Catarina Brandão

Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

MAIN RECOMMENDATIONS The following recommendations for post-polypectomy endoscopic surveillance should be applied only after a high quality baseline colonoscopy with complete removal of all detected neoplastic lesions.1 In the low risk group (patients with 1 - 2 tubular adenomas < 10 mm with low grade dysplasia), the ESGE recommends participation in existing national screening programmes 10 years after the index colonoscopy. If no screening programme is available, repetition of colonoscopy 10 years after the index colonoscopy is recommended (strong recommendation, moderate quality evidence). 2 In the high risk group (patients with adenomas with villous histology or high grade dysplasia or ≥10 mm in size, or ≥ 3 adenomas), the ESGE recommends surveillance colonoscopy 3 years after the index colonoscopy (strong recommendation, moderate quality evidence). Patients with 10 or more adenomas should be referred for genetic counselling (strong recommendation, moderate quality evidence). 3 In the high risk group, if no high risk adenomas are detected at the first surveillance examination, the ESGE suggests a 5-year interval before a second surveillance colonoscopy (weak recommendation, low quality evidence). If high risk adenomas are detected at first or subsequent surveillance examinations, a 3-year repetition of surveillance colonoscopy is recommended (strong recommendation, low quality evidence).4 The ESGE recommends that patients with serrated polyps < 10 mm in size with no dysplasia should be classified as low risk (weak recommendation, low quality evidence). The ESGE suggests that patients with large serrated polyps (≥ 10 mm) or those with dysplasia should be classified as high risk (weak recommendation, low quality evidence).5 The ESGE recommends that the endoscopist is responsible for providing a written recommendation for the post-polypectomy surveillance schedule (strong recommendation, low quality evidence).

Functional polymorphisms of Toll-like receptors 2 and 4 alter the risk for colorectal carcinoma in Europeans

BACKGROUND Colon carcinogenesis is associated with increased expression levels of Toll-like receptor 2 and Toll-like receptor 4. AIM To determine in a Caucasian population the role of Toll-like receptor 2 and Toll-like receptor 4 polymorphisms in colorectal cancer development. METHODS Hospital based multicentre case control study involving 193 colorectal cancer patients and 278 healthy individuals. DNA samples were extracted from blood cells and genotyping of TLR2+597T>C, TLR2-4760T>C, TLR4-3745A>G, TLR2Arg753Gln, TLR4Asp299Gly was performed. Functionality of risk polymorphisms was evaluated through production of TNF-α in cell culture and Toll-like receptors levels quantified by real-time RT-PCR. RESULTS TLR2+597CC homozygous had 5-fold decreased risk (odds ratio (OR)=0.21, 95% CI: 0.09-0.50, p<0.001) and TLR4 299Gly homozygous 3-fold increased risk of colorectal cancer (OR=3.30, 95% CI: 1.18-9.28, p=0.015). In stratified analysis, TLR2+597CC genotype protective effect was even higher in overweight individuals (OR=0.17, 95% CI: 0.06-0.53, p<0.001) and in never smokers (OR=0.11, 95% CI: 0.02-0.51, p=0.001). Also, the increased risk effect for TLR4 299Gly homozygous genotype was higher in overweight individuals (OR=8.67, 95% CI: 1.11-87.85, p=0.011). TLR2+597T>C polymorphism conferred 41% less (p=0.03) and TLR4Asp299Gly 65% more TNF-α production (p=0.02) with no differences in Toll-like receptors levels. CONCLUSION Functional Toll-like receptor 2 and Toll-like receptor 4 polymorphisms significantly alter the risk to have colorectal cancer. Obesity and smoking may influence the risk for colorectal cancer in individuals presenting these genetic profiles.

Validation of a Fluorescence In Situ Hybridization Method Using Peptide Nucleic Acid Probes for Detection of Helicobacter pylori Clarithromycin Resistance in Gastric Biopsy Specimens

ABSTRACT Here, we evaluated a previously established peptide nucleic acid-fluorescence in situ hybridization (PNA-FISH) method as a new diagnostic test for Helicobacter pylori clarithromycin resistance detection in paraffin-embedded gastric biopsy specimens. Both a retrospective study and a prospective cohort study were conducted to evaluate the specificity and sensitivity of a PNA-FISH method to determine H. pylori clarithromycin resistance. In the retrospective study (n = 30 patients), full agreement between PNA-FISH and PCR-sequencing was observed. Compared to the reference method (culture followed by Etest), the specificity and sensitivity of PNA-FISH were 90.9% (95% confidence interval [CI], 57.1% to 99.5%) and 84.2% (95% CI, 59.5% to 95.8%), respectively. In the prospective cohort (n = 93 patients), 21 cases were positive by culture. For the patients harboring clarithromycin-resistant H. pylori, the method showed sensitivity of 80.0% (95% CI, 29.9% to 98.9%) and specificity of 93.8% (95% CI, 67.7% to 99.7%). These values likely represent underestimations, as some of the discrepant results corresponded to patients infected by more than one strain. PNA-FISH appears to be a simple, quick, and accurate method for detecting H. pylori clarithromycin resistance in paraffin-embedded biopsy specimens. It is also the only one of the methods assessed here that allows direct and specific visualization of this microorganism within the biopsy specimens, a characteristic that allowed the observation that cells of different H. pylori strains can subsist in very close proximity in the stomach.

Genetic Variability in Key Genes in Prostaglandin E2 Pathway (COX-2, HPGD, ABCC4 and SLCO2A1) and Their Involvement in Colorectal Cancer Development

The pro-carcinogenic effects of prostaglandin E2 (PGE2) in colonic mucosa are not only regulated by the rates between Cyclooxygenase-2 (COX-2) biosynthesis and 15-Hydroxyprostaglandin Dehydrogenase (15-PGDH)-dependent degradation but also the steady-state levels of PGE2 in extracellular microenvironment, maintained by key specific prostaglandin transporters, the Multidrug Resistance Protein (MRP4) (efflux carrier) and Prostaglandin Transporter (PGT) (influx carrier). To understand the contribution of genetic variability in genes coding for COX-2/15-PGDH/MRP4/PGT proteins in CRC development, we conducted a hospital-based case-control study involving 246 CRC patients and 480 cancer-free controls. A total of 51 tagSNPs were characterized using the Sequenom platform through multiplexed amplification followed by mass-spectrometric product separation or allelic discrimination using real-time PCR. Seven tagSNPs were implicated in CRC development: the rs689466 in COX-2 gene, the rs1346271 and rs1426945 in 15-PGDH, the rs6439448 and rs7616492 in PGT and rs1751051 and rs1751031 in MRP4 coding genes. Upon a stratified analysis a measurable gene-environment interaction was noticed between rs689466 and smoking habits, with individuals ever-smokers carriers of rs689466 GG homozygous genotype having a nearly 6-fold increased susceptibility for CRC onset (95%CI: 1.49–22.42, P = 0.011). Furthermore, the multifactor dimensionality reduction (MDR) analysis identified an overall four-factor best gene-gene interactive model, including the rs1426945, rs6439448, rs1751051 and rs1751031 polymorphisms. This model had the highest cross-validation consistency (10/10, P<0.0001) and an accuracy of 0.6957 and was further associated with a 5-fold increased risk for CRC development (95%CI: 3.89–7.02, P<0.0001). In conclusion, specific low penetrance genes in the pro-carcinogenic PGE2 pathway appear to modulate the genetic susceptibility for CRC development. A clearer understanding on CRC etiology through the identification of biomarkers of colorectal carcinogenesis might allow a better definition of risk models that are more likely to benefit from targeted preventive strategies to reduce CRC burden.

Abdominal haematoma--a mesotherapy complication.

Sir, Mesotherapy is a treatment directed at the mesodermderived tissues (bone, fat, muscle, cartilage) by injection of multiple compounds. Since first described by Pistor (1), it has been used for multiple purposes such as musculoskeletal and dermatological pathologies, aesthetics and chronic pain (2). In the last few years some side effects have been described (3). The utility of mesotherapy in the treatment of localized obesity is increasing because of its vasodilator and lipolytic potential (4). A major complication resulting after mesotherapy in the treatment of localized obesity is reported here.

Using NVivo to assess a program of goal-corrected empathic attunement skills: a case study in the context of higher education

This paper focuses on the use of NVivo10 in the process of assessing a developmental program in goal-corrected emphatic attunement skills in the context of a psychology master’s program course. The authors present the way the software supported this work and discuss how it enabled a process of moving closer to and distancing themselves from the data. The possibility to analyse data in different perspectives—cross-sectional and longitudinal—is also discussed, using qualitative research and analysing different groups of participants (cases) and different years of the program as the project research questions evolved.

P. Bazeley and K. Jackson, Qualitative Data Analysis with NVivo (2nd ed.)

This is a “how to” book by two experienced researchers, with vast experience in qualitative research and NVivo, sharing many of the strategies and tips they learned while doing research and using the software, and which can certainly enhance the work of those who are interested in qualitative research with NVivo. Pat Bazeley and Kristi Jackson present these strategies using accessible and engaging language. The book offers support on methodology and technology, declaring itself methodfree—in other words, not holding itself to a particular approach. It shows that NVivo (version 10) has evolved into more than just a tool that stores and retrieves information, becoming open to different methods and data and showing how the software can be used from the first steps of the research. The first three chapters serve as an introduction to NVivo and to the (fundamental) idea that, as Bazeley and Jackson stress, the software should follow the research design and not lead it. In Chapter 1, the authors emphasize the importance of choosing methods according to the researcher’s purpose and how qualitative data analysis software (QDA) assists the researcher in knowing data, enabling the exercise of closeness and distance toward the data (borrowing the concept from Richards 1998) and that the use of QDA enables much more than the simple (but important) mechanization of routine tasks (such as coding according to certain criteria). Bazeley and Jackson take the reader on a guided tour of an NVivo sample project and, at the same time, present the software’s tools. By showing how the sample project is structured and possible ways to analyse it, the authors present a framework that helps readers understand how the different phases and elements of a research project can be realized in NVivo. Chapter 2 shows how the software can assist the definition of research questions and, by focusing on memos and journals, highlights the importance of thinking research from day one, putting thoughts and hypotheses on paper (i.e., on an NVivo memo). This is crucial in qualitative research and can be very helpful in latter phases of the research process, namely, when working in a team or writing about the research. In the first three chapters the authors cover the basics that researchers should consider before proceeding to coding in order to enhance the research process using the software. Chapters 4 and 5 focus on coding, moving from basic to more advanced questions, such as building theory on the basis of the fundamental process of coding. In Chapter 6, the authors explore the concept of cases (dear to many researchers working with NVivo’s previous versions), which enables better representation of the units of analysis of the project and, when important to the researcher, comparing and then using

In Case of Doubt See the Manual: A Comparative Analysis of (Self)Learning Packages Qualitative Research Software

One of the first precautions that a consumer/user has when acquiring a new product is related to how to use it. In this context, the user manuals can be assumed as one of the main communication channels between the companies that develop the products and the user. Regarding the use of software packages, literature indicates that one of the decisive factors for user’s dissatisfaction is related to the difficulty in learning how to work with a software. In this context, Qualitative Data Analysis Software (QDAS) enterprises are increasingly looking to develop features that can decrease user’s learning curve of their tools. In this way, this chapter illustrates a comparison of user support features, such as: support and typology of the User Manual; Training; Tutorials; Forums; Frequently asked questions (FAQ’s); Workshops. Through a systematic exploration of the native sites guided by a dedicated checklist, it was sought to identify the singularities of the resources to support (self)learning of the different software packages. In order to systematize the offers that each user can find, enabling him/her to choose the package that provides the solutions that best respond to his/her learning style. It was concluded that among the different software packages there are no noteworthy disparities, only in two packages analysed there were shortcomings in the offer of formative and autonomous learning.

Perforated Gastric Ulcer Associated with Anti-Angiogenic Therapy

Anti-angiogenic therapy with bevacizumab, an inhibitor of vascular endothelial growth factor, is commonly used in metastatic colorectal cancer and is rarely associated with gastrointestinal perforation, perforation being more frequent in the primary tumor site or at the anastomotic level. We present the case of a 64-year-old male with stage IV rectal adenocarcinoma who was on palliative chemotherapy with FOLFOX and bevacizumab. After the 4th chemotherapy cycle, our patient started fever and epigastric pain. He was hemodynamically stable, and signs of peritoneal irritation were absent. There were no alterations in the abdominal X-ray, and C-reactive protein was markedly elevated. A CT scan revealed a de novo thickness in the gastric antrum. Upper digestive endoscopy showed an ulcerated 40-mm lesion in the angulus, with a 20-mm orifice communicating with an exsudative cavity revested by the omentum. A conservative approach was decided including fasting, broad-spectrum intravenous antibiotics, and proton-pump inhibitors. Subsequent gastroduodenal series showed no contrast extravasation, allowing the resumption of oral nutrition. Esophagogastroduodenoscopy after 8 weeks showed perforation closure. Biopsies did not show neoplastic cells or Heliobacter pylori infection. Although the success in the conservative management of perforation allowing the maintenance of palliative chemotherapy (without bevacizumab), the patient died after 4 months due to liver failure. The reported case shows an uncommon endoscopic finding due to a rare complication of anti-angiogenic therapy. Additionally, it reminds clinicians that a history of gastroduodenal ulcers should be actively sought before starting anti-angiogenic treatment and that suspicion for perforation should be high in these cases.

Millennials’ Representations Regarding Cohabitation: A Qualitative Exploratory Study

This study focus on the representations of Millennials regarding cohabitation, the challenges associated to the process of transitioning to live with a partner and the strategies to use in order to manage cohabitation successfully. A qualitative exploratory study was conducted using an online questionnaire and a semi-structured interview with a couple cohabitating. Data was analyzed using qualitative thematic analysis with the support of NVivo11. Results suggest the importance of communication and planning before transitioning to cohabitation, as well as ensure space for oneself. Workload, financial management, coping with the routine and housework are anticipated as challenges. The couple’s experience is coherent with many of the representations regarding cohabitation. Curiously enough, social support was absent in the questionnaire data, but is experienced as fundamental by the couple. Knowing what Millennials think regarding cohabitation allows understanding how they approach this new chapter in life.