Polyhydroxyalkanoate Production from Eucalyptus Bark's Enzymatic Hydrolysate.

In recent years, polyhydroxyalkanoates (PHAs) have gained notoriety because of their desirable properties that include proven biodegradability, biocompatibility, and thermal stability, which make them suitable alternatives to fossil-based polymers. However, the widespread use of PHAs is still challenging because of their production costs, which are greatly associated with the cultivation medium used for bacterial cultivation. In Portugal, one-quarter of the forest area is covered by Eucalyptus globulus wood, making its residues a cheap, abundant, and sustainable potential carbon source for biotechnological uses. In this work, eucalyptus bark was used as the sole feedstock for PHA production in a circular bioeconomic approach. Eucalyptus bark hydrolysate was obtained after enzymatic saccharification using Cellic® CTec3, resulting in a sugar-rich solution containing glucose and xylose. Although with differing performances, several bacteria were able to grow and produce PHA with distinct compositions, using the enzymatic hydrolysate as the sole carbon source. Pseudomonas citronellolis NRRL B-2504 achieved a high cellular growth rate in bioreactor assays (24.4 ± 0.15 g/L) but presented a low accumulation of a medium-chain-length PHA (mcl-PHA) comprising the monomers hydroxydecanoate (HD, 65%), hydroxydodecanoate (HDd, 25%), and hydroxytetradecanoate (HTd, 14%). Burkholderia thailandensis E264, on the other hand, reached a lower cellular growth rate (8.87 ± 0.34 g/L) but showed a higher biopolymer accumulation, with a polyhydroxybutyrate (PHB) content in the cells of 12.3 wt.%. The new isolate, Pseudomonas sp., revealed that under nitrogen availability, it was able to reach a higher accumulation of the homopolymer PHB (31 wt.%). These results, although preliminary, demonstrate the suitability of eucalyptus bark's enzymatic hydrolysate as a feedstock for PHA production, thus offering an exciting avenue for achieving sustainable and environmentally responsible plastic products from an undervalued forestry waste.

Mediastinal Abscess Formation after EUS-Guided Sampling in a Young Patient with Sarcoidosis: Be Aware of the Increased Risk!

International guidelines establish EUS-guided sampling as safe and accurate for the evaluation of mediastinal solid lesions, such as lymphadenopathies of unknown origin, and point out an increased risk of severe infectious complications induced by needle puncture in mediastinal cystic lesions. A retrospective case series and a systematic review documented an increased risk of mediastinal abscess formation after EUS-guided lymph nodes sampling in patients with sarcoidosis. The authors describe a case of a 38-year-old male patient with a final diagnosis of sarcoidosis, who developed a large mediastinal abscess after EUS-guided fine-needle biopsy of mediastinal lymphadenopathies. Endoscopists should be aware of the potential increased risk of severe infectious complications when sampling mediastinal lymph nodes in suspected sarcoidosis, and a strategy to minimize such risk should be pursued.

As normas de consenso internacionais estabelecem a biopsia guiada por ecoendoscopia como segura e precisa no diagnóstico de lesões sólidas do mediastino, tais como adenopatias de origem indeterminada, e sublinham o risco significativo de complicações infecciosas graves associado à punção de lesões mediastínicas quísticas. Uma série retrospectiva e uma revisão sistemática apontaram para um risco aumentado de abcesso mediastínico após punção guiada por ecoendoscopia de gânglios linfáticos em doentes com sarcoidose. Os autores descrevem o caso cínico de um jovem de 38 anos, com o diagnóstico final de sarcoidose, que desenvolveu um volumoso abcesso mediastínico após biopsia guiada por ecoendoscopia de adenopatias mediastínicas. Os endoscopistas deverão reconhecer o risco aumentado de complicações infeciosas graves aquando da punção de adenopatias mediastínicas na suspeita de sarcoidose e procurar definir uma estratégia preventiva para minimizar o referido risco.

Idiopathic Hypereosinophilic Syndrome: A Case Report.

Idiopathic hypereosinophilic syndrome is a rare condition characterized by persistent severe eosinophilia and organ damage without any apparent cause. A 20-year-old male patient with no significant medical history was admitted to the Emergency Department with retrosternal chest pain, fatigue and asthenia. EKG showed ST elevation I, II, III, aVF, V4-V6 and blood tests showed elevated troponin levels. An echocardiogram was performed revealing severe global left ventricular systolic dysfunction. Further evaluations included cardiac magnetic resonance imaging and endomyocardial biopsy, confirming the diagnosis of eosinophilic myocarditis. The patient was started on systemic corticosteroid therapy, resulting in clinical improvement. The patient was discharged after 12 days of hospitalization, following a recovery of biventricular function and he was told to continue oral corticosteroid therapy at home. Further investigation ruled out other causes of hypereosinophilic syndromes, therefore the diagnosis of idiopathic hypereosinophilic syndrome was assumed. Despite the attempt to reduce corticosteroid therapy, the eosinophil count became elevated again, so the dosage was increased and associated with azathioprine with subsequent favorable analytical evolution. This case highlights the challenges in diagnosing and managing idiopathic hypereosinophilic syndrome and emphasizes the importance of prompt treatment initiation to prevent complications.

Endoscopic Reconstruction of an Oral Feeding Route Using a Rendezvous Approach.

Background: The approach to esophageal obstruction or discontinuity remains challenging and often involves complex reconstructive surgeries. The rendezvous endoscopic technique might be interesting in cases of complete esophageal obstruction. Case Presentation: Herein we describe a successful case of endoscopic recanalization of the esophageal lumen in a patient with a long-standing esophageal discontinuity resulting from several surgeries and chemoradiation for a squamous cell carcinoma of the hypopharynx, ending in a major cervical amputation, construction of a neopharynx, and definitive surgical closure of the superior esophagus with a PEG placement. With a rendezvous technique (peroral and through the gastrostomy) and under radiographic guidance, puncture from the neopharynx into the distal esophagus was performed, followed by balloon dilation and covered metal stent placement in order to reconstruct a neoesophagus. Five weeks later, the stent was removed (using a stent-in-stent technique). No complications occurred. The patient has been able to eat soft food and is being kept under regular endoscopic surveillance to control/treat a luminal stenosis of the neoesophagus. Conclusions: This case report illustrates a successful endoscopic treatment of post-surgical complete esophageal obstruction. This approach should be considered in the therapeutic armamentarium of these difficult clinical settings.

Introdução: A abordagem da descontinuidade esofágica permanece desafiante e frequentemente envolve cirurgias reconstrutivas complexas. A técnica endoscópica de rendez-vous pode ser interessante em casos de obstrução esofágica completa. Apresentação do caso: Descrevemos um caso de sucesso de recanalização endoscópica do lúmen esofágico de um doente com descontinuidade esofágica de longa duração, em resultado de múltiplas cirurgias e quimioradiação por um carcinoma pavimento-celular da hipofaringe, que resultou numa amputação cervical major, construção de uma neofaringe e encerramento cirúrgico definitivo do esófago com colocação de PEG. Por técnica de rendez-vous (peroral e por gastrostomia) e sob apoio radiológico, foi realizada punção da neofaringe, seguido de dilatação com balão e colocação de prótese metálica coberta para criar um neo-esófago. Cinco semanas depois, a prótese foi removida (por técnica stent-in-stent). Não ocorreram complicações. O doente tem mantido capacidade de ingerir comida pastosa e é submetido a vigilância regular endoscópica para controlar/tratar uma estenose do lúmen do neo-esófago. Conclusão: Este caso ilustra o tratamento endoscópico bem-sucedido de um doente com obstrução pós-cirúrgica completa do esófago. Esta abordagem deverá ser considerada no arsenal terapêutico destes quadros clínicos complexos.

Endoscopic Management of Symptomatic Duodenal Duplication Cysts: Two Case Reports.

Background: Duodenal duplication cysts (DDCs) are rare congenital anomalies typically manifesting during childhood. Clinical manifestations are uncommon in adulthood. DDCs were classically treated surgically, but endoscopic treatment has been increasingly reported. Endoscopic cyst marsupialization establishes a communication between the cyst cavity and the duodenal lumen so that the cystic content can be drained continuously into the duodenum. We herein describe two cases of symptomatic DDCs diagnosed in adulthood and submitted to endoscopic marsupialization using different techniques and devices. Case Summary: Case 1: A 23-year-old female patient was admitted with the diagnosis of acute pancreatitis. Endoscopic ultrasound revealed a 35-mm duodenal subepithelial lesion whose proximal limit was immediately distal to the ampulla of Vater and filled with fluid and calcifications. Using a duodenoscope, deroofing of the lesion was made with a diathermic snare. Pathology confirmed the diagnosis of DDC. Case 2: A 41-year-old female, submitted to laparoscopic cholecystectomy 1 month earlier due to suspected lithiasic acute pancreatitis, was admitted due to suspicion of iatrogenic biliary fistula. An endoscopic retrograde cholangiopancreatography was performed and the bile leak was treated. Immediately distal to the papillary orifice, a 20-mm subepithelial lesion was also detected. A biopsy forceps was used to fenestrate its wall, allowing the exit of mucous fluid and stones, and a sphincterotome was used to expand the incision. No recurrence was documented in both cases. Conclusion: These cases highlight DDC as a potential cause for acute pancreatitis in adults and endoscopy as an easy treatment option.

Introdução: Os quistos de duplicação duodenais (QDD) são anomalias congénitas raras que tipicamente se manifestam durante a infância. As manifestações clínicas são pouco frequentes em adultos. Os QDD eram classicamente tratados cirurgicamente, mas o tratamento endoscópico tem sido crescentemente reportado. A marsupialização endoscópica do quisto estabelece uma comunicação entre a cavidade do quisto e o lúmen duodenal, permitindo que o conteúdo do quisto drene continuamente para o duodeno. Reportamos 2 casos de QDD diagnosticados em adultos e submetidos a marsupialização endoscópica, utilizando diferentes técnicas e dispositivos. Casos clínicos: Caso 1: Doente do sexo feminino, 23 anos, internada por pancreatite aguda. Por ecoendoscopia documentou-se lesão subepitelial duodenal com 35 mm com limite proximal imediatamente distal à ampola de Vater, preenchida por líquido e calcificações. Usando um duodenoscópio, foi feita marsupialização da lesão com ansa diatérmica. Histologia confirmou o diagnóstico de QDD. Caso 2: Doente do sexo feminino, 41 anos, submetida a colecistectomia laparoscópica 1 mês antes por suspeita de pancreatite aguda litiásica, foi internada por suspeita de fístula biliar iatrogénica. Por CPRE confirmouse fuga biliar que foi tratada. Imediatamente distal ao orifício papilar, foi também detetada uma lesão subepitelial com 20 mm. Uma pinça de biopsia foi usada para fenestrar a sua parede, permitindo a saída de fluido mucoso e cálculos e um esfincterótomo foi usado para expandir a incisão. Não se registou recorrência em nenhum dos casos. Conclusão: Estes casos destacam os QDD como causa potencial de pancreatite aguda em adultos e a endoscopia como possível opção terapêutica.

Safety Aspects of Perinatal Ultrasound.

Ultrasound safety is of particular importance in fetal and neonatal scanning. Fetal tissues are vulnerable and often still developing, the scanning depth may be low, and potential biological effects have been insufficiently investigated. On the other hand, the clinical benefit may be considerable. The perinatal period is probably less vulnerable than the first and second trimesters of pregnancy, and ultrasound is often a safer alternative to other diagnostic imaging modalities. Here we present step-by-step procedures for obtaining clinically relevant images while maintaining ultrasound safety. We briefly discuss the current status of the field of ultrasound safety, with special attention to the safety of novel modalities, safety considerations when ultrasound is employed for research and education, and ultrasound of particularly vulnerable tissues, such as the neonatal lung. This CME is prepared by ECMUS, the safety committee of EFSUMB, with contributions from OB/GYN clinicians with a special interest in ultrasound safety.

The use of flow cytometry to assess Rhodosporidium toruloides NCYC 921 performance for lipid production using Miscanthus sp. hydrolysates.

The yeast Rhodosporidium toruloides NCYC 921 was used for lipid production, using Miscanthus biomass hydrolysate as carbon source. The hydrolysate was obtained by enzymatic hydrolysis of Miscanthus biomass (at high solids loading) previously subjected to a hydrothermal pre-treatment. Afterwards R. toruloides was grown on Miscanthus sp. hydrolysate (MH), undiluted and diluted, at the ratios of 1:4 (20 % v/v), 1:2 (33.3 % v/v) and 3:1 (75 % v/v). The best yeast performance was observed for MH 1:2 medium dilution, reaching the maximal biomass concentration of 6.3 g/L, the lipid content of 30.67 % w/w dry cell weight and the lipid concentration of 1.64 g/L. Flow cytometry demonstrated that R. toruloides cell membrane was massively damaged when the yeast was grown on undiluted MH, due to the presence of phenolic compounds; however, when the yeast was grown on diluted MH 1:2 and 1:4, the proportion of intact cells has increased during the yeast cultivation.

GRUPUGE PERSPECTIVE: Endoscopic Ultrasound-Guided Biliary Drainage.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to percutaneous and surgical drainage in bile duct obstruction when endoscopic retrograde cholangiopancreatography fails. EUS-BD can be achieved with several techniques, including EUS-guided hepaticogastrostomy (HGS), anterograde transpapillary stent placement, choledochoduodenostomy (CDS), and rendez-vous technique. Lately, with increased experience and development of directed equipment, elevated technical and clinical success as well of lower adverse event rates have been reported. In this article, GRUPUGE presents an updated perspective of the potential role of EUS-guided biliary drainage, addressing the selection criteria and technical issues of different techniques and analyzing recent data on their safety and efficacy.

A drenagem biliar guiada por ecoendoscopia é uma alternativa à drenagem percutânea ou cirúrgica em casos de obstrução biliar, quando a colangiopancreatografia retrógrada endoscópica (CPRE) falha. Esta poderá ser realizada através de diversas técnicas, incluindo a hepatogastrostomia, colocação de prótese transpapilar por via anterógrada, coledocoduodenostomia e técnica de rendez-vous. Recentemente, têm sido reportadas elevadas taxas de sucesso técnico e clínico, assim como uma menor taxa de efeitos adversos, em relação com o aumento da experiência local e desenvolvimento de dispositivos especializados. No presente artigo, o GRUPUGE apresenta uma perspetiva atual do potencial papel da drenagem biliar guiada por ecoendoscopia, focando aspetos relativos à seleção dos doentes, questões técnicas dos vários procedimentos disponíveis e analisando dados emergentes relativos à sua segurança e eficácia.

The Impact of Recent Advances in Endoscopic Ultrasound-Guided Tissue Acquisition on the Management of Pancreatic Cancer.

Over the last few decades, endoscopic ultrasound (EUS)-guided tissue acquisition has become the method of choice for the pathological diagnosis of solid pancreatic lesions. Due to its high diagnostic yield and low complication rate, EUS-guided tissue acquisition has surpassed percutaneous sampling techniques. For many years, EUS-guided fine-needle aspiration (EUS-FNA) was traditionally used to obtain cytological aspirates of solid pancreatic lesions, with sensitivity values ranging from 80 to 90% for the diagnosis of malignancy. Nevertheless, despite numerous technical advances, EUS-FNA still presents some limitations. Therefore, EUS-guided fine-needle biopsy (EUS-FNB) has been introduced to provide tissue core biopsies, allowing histological assessment. A newly developed generation of FNB needles has demonstrated an outstanding diagnostic accuracy of over 95% for solid pancreatic lesions and provides samples appropriate for ancillary testing, such as immunohistochemistry and tumour molecular profiling. As a result, EUS-FNB is rapidly replacing EUS-FNA and is now the recommended technique for EUS-guided tissue acquisition in pancreatic cancer. Furthermore, with the recent expansion of neoadjuvant treatment criteria and with the advent of novel and personalised anti-cancer therapies, EUS-FNB is gaining a pivotal role in pancreatic cancer management and might soon be generalised to all patients, independent of disease stage. In this article, the authors present an updated review of the role of EUS-guided tissue acquisition in pancreatic cancer. Current indications, several technical aspects and new applications of EUS-FNA and EUS-FNB are discussed.

Nas últimas décadas, a aquisição de tecido por ecoendoscopia tornou-se o método de eleição para o diagnóstico patológico de lesões sólidas do pâncreas. Devido à sua elevada capacidade diagnóstica e baixa taxa de complicações, a aquisição de tecido por ecoendoscopia ultrapassou as técnicas de biópsia por via percutânea. Durante muito anos, a aspiração com agulha fina guiada por ecoendoscopia (EUS-FNA) foi tradicionalmente usada para obter aspirados citológicos de lesões sólidas do pâncreas, com valores de sensibilidade que variam entre os 80% e os 90% no diagnóstico de malignidade. Contudo, apesar de numerosos avanços técnicos, a EUS-FNA apresenta ainda algumas limitações. Assim, a biópsia com agulha fina guiada por ecoendoscopia (EUS-FNB) foi introduzida para obter biópsias com cores de tecido, permitindo avaliação histológica. Uma nova geração de agulhas de FNB recentemente desenvolvida demonstra uma acuidade diagnóstica excecional acima de 95% nas lesões sólidas do pâncreas e obtém amostras adequadas para estudos ancilares, designadamente imunohistoquímica e caracterização molecular tumoral. Por conseguinte, a EUS-FNB está rapidamente a substituir a EUS-FNA e é hoje a técnica recomendada para aquisição de tecido no cancro do pâncreas. Além disso, com a recente expansão dos critérios para tratamento neoadjuvante e com o advento de terapias anti-tumorais novas e personalizadas, a EUS-FNB está a adquirir um papel essencial na abordagem do cancro do pâncreas e poderá em breve ser generalizada a todos os doentes, independentemente do estádio da doença. Neste artigo, os autores apresentam uma revisão atualizada do papel da aquisição de tecido por ecoendoscopia no cancro do pâncreas. As indicações atuais, vários aspetos técnicos e novas aplicações da EUS-FNA e EUS-FNB são discutidos.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Fine-Needle Tattooing and Fiducial Placement in Pancreatic Cancer.

In the last 2 decades, endoscopic ultrasound (EUS) has become an important procedure for the diagnosis and management of several pancreatic diseases, including pancreatic cancer. This article presents two recently developed EUS-guided techniques for the management of pancreatic cancer: fine-needle tattooing and fiducial placement. Preoperative EUS-guided fine-needle tattooing of small pancreatic tumors helps in precise localization of these lesions during surgery, potentially ensuring adequate margins of resection while preserving healthy pancreatic tissue. In pancreatic cancer patients planned for imaging-guided radiation therapy, EUS-guided fiducial placement improves the accuracy of target delineation during stereotactic body radiation therapy (SBRT). Hydrogel, a new injectable liquid with multimodal visibility recently approved as a liquid fiducial, is currently under investigation in pancreatic head cancer as an EUS-injected spacer to potentially reduce SBRT gastrointestinal wall toxicity. In this article, GRUPUGE presents an updated perspective of these two EUS-guided techniques, addressing their current clinical applications and technical aspects and analyzing existing data on their efficacy and safety.

Durante as duas últimas décadas, a ecoendoscopia tor-nou-se um procedimento importante para o diagnóstico e abordagem de diversas doenças pancreáticas, incluindo o cancro do páncreas. Neste artigo sao apresentadas duas técnicas guiadas por ecoendoscopia desenvolvidas recentemente na abordagem do cancro do páncreas: tatuagem com agulha fina e marcação com fiduciais. A tatuagem pré-operatória com agulha fina guiada por ecoendoscopia de pequenos tumores pancreáticos ajuda na localização precisa destas lesões durante a cirurgia, potencialmente assegurando margens de resseção adequa-das e preservando parênquima pancreático saudável. Nos doentes com cancro do pêncreas com indicação para radioterapia guiada por imagem, a marcação com fiduciais guiada por ecoendoscopia melhora a acuidade da radioterapia estereotáxica corporal na delineação do alvo. O hidrogel, um novo líquido injetável com visibilidade multimodal recentemente aprovado como marcador fiducial, está atualmente em investigação como um espaçador injetado por ecoendoscopia no cancro da cabeça do páncreas para potencialmente reduzir a toxicidade da radioterapia estereotáxica corporal sobre a parede gastrointestinal. Neste artigo, o GRUPUGE apresenta uma perspetiva atualizada destas duas técnicas guiadas por ecoendoscopia, abordando as suas atuais aplicações clínicas e aspetos técnicos e analisando os dados existentes sobre a sua eficácia e segurança.

The Role of Endoscopic Ultrasound in Pancreatic Cancer Staging in the Era of Neoadjuvant Therapy and Personalised Medicine.

Precise staging of pancreatic cancer is crucial for treatment choice. In clinical practice, this includes the TNM staging and determination of tumour resectability, based on a multimodality imaging workup. International guidelines recommend multi-detector computed tomography (CT), with a dedicated pancreatic protocol, as the first-line tool for TNM staging and evaluation of tumour-vessel relationships. In non-metastatic disease upon initial CT assessment, both magnetic resonance imaging and endoscopic ultrasound (EUS) may add relevant information, potentially changing treatment sequence. EUS may have distinct advantages in pancreatic cancer diagnosis and staging when compared with other modalities, being particularly valuable in the determination of portal venous confluence involvement (particularly in small and ill-defined/isoattenuating tumours on CT), in locoregional nodal staging and in the detection of ascites. As we step forward to a more frequent use of neoadjuvant chemotherapy and to personalised medicine, the importance of EUS-guided fine-needle biopsy (EUS-FNB) also increases. The recent availability of third-generation biopsy needles significantly increased the diagnostic yield of EUS-guided tissue acquisition, providing diagnostic cell blocks in approximately 95% of cases with only two dedicated passes and allowing ancillary testing, such as immunohistochemistry and molecular profiling of the tumour. In this article, the authors present an updated perspective of the place of EUS and EUS-FNB in the staging algorithm of pancreatic cancer. Data supporting the increasing role of neoadjuvant therapy and the importance of a patient-tailored treatment selection, based on tumoural subtyping and molecular profiling, are also discussed.

No cancro do pâncreas é fundamental um estadiamento preciso para a decisão terapéutica. Na prática clínica, istoinclui o estadiamento TNM e a avahação da ressecabilidade cirúrgica, baseada numa avahação imagiológica multimodal. As recomendações de consenso recomendam a tomografia computorizada (TC) multi-detector, com protocolo pancreático, como exame de primeira linha para o estadiamento TNM e determinação de invasão vascular loco-regional. Na doença loco-regional não-metastática (após TC inicial), a ressonância magnética e a ecoendoscopia poderão acrescentar informação relevante, com potencial impacto na decisão terapéutica. A ecoendoscopia apresenta vantagens únicas comparativamente a outros métodos de estadiamento, sendo particularmente útil na avahação da relação do tumor com a confluência espleno-portal (especialmente na presença de tumores pequenos e isodensos/mal-definidos na TC), no estadiamento ganglionar loco-regional (N) e na detecção de ascite. À medida que caminhamos no sentido da utilização crescente de quimioterapia neoadjuvante e da Medicina personalizada, a relevância da biopsia guiada por ecoendoscopia também aumenta. A recente disponibilização de agulhas de biopsia de terceira geração aumentou significativamente a rentabilidade diagnóstica da punção guiada por ecoendoscopia, obtendo cell-blocks para avahado histológica em cerca de 95% dos casos (com apenas duas passagens), permitindo a realização de estudos ancilares, como avahação imuno-histoquímica e caracterização molecular do tumor. No presente artigo os autores apresentam uma perspetiva do papel atual da ecoendoscopia e da biopsia guiada por ecoendoscopia no algoritmo de estadiamento do cancro do páncreas. É ainda analisada a evidência atual que favorece o papel crescente da terapéutica neoadjuvante e a importância da seleção individualizada do tratamento, baseada na definição do subtipo de tumor e na caracterizado molecular.

Endoscopic Ultrasound-Guided Ablation of Focal Pancreatic Lesions: The GRUPUGE Perspective.

Focal pancreatic lesions include a heterogeneous group of solid and cystic lesions, with different natures and variable clinical, imagiological, and pathological characteristics. Several endoscopic ultrasound (EUS)-guided ablative techniques have been tested during the last decade for the treatment of these pancreatic lesions, mostly consisting of the injection of ablative agents and, more recently, radiofrequency ablation. The most encouraging EUS-guided ablation outcomes are being reached in the treatment of some pancreatic cystic neoplasms and small (≤2 cm) pancreatic neuroendocrine tumours (pNETs). Data supporting a potential role of ablative therapies in the treatment of pancreatic ductal adenocarcinoma is still lacking. In this article, GRUPUGE presents an updated perspective of the potential role of EUS-guided ablation for the treatment of pancreatic cystic neoplasms and pNETs, addressing the selection criteria and technical issues of different techniques and analysing recent data on their safety and efficacy.

As lesões focais do pâncreas integram grupos heterogéneos de lesões sólidas e quísticas, de diferentes naturezas e com características clínicas, imagiológicas e patológicas variáveis. Na última década foram avaliadas diversas técnicas ablativas guiadas por ecoendoscopia para o tratamento destas lesões pancreáticas focais, consistindo maioritariamente na injeção de agentes ablativos e, mais recentemente, na ablação por radiofrequência. Os resultados mais promissores das técnicas ablativas guiadas por ecoendoscopia têm surgido no tratamento de algumas lesões quísticas do pâncreas e pequenos tumores neuro-endócrinos pancreáticos (≤2 cm). Ainda existem poucos dados a suportar um potencial papel das terapêuticas ablativas no tratamento do adenocarcinoma ductal do pancreas. No presente artigo o GRUPUGE apresentada uma perspectiva atual do potencial papel da ablação guiada por ecoendoscopia no tratamento de neoplasias quísticas do pâncreas e de tumores neuro-endócrinos pancreáticos, focando aspectos relativos à seleção dos doentes, questões técnicas dos vários procedimentos disponíveis e analisando dados recentes relativos à sua segurança e eficácia.

Estimating the Impact of Switching from a Lower to Higher Valent Pneumococcal Conjugate Vaccine in Colombia, Finland, and The Netherlands: A Cost-Effectiveness Analysis.

INTRODUCTION: Widespread use of ten-valent (Synflorix™, GSK) or 13-valent (Prevenar 13™; Pfizer) conjugate vaccination programs has effectively reduced invasive pneumococcal disease (IPD) globally. However, IPD caused by serotypes not contained within the respective vaccines continues to increase, notably serotypes 3, 6A, and 19A in countries using lower-valent vaccines. Our objective was to estimate the clinical and economic benefit of replacing PCV10 with PCV13 in Colombia, Finland, and The Netherlands. METHODS: Country-specific databases, supplemented with published and unpublished data, informed the historical incidence of pneumococcal disease as well as direct and indirect medical costs. A decision-analytic forecasting model was applied, and both costs and outcomes were discounted. The observed invasive pneumococcal disease (IPD) trends from each country were used to forecast the future number of IPD cases given a PCV13 or PCV10 program. RESULTS: Over a 5-year time horizon, a switch to a PCV13 program was estimated to reduce overall IPD among 0-2 year olds by an incremental - 37.6% in Colombia, - 32.9% in Finland, and - 26% in The Netherlands, respectively, over PCV10. Adults > 65 years experienced a comparable incremental decrease in overall IPD in Colombia (- 32.2%), Finland (- 15%), and The Netherlands (- 3.7%). Serotypes 3, 6A, and 19A drove the incremental decrease in disease for PCV13 over PCV10 in both age groups. A PCV13 program was dominant in Colombia and Finland and cost-effective in The Netherlands at 1 × GDP per capita (€34,054/QALY). CONCLUSION: In Colombia, Finland, and The Netherlands, countries with diverse epidemiologic and population distributions, switching from a PCV10 to PCV13 program would significantly reduce the burden of IPD in all three countries in as few as 5 years.

GRUPUGE Perspective: Endoscopic Ultrasound-Guided Drainage of Peripancreatic Collections.

Pancreatic and peripancreatic collections (PPC) are a known complication of acute pancreatitis. They are categorized into four types of collection: (1) acute peripancreatic fluid collection, (2) pseudocyst, (3) acute necrotic collection and (4) walled-off necrosis. Most PPC resolve spontaneously or are persistent but asymptomatic. Intervention is needed in a minority of patients with infected or symptomatic collection. Endoscopic ultrasound-guided transmural drainage is currently the first-line treatment option for PPC management. It has shown great technical and clinical success, similar to percutaneous or surgical approaches, but with lower morbidity and costs and better quality of life. In this review article, the GRUPUGE presents an updated perspective on the potential role of endoscopic ultrasound-guided drainage of peripancreatic collections, addressing the selection criteria and the technical issues of different techniques and analysing emerging data on their efficacy and safety.

As coleções pancreáticas e peripancreáticas constituem uma complicação conhecida de pancreatite aguda. As coleções são classificadas em quatro tipos: (1) coleção líquida peripancreática aguda, (2) pseudoquisto, (3) coleção necrótica aguda e (4) coleção necrótica encapsulada (walled-off necrosis). A maioria das coleções peripancreáticas resolvem espontaneamente ou mantém-se assintomáticas. A drenagem está indicada numa minoria de doentes em que a coleção infecta ou se torna sintomática. A drenagem de coleções peripancreáticas guiada por ecoendoscopia é atualmente considerada a primeira linha de tratamento. Os procedimentos guiados por ecoendoscopia têm mostrado uma elevada taxa de sucesso técnico e clínico, semelhante às abordagens cirúrgica e percutânea, mas está associada a menor morbilidade e custos e a melhor qualidade de vida. Neste artigo de revisão, o GRUPUGE apresenta uma perspetiva atualizada do papel da ecoendoscopia na drenagem de coleções peripancreáticas, abordando critérios de seleção e questões técnicas relativas aos diferentes procedimentos, e analisando os dados disponíveis sobre a sua eficácia e segurança.

Endoscopic Ultrasound-Guided Celiac Plexus Interventions.

Abdominal pain related to pancreatic disease is often extremely disabling. Endoscopic ultrasound (EUS)-guided celiac plexus block (CPB) is used to control pain associated with chronic pancreatitis. EUS-guided celiac plexus neurolysis (CPN) is typically used to reduce pain associated with pancreatic cancer and can be considered early at the time of diagnosis of inoperable disease. EUS-guided celiac plexus interventions have been shown to be significantly effective in pancreatic pain relief, which is achieved in approximately 70-80% of patients with pancreatic cancer and in 50-60% of those with chronic pancreatitis. Serious complications from CPB and CPN are rare. Most frequent adverse events are diarrhoea, orthostatic hypotension, and a transient increase in abdominal pain. In this article, the Portuguese Group for Ultrasound in Gastroenterology (GRUPUGE) presents an updated perspective of the potential role of EUS-guided celiac plexus interventions, addressing the selection criteria and technical issues of different techniques and analysing recent data on their safety and efficacy.

A dor abdominal relacionada com doença pancreática pode ser extremamente incapacitante. O bloqueio do plexo celíaco (CPB) guiado por ecoendoscopia (EUS) é utilizado para controlo da dor associada à pancreatite crónica. A neurólise do plexo celíaco (CPN) guiada por EUS é utilizada na terapêutica da dor associada ao cancro do pâncreas, podendo ser utilizada numa fase precoce, após o diagnóstico de doença irressecável. As intervenções no plexo celíaco guiadas por EUS demonstraram ser eficazes no alívio da dor. O sucesso terapêutico é alcançado em aproximadamente 70 a 80% dos pacientes com cancro do pâncreas, e em 50 a 60% dos pacientes com pancreatite crónica. São raras as complicações severas associadas a CPB e CPN. Os eventos adversos mais frequentemente documentados correspondem a diarreia, hipotensão ortostática e a aumento transitório da dor abdominal. Neste artigo, o GRUPUGE apresenta uma perspetiva das intervenções no plexo celíaco guiadas por EUS, onde se abordam os critérios de seleção, questões técnicas relativas aos procedimentos e se analisam os dados sobre sua segurança e eficácia.

Integrated Process for Bioenergy Production and Water Recycling in the Dairy Industry: Selection of Kluyveromyces Strains for Direct Conversion of Concentrated Lactose-Rich Streams into Bioethanol.

Dairy industries have a high environmental impact, with very high energy and water consumption and polluting effluents. To increase the sustainability of these industries it is urgent to implement technologies for wastewater treatment allowing water recycling and energy savings. In this study, dairy wastewater was processed by ultrafiltration and nanofiltration or ultrafiltration and reverse osmosis (UF/RO) and retentates from the second membrane separation processes were assessed for bioenergy production. Lactose-fermenting yeasts were tested in direct conversion of the retentates (lactose-rich streams) into bioethanol. Two Kluyveromyces strains efficiently fermented all the lactose, with ethanol yields higher than 90% (>0.47 g/g yield). Under severe oxygen-limiting conditions, the K. marxianus PYCC 3286 strain reached 70 g/L of ethanol, which is compatible with energy-efficient distillation processes. In turn, the RO permeate is suitable for recycling into the cleaning process. The proposed integrated process, using UF/RO membrane technology, could allow water recycling (RO permeate) and bioenergy production (from RO retentate) for a more sustainable dairy industry.

Experience of a Portuguese Center: Effectiveness of Direct-Acting Antiviral Therapy for Hepatitis C.

INTRODUCTION: In late 2014, Portugal implemented a national program for the treatment of patients with chronic hepatitis C with directacting antiviral agents. This program has made Portugal one of the first European countries to implement a structured measure of treatment to eliminate this serious public health problem. The aim of this study was to assess the effectiveness of direct-acting antiviral therapy in the treatment of patients with chronic hepatitis C virus infection. MATERIAL AND METHODS: A retrospective observational study was conducted at Centro Hospitalar de Lisboa Ocidental on the national online platform from December 2014 until February 2017 and included patients with hepatitis C virus infection who underwent treatment. The primary endpoint was sustained virologic response at least 12 weeks post treatment. Data was analyzed with the SPSS 17.0 program. RESULTS: During the study period, 820 patients completed therapy and achieved sufficient follow-up time to assess sustained virologic response with an overall response rate of 97.2% (n = 797) and a response rate of 98.0%, 99.5%, 90.9%, 95.1% and 94.2% for genotypes 1a, 1b, 2, 3 and 4, respectively. Data suggested that advanced fibrosis (F3/F4), human immunodeficiency virus co-infection and treatment failure with interferon and ribavirin were not negatively related with sustained virologic response in our population. Most patients (80.1%) completed treatment with ledipasvir/sofosbuvir ± ribavirin. The most common adverse events were fatigue and insomnia followed by headache and weight loss. DISCUSSION: Patients predominantly had genotype 1 infection which correlates with HCV distribution in Europe, but we found a major proportion in genotype 4 which can be explained by immigration from African countries. Our patients' ages ranging from 22 to 90 years, reflected a new approach with no upper age limit. Direct-acting antivirals regimens resulted in remarkably high SVR rates compared to interferon-based regimens, which were consistent with clinical trials data. CONCLUSION: Our data showed that direct-acting antiviral-based regimens are safe and have a high success rate in the treatment of patients with hepatitis C virus infection in a real-world setting.

Introdução: No final de 2014 foi implementado em Portugal um programa nacional para o tratamento de doentes com infecção crónica por vírus da hepatite C com recurso a antivíricos de acção directa. Este programa fez com que Portugal fosse um dos primeiros países europeus a implementar uma medida estruturante para a eliminação da hepatite C. Este estudo tem como objectivo a avaliação da efectividade dos antivíricos de acção directa no tratamento da hepatite C crónica. Material e Métodos: Estudo retrospectivo observacional dos doentes seguidos no Centro Hospitalar de Lisboa Ocidental, entre dezembro de 2014 e fevereiro de 2017. O objectivo primário do estudo é avaliar a resposta virológica sustentada a partir das 12 semanas pós tratamento. Analisámos os dados com o programa SPSS 17.0. Resultados: Durante o período do estudo 820 doentes completaram o tratamento e o tempo necessário para avaliação da resposta virológica sustentada. A resposta virológica sustentada global foi de 97.2% (n = 797), com taxas de resposta de 97,2%, 98,5%, 90,9%, 95,1% e 94,2% para os genótipos 1a, 1b, 2, 3 e 4, respectivamente. Os dados sugerem não haver relação entre a fibrose avançada (F3 / F4), a coinfecção pelo vírus da imunodeficiência humana e a falência do tratamento com interferão e ribavirina e uma menor resposta ao tratamento. A maioria dos doentes (80,1%) concluiu o tratamento com ledipasvir/sofosbuvir ± ribavirina. Os eventos adversos mais frequentes foram a fadiga e a insónia, seguida de dor de cabeça e perda de peso. Discussão: A população em estudo apresentou maior prevalência de infecção pelo genótipo 1, à semelhança dos restantes países Europeus, contudo a prevalência do genótipo 4 foi superior, reflectindo a imigração africana. A faixa etária (22 - 90 anos) dos doentes tratados reflecte uma nova abordagem sem limite superior de idade. A taxa de RVS obtida, muito superior à obtida com regimes baseados em interferão, foi consistente com os dados dos ensaios clínicos. Conclusão: Os dados encontrados demonstram que os regimes baseados em antivirais de acção directa, em contexto de vida real, são seguros e eficazes no tratamento de doentes com infecção por vírus da hepatite C.