Disturbed by a sandfly: visceral leishmaniasis in ileal Crohn´s disease under combined immunosuppression.

This case reports illustrates a 44-year-old Caucasian male with ileal Crohn´s disease under combined immunosuppression that first presented with unspecific constitutional symptoms, newly pancytopenia and elevated inflammatory markers. The infectious screening was negative except for an ileal abscess that resolved with conservative antibiotic therapy. Due to concerns for lymphoproliferative disease in a patient under anti-TNF and azathioprine, a myelogram was performed that ruled out dysplastic changes. After abscess resolution the symptoms relapsed with evening fever, nocturnal sudoresis and worsen pancytopenia. A more thorough work-up was performed with bone marrow and ileal biopsies that demonstrated numerous intra-and-extracellular leishmania amastigote forms, which confirmed the diagnosis of visceral leishmaniasis infiltrating the small bowel. The patient recovered after adequate treatment and withheld of immunosuppression during follow-up.

Fecal occult blood and calprotectin testing to prioritize primary care patients for colonoscopy referral: The advantage study.

BACKGROUND: Colonoscopy is the gold standard for colorectal cancer (CRC) diagnosis and screening, but endoscopy services are usually overburdened. This study aims to investigate the usefulness of fecal hemoglobin (fHb) and calprotectin (FC) for the identification of patients with high probability of CRC who need urgent referral. METHODS: In a multicenter prospective study, we enrolled symptomatic patients referred from primary care for colonoscopy. Prior to bowel preparation, fHb and FC quantitative tests were performed. The diagnostic performance was estimated for each biomarker/combination. We built a multivariable predictive model based on logistic regression, translated to a nomogram and a risk calculator to assist clinicians in the decision-making process. RESULTS: The study included 1224 patients, of whom 69 (5.6%) had CRC. At the fHb cut-offs of >0 and 10 µg/g, the negative predictive values for CRC were 98.8% (95% confidence interval 97.8%-99.3%) and 98.6% (95%CI 97.7%-99.1%), and the sensitivities were 85.5% (95%CI 75.0%-92.8%) and 79.7% (95%CI 68.3%-88.4%), respectively. When we added the cut-off of 150 µg/g of FC to both fHb thresholds, the sensitivity of fecal tests improved. In the multivariate logistic regression model, the concentration of fHb was an independent predictor for CRC; age and gender were also independently associated with CRC. CONCLUSIONS: fHb and FC are useful as part of a triage tool to identify those symptomatic patients with high probability of CRC. This can be easily applied by physicians to prioritize high-risk patients for urgent colonoscopy.

Clinical Nutrition in Portuguese Gastroenterology Departments: A Multicentric Study.

BACKGROUND: Hospital nutrition is a major public health problem, as up to 50% of hospitalized patients suffer from undernutrition. Adequate nutritional support (NS) decreases morbidity/mortality, shortens the length of stay, and reduces costs. We aimed to evaluate the engagement of Portuguese gastroenterology departments in NS, especially in artificial nutrition (AN). METHODS: Cross-sectional multicentric study, using an online survey sent to 31 Portuguese gastroenterology departments. RESULTS: Nine centers were involved, and all departments were engaged in NS activities. The most performed nutrition technique was endoscopic gastrostomy and not all departments had the expertise to perform all nutrition procedures, namely, endoscopic jejunostomy. Two departments had an AN outpatient clinic. Five centers were involved in hospital nutrition committees. Only four performed systematic nutritional evaluation of every patient on admission. Two departments developed research in the nutrition field. An increase staff and nutrition training were pointed out as suggestions to improve NS. CONCLUSIONS: This study outlines a broad picture of NS/AN in Portuguese gastroenterology departments. Medical nutritional training and increasing nutrition teams' staff may contribute to developing NS/AN. Multidisciplinary management of nutrition-related disorders is of utmost importance, and gastroenterologists are expected to be at the core of hospital nutrition.

Nursing supervised curricular internship in the Covid-19 pandemic: experience in the program Brasil Conta Comigo.

OBJECTIVE: To report the experience of the nursing supervised curricular internship in the program "O Brasil Conta Comigo" carried out in the Covid-19 pandemic. METHOD: Experience report of activities developed in Primary Health Care in a municipality in the southern region of the state of Goiás during the Covid-19 pandemic, from April to November 2020. RESULTS: The inclusion in the government program allowed the strengthening of the student's active role in the teaching-learning process and teaching-service approximation, with the student as the point of connection, which resulted in the implementation of actions for the fight against the pandemic in the municipality, such as elaboration, implementation, and evaluation of the service flowchart for people with suspected Covid-19. CONCLUSION: The experience was successful, as it consolidated knowledge regarding leadership and autonomy, integration between theory and practice, critical thinking, and evidence-based problem solving. The participation in the program allowed for contributions to assistance and management in the actions to combat the new coronavirus in the scope of primary care, as well as for the contribution to the training of the student tutored by nurses in the field and supervised by professors from the federal university of origin.

The Effect of Hyperbaric Oxygen Therapy on Rectal Ulcers after Argon Plasma Coagulation.

Chronic radiation proctitis usually develops 3 months after therapy. Despite the lack of standard guidelines regarding treatment, argon plasma coagulation is often a safe and effective endoscopic therapy. However, rectal ulcers are a common complication after argon plasma coagulation. Nevertheless, most patients are asymptomatic and do not require additional monitoring or treatment. We report a case of an argon plasma coagulation-induced ulcer with relevant symptoms and refractory to medical treatment. The patient was treated with hyperbaric oxygen therapy and had complete resolution of the rectal ulcer. Hyperbaric oxygen therapy has shown efficacy in severe chronic proctitis and radiation-induced rectal ulcers, but no clinical report has ever been published on using hyperbaric oxygen therapy for ulcers after argon plasma coagulation. In this case, hyperbaric oxygen therapy was an effective alternative option and can be considered in patients with refractory argon plasma coagulation-induced rectal ulcers.

A proctite rádica crónica desenvolve-se habitualmente 3 meses após radioterapia. Não obstante a ausência de recomendações em relação ao tratamento desta patologia, a terapêutica endoscópica com árgon-plasma é segura e eficaz. Contudo, as úlceras retais são uma complicação frequente, apesar da maioria dos doentes serem assintomáticos e não requerem vigilância e/ou tratamento. Os autores apresentam um caso clínico de um doente com o diagnóstico de proctite rádica crónica, submetido a terapêutica com árgon-plasma com posterior desenvolvimento de úlcera retal refratária a tratamento médico conservador. O doente foi submetido a oxigenoterapia hiperbárica com resolução completa da úlcera retal. De acordo com a literatura, a oxigenoterapia hiperbárica apresenta eficácia na proctite rádica crónica grave e nas úlceras retais induzidas por radioterapia. Contudo, a utilização da oxigenoterapia hiperbárica nas úlceras retais secundárias a terapêutica com árgon-plasma ainda não foi descrita. Neste caso, a oxigenoterapia hiperbárica foi uma opção terapêutica eficaz, podendo ser considerada nas úlceras retais refratárias secundárias a terapêutica com argon-plasma.

Conselhos Municipais de Porto Alegre: Histórico e desafios na gestão democrática da cidade / Porto Alegre Municipal Councils: History and challenges in the democratic management of the city

Este livro foi concebido no contexto da revitalização do Fórum Municipal dos Conselhos da Cidade de Porto Alegre (FMCC), o qual buscou articular os conselhos de forma sistemática, desencadeando várias ações em prol do seu fortalecimento. Em 2018, o FMCC desenvolveu um seminário de planejamento participativo, uma pesquisa sobre a situação dos conselhos e um seminário de formação, em parceria com a Universidade Federal do Rio Grande do Sul. Nesse seminário, os conselhos puderam debater a conjuntura, as potencialidades e dificuldades de sua atuação como órgãos de controle social. Essa profícua parceria com a Universidade e a mobilização da maioria dos conselhos foram materializadas no presente livro, como instrumento de sistematização dos modos de atuação, das dificuldades e desafios, dos projetos e das potencialidades políticas dos conselhos da cidade. Este livro apresenta o registro das ações, as competências, as particularidades de cada conselho, ao mesmo tempo em que retrata o trabalho que o FMCC vem desenvolvendo nos últimos anos, buscando vincular os conselheiros e outros atores da cena política da cidade. Com o objetivo de disponibilizar um material que tornasse acessível o histórico e as especificidades de cada colegiado, este livro alçou mão de um empolgante e exitoso trabalho de produção textual junto aos conselhos da cidade, conduzido por membros do Grupo de Pesquisa Associativismo, Contestação e Engajamento (GPACE/UFRGS), que se dividiram para assessorar os coletivos na elaboração dos capítulos. Foi um processo muito bem sucedido, que resultou na elaboração de dezenove capítulos, cada um correspondente ao relato de um conselho, além de reflexões do FMCC, discutindo o percurso recente de mobilização e articulação destes atores, e um capítulo analítico, escrito por pesquisadores do GPACE, que analisaram os dados produzidos pelas pesquisas, pelas oficinas e pelos processos de escrita desencadeados para a construção deste livro. Todo o trabalho de revisão e composição foi construído coletivamente com a contribuição dos atores envolvidos, o que expressa a força do trabalho coletivo.

Prevalence and risk factors of fatty liver in Portuguese adults.

BACKGROUND: Prevalence of fatty liver (FL) and nonalcoholic fatty liver disease (NAFLD) depends mainly on obesity, diabetes and genetic factors. FL and NAFLD prevalence was evaluated in Portuguese adult population and correlated with several risk factors and related mortality data, within the same period. MATERIALS AND METHODS: A cross-sectional, population-based multicenter study, voluntary and randomly selected in 834 Portuguese adults (18-79 years). Participants were evaluated after 12-hour fasting. Anthropometric data, past history including alcohol consumption, and associated diseases were registered. Blood samples were collected for biochemical testing. Dietary intake was evaluated using a semi-quantitative food frequency questionnaire. Presence of FL was evaluated using ultrasound, and NAFLD was diagnosed after exclusion of other causes for liver disease. RESULTS: Adjusted prevalence of FL and NAFLD was 37.8% and 17.0%, respectively. FL individuals were older, more frequently males, with increased probability of having obesity, diabetes or harmful alcohol consumption (HAC). NAFLD individuals were also older, but had a similar sex distribution and an increased probability of obesity and diabetes. In both groups, no differences were found regarding dietary pattern or physical activity. During the same time period, nonalcoholic steatohepatitis (NASH) liver-related deaths in Portugal were 0.105/100 000, while alcohol-related liver disease mortality was 6.790/100 000. CONCLUSION: The large spectrum of FL was present in more than one third of the population, although only less than half could be classified as NAFLD. Other significant risk factors, such as HAC, are probably implicated in FL, explaining the low NASH-related mortality compared with the high alcohol-related mortality during the same time period.

What Is the Role of the New Index Relative Fat Mass (RFM) in the Assessment of Nonalcoholic Fatty Liver Disease (NAFLD)?

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) is the liver manifestation of adiposopathy. Recently, a new score was developed to estimate body fat percentage (relative fat mass, RFM). We aimed to evaluate the value of RFM in predicting the presence and severity of NAFLD, compared with other anthropometric measurements. METHODS: RFM, body mass index (BMI), and other anthropometric measurements were evaluated in two cohorts of subjects: a cohort from a Portuguese prospective epidemiological study (e_Cor) and morbidly obese patients with biopsy-proven NAFLD. We evaluated if RFM and BMI were related with the presence and severity of liver disease, which was assessed by noninvasive tools in the first cohort and by liver histology in the morbidly obese cohort. The independence of relations found in univariate analysis was assessed with multivariable logistic regression analysis. RESULTS: In the general population cohort, 744 subjects (48% male) were enrolled. BMI-defined obesity was present in 23% and RFM-defined obesity in 86%. Insulin resistance (IR) related with BMI-defined obesity (OR 4.37 [2.16-8.84]) and weight (OR 1.05 [1.02-1.08]) in men, and waist circumference (WC) (OR 1.07 [1.03-1.11]) in women. Dyslipidemia and hypertension related with RFM-defined obesity in men (OR 2.96 [1.36-6.47] and OR 5.37 [1.31-22.06], respectively). Ultrasound-diagnosed NAFLD in 33% related with weight in men (OR 1.03 [1.003-1.06] and WC in women (OR 1.06 [1.02-1.10]). In men, ALT elevation related with weight (OR 1.04 [1.02-1.07]). In women, advanced fibrosis (estimated by NAFLD Fibrosis Score) associated with BMI-defined obesity (OR 42.43 [3.61-498.13]). In the morbidly obese cohort, 152 subjects were enrolled, of whom 84% were female, 37% had steatohepatitis, and 9.4% had advanced fibrosis. Adiponectin associated inversely and leptin positively with RFM in men. The severity of steatosis increased linearly with BMI and WC in women. Higher BMI associated with steatohepatitis in women and advanced fibrosis in men. CONCLUSION: RFM-defined obesity better predicted dyslipidemia and hypertension (though not IR) and adipokine imbalance; however, it did not add value to BMI-defined obesity in predicting NAFLD or liver injury.

No Evidence for Lower Levels of Serum Vitamin D in the Presence of Hepatic Steatosis. A Study on the Portuguese General Population.

Introduction and aims: Nonalcoholic fatty liver disease (NAFLD) has become highly prevalent, paralleling the pandemic of obesity and diabetes, and represents an important burden. Nutrition knowledge is fundamental, in prevention, evolution and treatment of NAFLD. Association of low serum levels of vitamin D (VD) with several diseases, including NAFLD, has been emphasized in the last decade. We evaluated how serum levels of VD correlate with the presence of hepatic steatosis, and VD intake, in a random sample of the Portuguese adult population. Methods: Participants underwent a dietary intake inquiry, using a semi-quantitative food frequency questionnaire representative of the usual intake over the previous year. Anthropometric measures, blood tests and ultrasound were done. Hepatic steatosis was quantified according to Hamaguchi's ultrasonographic score (steatosis defined by a score ≥ 2). Results: We recruited 789 adult individuals, 416 males (52.7%), mean age of 49.9 ± 17.0 years (18-79). Prevalence of hepatic steatosis was 35.5%, and after exclusion of excessive alcohol consumption, 28.0%. Mean VD serum levels were 26.0 ± 9.8 ng/ml and 68.4% participants had serum VD levels below 30 ng/ml. Mean serum levels of VD were not significantly different between participants with steatosis vs. no steatosis: 25.2±8.7 vs. 26.4±10.3 ng/ml, respectively (p=0.071). There was no correlation between VD serum levels and VD intake, measured by the FFQ, r=0.075 (p= 0.383). Conclusions: In spite of a high prevalence rate, there was no evidence that decreased VD serum levels were associated with hepatic steatosis. No significant correlation was found between VD dietary ingestion and VD serum levels.

Bouveret's syndrome / Síndrome de bouveret

No disponible

Trichotillomania and trichophagia: the causes of Rapunzel syndrome

No disponible

Phenotype-genotype profiles in Crohn's disease predicted by genetic markers in autophagy-related genes (GOIA study II).

BACKGROUND: About 70 loci are associated with susceptibility to Crohn's disease (CD), particularly in pathways of innate immunity, autophagy, and pathogen recognition. Phenotype-genotype associations are inconsistent. METHODS: CD susceptibility polymorphisms ATG16L1 rs2241880, ICAM1 rs5498, IL4 rs2070874, IL17F rs763780, IRGM rs13361189, ITLN1 rs2274910, LRRK2 rs11175593, and TLR4 rs4986790 were genotyped in a Portuguese population (511 CD patients, 626 controls) and assessed for association with CD clinical characteristics. RESULTS: There is a significant association of CD with the single nucleotide polymorphisms (SNPs) in ATG16L1 (odds ratio [OR] 1.36 [1.15-1.60], P = 2.7 × 10(-6) for allele G), IRGM (OR 1.56 [1.21-1.93], P = 3.9 × 10(-4) for allele C), and ITLN1 (OR 1.55 [1.28-1.88], P = 4.9 × 10(-4) for allele C). These SNPs are associated with ileal location (OR, respectively, 1.49, 1.52, and 1.70), ileocolonic location (OR, respectively, 1.31, 1.57, and 1.68), and involvement of the upper digestive tract (OR, respectively for ATG16L1 and IRGM, 1.96 and 1.95). The risk genotype GG in ATG16L1 is associated with patients who respond to steroids (OR 1.89), respond to immunosuppressants (OR 1.77), and to biologic therapy (OR 1.89). The SNPs in ITLN1 and IRGM are both associated with a positive response to biologic therapy. The risk for ileal, ileocolonic, and upper digestive tract locations increases with the number of risk alleles (OR for three alleles, respectively, 7.10, 3.54, and 12.07); the OR for positive response to biologic therapy is 3.66. CONCLUSIONS: A multilocus approach using autophagy-related genes provides insight into CD phenotype-genotype associations and genetic markers for predicting therapeutic responses.