to acid than the intrasphincteric region.

Air pollution and child mortality: a time-series study in São Paulo, Brazil.

Although most available evidence relating air pollution and mortality was obtained for adults, pollution has been also associated with increased mortality in children, but in a significantly smaller number of studies. This study was designed to evaluate the association between child mortality and air pollution in the city of São Paulo, Brazil, from 1994 to 1997. Daily records of mortality due to respiratory diseases for children under 5 years of age were obtained from the municipal mortality information improvement program. Daily concentrations of sulfur dioxide (SO(2)), carbon monoxide (CO), inhalable particulate matter less than 10 microm in diameter (PM(10)), and ozone were obtained from the state air pollution controlling agency. Information on minimum daily temperature and on relative humidity were obtained from the Institute of Astronomy and Geophysics of the University of São Paulo. Statistical analysis was performed through generalized additive models considering a Poisson response distribution and a log link. Explanatory variables were time, temperature, humidity, and pollutant concentrations. The loess smoother was applied to time (in order to model seasonality) and temperature. Significant associations between mortality and concentrations of CO, SO(2), and PM(10) were detected. The coefficients (and standard errors) of these three pollutants were 0.0306 (0.0076), 0.0055 (0.0016), and 0.0014 (0.0006), respectively. The observed associations were dose dependent and quite evident after a short period of exposure (2 days). According to the proposed model and considering the mean of the pollutant concentration during the period of the study, the estimated proportions of respiratory deaths attributed to CO, SO(2), and PM(10), when considered individually, are around 15, 13, and 7%, respectively.

Effects of the "special bomb": recollections of a neurosurgeon in Hiroshima, August 8-15, 1945.

This article recountsOFF (Shimada) Kishi's experience when he was appointed as chief of the First Investigation Committee that evaluated the damage caused by the atom bomb dropped on Hiroshima.

Association between air pollution and intrauterine mortality in São Paulo, Brazil.

The associations among daily counts of intrauterine mortality and pollutant concentrations (NO2, SO2, CO, O3, and particulate matter (3/4)10 microm) were investigated for the period ranging from January 1991 to December 1992 in the city of São Paulo, Brazil. We used Poisson regression techniques, adjusted for season and weather. The association between intrauterine mortality and air pollution was strong for NO2 (coefficient = 0.0013/ microg/m3; p<0.01) but lesser for SO2 (coefficient = 0.0005/ microg/m3; p<0.10) and CO (coefficient = 0.0223/ppm; p<0.10). A significant association was observed when an index that combined these three pollutants was considered in the models instead of considering each pollutant individually (p<0.01). These associations exhibited a short time lag, not over 5 days. In addition, some evidence of fetal exposure to air pollution was obtained by disclosing a significant association between the levels of carboxyhemoglobin of blood sampled from the umbilical cord and ambient CO levels in children delivered by nonsmoking pregnant women in the period from May to July 1995. Our results suggest that air pollution in São Paulo may promote adverse health effects on fetuses.