Denis Szejnfeld

Effect of 6-month nutritional intervention on non-alcoholic fatty liver disease.

OBJECTIVE We evaluated the effect of diet therapy as exclusive treatment on insulin resistance, biochemical parameters of metabolic syndrome, and degree of hepatic steatosis in patients with non-alcoholic fatty liver disease. METHODS Thirty-one patients with non-alcoholic fatty liver disease received a diet with a reduction of 500 to 1000 cal/d, containing 15% protein, 55% carbohydrates, and 30% fat, for 6 mo. At entry and 6 mo after dietary instructions, degrees of hepatic steatosis and visceral obesity were assessed by computed tomography; serum aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, glucose, triacylglycerols, and high-density lipoprotein cholesterol were measured by automated methods. Body mass index, waist circumference, waist-to-hip ratio, and food intake (7-d diary) were also evaluated. At the end of follow-up, the patients were classified as adherent or non-adherent to treatment according to a weight loss of more or less than 5% of initial body weight, respectively. RESULTS Seventeen patients were classified as adherent (group 1) and 14 as non-adherent (group 2). Group 2 only presented a significant reduction in body mass index and waist circumference. In contrast, in group 1, in addition to significant improvement of all anthropometric parameters, a significant reduction was observed in alanine aminotransferase and γ-glutamyl transferase levels, homeostasis model assessment for insulin resistance, visceral fat and tomographic liver density, together with an increase in serum high-density lipoprotein cholesterol levels. These patients presented a significant decrease in total energy intake and in total and saturated fats. CONCLUSION Nutritional intervention as exclusive treatment, with a loss of at least 5% of initial weight, is effective in the treatment of non-alcoholic fatty liver disease.

Relationship between Intestinal Parasitic Infection in Children and Soil Contamination in an Urban Slum

PURPOSE Urban slums are well known for their high infant mortality and morbidity rates, and parasitic infections seem to be a common problem among these children. The aim of the present study was to determine protozoa and nematodes prevalence among children of a selected community located in São Paulo, Brazil, and access the relation between soil and children infection. METHODS Soil contamination samples from 15 strategic locations in the slum area as well as stool samples (examined for protozoa and nematodes through five different methods) from 120 children aged 2-14 years (49% M: 51% F, mean +/- SD = 7.9 +/- 3.8 years) were assessed in a cross-sectional study. Childrens domicile locations were determined, and a comparative analysis was undertaken to correlate children and soil infection. RESULTS Overall infection rate was 30.8% (n = 37), without difference between genders. The most frequent intestinal protozoa were Endolimax nana (20.8%), Entamoeba coli (15.8%) and Giardia lamblia (16.7%). Frequencies of Ascaris lumbricoides and Enterobius vermicularis in stool samples were 2.5 and 1.7%, respectively. No cases of hookworms, Schistosoma mansoni or Tricuris trichiura were identified. Polyparasitism occurred in 10.8% of the children, while 69.2% were free of parasitic infections. Out of the 15 soil samples analyzed, Ascaris sp. eggs were found in 20% and hookworm eggs in 6.7%. CONCLUSION Helminth infection is not as prevalent as previously reported in urban slums in São Paulo, neither as clinical disease nor in soil samples. Protozoa intestinal infection, however, is still frequent in some marginalized populations in São Paulo. Improvement in living standards, mostly sanitation might decrease the prevalence of these diseases.

Radiofrequency Ablation of Functioning Adrenal Adenomas: Preliminary Clinical and Laboratory Findings

PURPOSE To evaluate clinical and laboratory findings in patients undergoing radiofrequency (RF) ablation for functioning adrenal adenomas. MATERIALS AND METHODS Eleven adult patients, nine with Conn syndrome and two with Cushing syndrome, underwent percutaneous computed tomography-guided RF ablation for benign adrenal neoplasms. Systolic, diastolic, and mean blood pressure and the number of classes of antihypertensive drugs used by each patient were analyzed before and 1, 4, and 12 weeks after the procedure. Serum hormone levels were analyzed within 30 days before and 12 weeks after the procedure. RESULTS Of the nine patients with Conn syndrome, eight showed normal serum aldosterone levels after the procedure and one patient had a nodule located very close to the inferior vena cava, resulting in incomplete ablation. The two patients with Cushing syndrome had normal serum and salivary cortisol levels after the procedure. Mean aldosterone concentration at baseline was 63.3 ng/dL ± 28.0 and decreased to 13.3 ng/dL ± 13.5 at 12 weeks postoperatively (P = .008). Systolic, diastolic, and mean blood pressures decreased significantly in the first week after the procedure (P < .001) and remained stable during further follow-up. CONCLUSIONS In patients with Conn syndrome or Cushing syndrome, percutaneous RF ablation of functioning adrenal adenomas may result in normalization of hormone secretion, improvement in blood pressure, and reduced need for antihypertensive drugs.

Transcatheter arterial embolization for unresectable symptomatic giant hepatic hemangiomas: single-center experience using a lipiodol-ethanol mixture.

Objective The present article is aimed at reporting the author’s experience with transcatheter arterial embolization using a lipiodol-ethanol mixture in three cases of unresectable symptomatic giant hepatic hemangiomas. Materials and Methods The cases of three patients with giant unresectable symptomatic hepatic hemangiomas embolized in the period 2009–2010 were retrospectively reviewed. In all the cases, transarterial embolization was performed with an ethanol-lipiodol mixture. Results Symptoms regression and quality of life improvement were observed in all the cases. No complications were observed and all the patients were discharged within 12 hours after the procedure. Conclusion Transcatheter arterial embolization using ethanol mixed with lipiodol was a safe and effective treatment for symptomatic giant hepatic hemangiomas in this small series of patients.

Imaging procedures in adrenal pathology

Imaging plays a vital role in the evaluation of adrenal pathology. The most widely used modalities are computed tomography and magnetic resonance imaging. Alone or in conjunction with appropriate clinical and biochemical data, imaging can provide specific diagnoses that preclude the need for tissue sampling. This article reviews imaging features of normal and diseased adrenals, from both benign and malignant causes.

Espectroscopia por ressonância magnética no diagnóstico do câncer de próstata: experiência inicial

OBJECTIVE: To report an experiment involving the introduction of a protocol utilizing commercially available three-dimensional 1H magnetic resonance spectroscopy imaging (3D 1H MRSI) method in patients diagnosed with prostatic tumors under suspicion of neoplasm. MATERIALS AND METHODS: Forty-one patients in the age range between 51 and 80 years (mean, 67 years) were prospectively evaluated. The patients were divided into two groups: patients with one or more biopsies negative for cancer and high specific-prostatic antigen levels (group A), and patients with cancer confirmed by biopsy (group B). The determination of the target-area (group A) or the known cancer extent (group B) was based on magnetic resonance imaging and MRSI studies. RESULTS: The specificity of MRSI in the diagnosis of prostate cancer was lower than the specificity reported in the literature (about 47%). On the other hand, for tumor staging, it corresponded to the specificity reported in the literature. CONCLUSION: The introduction and standardization of 3D 1H MRSI has allowed the obtention of a presumable diagnosis of prostate cancer, by a combined analysis of magnetic resonance imaging and metabolic data from 3D 1H MRSI.

The value of percutaneous transhepatic treatment of biliary strictures following pediatric liver transplantation

Objective To evaluate the percutaneous transhepatic approach to the treatment of biliary strictures in pediatric patients undergoing liver transplantation. Materials and Methods This was a retrospective study of data obtained from the medical records, laboratory reports, and imaging examination reports of pediatric liver transplant recipients who underwent percutaneous transhepatic cholangiography, because of clinical suspicion of biliary strictures, between 1st September 2012 and 31 May 2015. Data were collected for 12 patients, 7 of whom were found to have biliary strictures. Results In the 7 patients with biliary strictures, a total of 21 procedures were carried out: 2 patients (28.6%) underwent the procedure twice; 3 (42.8%) underwent the procedure three times; and 2 (28.6%) underwent the procedure four times. Therefore, the mean number of procedures per patient was 3 (range, 2–4), and the average interval between them was 2.9 months (range, 0.8–9.1 months). The drainage tube remained in place for a mean of 5.8 months (range, 3.1–12.6 months). One patient presented with a major complication, hemobilia, which was treated with endovascular embolization. Clinical success was achieved in all 7 patients, and the mean follow-up after drain removal was 15.4 months (range, 5.3–26.7 months). Conclusion The percutaneous transhepatic approach to treating biliary strictures in pediatric liver transplant recipients proved safe, with high rates of technical and clinical success, as well as a low rate of complications.

Radiological findings in megaesophagus secondary to Chagas disease: chest X-ray and esophagogram

Objective To identify and classify the radiographic patterns of megaesophagus in Chagas disease, as seen on esophagograms and chest X-rays. Materials and Methods This was a prospective study of 35 patients diagnosed with esophageal disease via manometry. The changes found on esophagograms were stratified according to Rezendes classification, divided into four categories (grades I through IV) determined by the degree of dilatation and impairement of esophageal motility. We subsequently correlated that ranking with the chest X-ray findings: gastric air bubble; air-fluid level; and mediastinal widening. Results Among the 35 patients, the esophageal disease was classified as grade I in 9 (25.7%), grade II in 3 (8.6%), grade III in 19 (54.3%), and grade IV in 4 (11.4%). None of the patients with grade I esophageal disease showed changes on chest X-rays. In two of the three patients with grade II disease, there was no gastric air-bubble, although there were no other findings in any of the grade II patients. Of the 19 patients with grade III disease, 15 had abnormal findings on X-rays. All four patients with grade IV disease showed abnormalities. Conclusion The use of Rezendes classification is feasible, encompassing findings ranging from the subtle changes that characterize the initial phases of esophageal disease to the complete akinesia seen in dolicomegaesophagus. Chest X-ray findings are more common in patients with advanced stages of the disease and indicate the degree of esophageal involvement in Chagas disease.

Interventional radiology and endovascular surgery in the treatment of ectopic pregnancies

The advent of interventional radiology enabled remarkable advances in diagnosis and treatment of several situations in obstetrics and gynecology. In the field of obstetrics, these advances include temporary occlusion of the iliac arteries to the management of placenta accreta and/or prior, arteriovenous fistulas after embolization of uterine curettage and management of ectopic uterine and extra-uterine pregnancies. The non-tubal ectopic pregnancy, either cervical, abdominal, ovarian or in a cesarean scar, often represents major therapeutic challenge, especially when exists a desire to maintain fertility. Despite the systemic methotrexate therapy and surgical resection of the ectopic gestational sac be the most used therapeutic options, the interventionist approach of non-tubal ectopic pregnancies, direct injection of methotrexate in the gestational sac and intra-arterial chemoembolization of uterine arteries constitute in the currently literature viable, safe, effective modalities with low morbidity, shorter hospital stay, and rapid clinical recovery. Because of little variety of materials used, and the increase in training of specialists in the area, the radiological intervention as a treatment option in ectopic pregnancies is financially viable and present considerable accessibility in the world and at most of Brazilian medical centers.

Evaluation of the efficacy and reproducibility of cholangiopancreatography by magnetic resonance for detecting biliary complications following orthotopic liver transplantation

PURPOSE To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6% and 82.1% of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100% of the exams, by both observers. Six biliary complications were detected (21.4%), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100% sensitivity, 95.45% specificity, 85.7% positive predictive value and 100% negative predictive value for the detection of biliary complications. CONCLUSIONS MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.