Helenice Pankowski Breyer

Clinical efficacy of dexmedetomidine alone is less than propofol for conscious sedation during ERCP

BACKGROUND Propofol is an accepted method of sedation for an ERCP and generally achieves deep sedation rather than conscious sedation, and dexmedetomidine has sedative properties of equivalent efficacy. OBJECTIVE To examine the hypothesis that dexmedetomidine is as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. DESIGN AND SETTING Randomized, blind, double-dummy clinical trial. PATIENTS Twenty-six adults, American Society of Anesthesiologists status I to III, underwent an ERCP. INTERVENTIONS Patients were randomized to receive either propofol (n = 14) (target plasma concentration range 2-4 microg/mL) combined with fentanyl 1 microg/kg, or dexmedetomidine (n = 12) 1 microg/kg for 10 minutes, followed by 0.2 to 0.5 microg/kg/min. Additional sedatives were used if adequate sedation was not achieved at the maximum dose allowed. MAIN OUTCOMES MEASUREMENTS The sedation level was assessed by the Richmond alertness-sedation scale and the demand for additional sedatives. Furthermore, heart rate, blood pressure, oxygen saturation, and respiratory rate were continuously assessed. RESULTS The relative risk (RR) was 2.71 (95% CI, 1.31-5.61) and the number of patients that needed to be treated (NNT) was 1.85 (95% CI, 1.19-4.21) to observe one additional patient with drowsiness 15 minutes after sedation in the dexmedetomidine group. Also, the RR was 9.42 (95% CI, 1.41-62.80), and the NNT was 1.42 (95% CI, 1.0-2.29) to require additional analgesic. However, there was also a greater reduction in blood pressure, a lower heart rate, and greater sedation after the procedure. CONCLUSIONS Dexmedetomidine alone was not as effective as propofol combined with fentanyl for providing conscious sedation during an ERCP. Furthermore, dexmedetomidine was associated with greater hemodynamic instability and a prolonged recovery.

Mate (chimarrão) é consumido em alta temperatura por população sob risco para o carcinoma epidermóide de esôfago

ABSTRACT – “Mate”, a popular hot infusion of a herb ( Ilex paraguayensis) drunk in large volumes, is a known risk factor for squamous cellcarcinoma of the esophagus and there is a suspicion that high temperature of boiled water used for the infusion may contribute for carcinogenesis. Methods - We measured the temperature of “mate” infusion drank by a sample of the population at risk for this carcinoma in Taquara, so uthernBrazil. We interviewed inhabitants for drinking habits and the temperature of the infusion was measured with high precision thermometers.Temperature of the infusion was asked to consumers and their estimate compared to our measurements. We considered 60 o C or higher as “hot”. Results - In 36 residencies, 107 individuals were drinking “mate”. Most individuals drunk it daily (97,2%), and the medium daily volume was1,265 ml (SD ± 1,132 mL) ranging from 250 to 6,000 mL. The measured temperature was 60 o C or higher in 72% of residencies with mediumof 63.4 o C (51-78 o

Predictive factors of oxygen desaturation of patients submitted to endoscopic retrograde cholangiopancreatography under conscious sedation

BACKGROUND AND AIMS Hypoxemia can occur during endoscopic retrograde cholangiopancreatography probably induced by the analgesia and sedation done. Moreover the patients prone position difficults the adequate ventilation. The hypoxemia and hypoventilation may not be noticed by nursing staff. A transversal study was used to investigate possible predictive factors of oxygen desaturation in sedated patients with midazolam associated to meperidine undergoing endoscopic retrograde cholangiopancreatography. PATIENTS AND METHODS A total of 186 patients were monitored with continuous pulse oximetry. Poisson regression was used to measure the independent effect of each factor adjusted for effects of each of the other factors. The variables studied were: age, gender, hematocrit and hemoglobin levels, scopolamine use, diagnostic or therapeutic exam, American Society of Anesthesiologists Scores (ASA), duration time of exam, sedative used midazolam in the average of 0.07 mg/kg and analgesic drug meperidine in the average of 0.7 mg/kg that was titrated according patients reaction. RESULTS No desaturation was found in 113 (60.8%) patients, mild desaturation (SpO2 <92%) in 22 (11.8%) and severe desaturation (SpO2 <90%) in 51 (27.4%). This desaturation was recognized only by the pulse oximeter. There was no need to use any antagonist drug of the sedatives in patients who had severe desaturation, they were just stimulated to deep breaths and oxygen was offered at 2 liters per minute via catheter. The variables found to predict desaturation were age >60 years old and ASA score III. The duration of exam was barely significant for desaturation. CONCLUSIONS The variables of age of 60 years old or more, and ASA III score are identified as increased risk for desaturation for patients who undergo endoscopic retrograde cholangiopancreatography under conscious sedation. Long time of exam suggests the patient oxygen desaturate. Such patients require very close monitoring to desaturation and hypoventilation by the assistants and nursing staff alerting to respiratory depression. The use of pulse oximeter and asking for deep breaths during the exam helps to diminish such risks.

Detection of Helicobacter pylori resistance to clarithromycin and fluoroquinolones in Brazil: A national survey

AIM To evaluate bacterial resistance to clarithromycin and fluoroquinolones in Brazil using molecular methods. METHODS The primary antibiotic resistance rates of Helicobacter pylori (H. pylori) were determined from November 2012 to March 2015 in the Southern, South-Eastern, Northern, North-Eastern, and Central-Western regions of Brazil. Four hundred ninety H. pylori patients [66% female, mean age 43 years (range: 18-79)] who had never been previously treated for this infection were enrolled. All patients underwent gastroscopy with antrum and corpus biopsies and molecular testing using GenoType HelicoDR (Hain Life Science, Germany). This test was performed to detect the presence of H. pylori and to identify point mutations in the genes responsible for clarithromycin and fluoroquinolone resistance. The molecular procedure was divided into three steps: DNA extraction from the biopsies, multiplex amplification, and reverse hybridization. RESULTS Clarithromycin resistance was found in 83 (16.9%) patients, and fluoroquinolone resistance was found in 66 (13.5%) patients. There was no statistical difference in resistance to either clarithromycin or fluoroquinolones (P = 0.55 and P = 0.06, respectively) among the different regions of Brazil. Dual resistance to clarithromycin and fluoroquinolones was found in 4.3% (21/490) of patients. The A2147G mutation was present in 90.4% (75/83), A2146G in 16.9% (14/83) and A2146C in 3.6% (3/83) of clarithromycin-resistant patients. In 10.8% (9/83) of clarithromycin-resistant samples, more than 01 mutation in the 23S rRNA gene was noticed. In fluoroquinolone-resistant samples, 37.9% (25/66) showed mutations not specified by the GenoType HelicoDR test. D91N mutation was observed in 34.8% (23/66), D91G in 18.1% (12/66), N87K in 16.6% (11/66) and D91Y in 13.6% (9/66) of cases. Among fluoroquinolone-resistant samples, 37.9% (25/66) showed mutations not specified by the GenoType HelicoDR test. CONCLUSION The H. pylori clarithromycin resistance rate in Brazil is at the borderline (15%-20%) for applying the standard triple therapy. The fluoroquinolone resistance rate (13.5%) is equally concerning.

Changing pattern of indications of endoscopic retrograde cholangiopancreatography in children and adolescents: a twelve-year experience

BackgroundThere are few data regarding endoscopic retrograde cholangiopancreatography (ERCP) usefulness in children and adolescents. We reviewed the long-term experience with diagnostic and therapeutic ERCP in a tertiary single center in Southern Brazil.MethodsA retrospective chart review of patients aged 0–18 years who had undergone ERCPs from January 2000 to June 2012 was done. Data on demographics, indications, diagnosis, treatments, and complications were collected.ResultsSeventy-five ERCPs were performed in 60 patients. The median age of the patients at the procedure was 13.9 years (range: 1.2–17.9). Of the 60 patients, 47 (78.3%) were girls. Of all ERCPs, 48 (64.0%) were performed in patients above 10 years and 35 (72.9%) of them were in girls. ERCP was indicated for patients with bile duct obstruction (49.3%), sclerosing cholangitis (18.7%), post-surgery complication (12%), biliary stent (10.7%), choledochal cyst (5.3%), and pancreatitis (4%). The complication rate of ERCP was 9.7% involving mild bleeding, pancreatitis and cholangitis. Patients who had therapeutic procedures were older (13.7±3.9 vs. 9.9±4.9 years; P=0.001) and had more extrahepatic biliary abnormalities (82% vs. 50%; P=0.015) than those who had diagnostic ERCPs. A marked change in the indications of ERCPs was found, i.e., from 2001 to 2004, indications were more diagnostic and from 2005 therapeutic procedures were predominant.ConclusionsDiagnostic ERCPs are being replaced by magnetic resonance cholangiopancreatography and also by endoscopic ultrasound. All these procedures are complementary and ERCP still has a role for therapeutic purposes.

⁎3521 METHYLENE BLUE CAN DISCLOSE INTESTINAL METAPLASIA IN BARRETT'S ESOPHAGUS?

Barretts esophagus(BE)is a change in the esophageal epithelium of any lenght that can be recognized at endoscopy and is confirmed to have intestinal metaplasia(IM)by biopsy. Intestinal metaplasia of the esophagus is the premalignant lesion for adenocarcinoma.Multiple biopsies are necessary because of the often focal nature of IM, dysplasia and cancer in these patients. Methylene blue(MB)is a vital stain taken up by actively absorting tissues, such as small intestinal and colonic epithelium. The potential of MB directed biopsy for intestinal metaplasia in BE was suggested in a pilot study by Canto et al.We report preliminary results of a study that prospectively evaluated the use of MB staining in patients previously proven to have BE. Methods:A total of 30 patients underwent upper G.I endoscopy with 0.5% MB staining after cleaning the mucosa with 10% solution of N-acetylcystein.Water was gently sprayed on the esophageal mucosa to wash off excess dye.Positive staining was defined as blue-stained esophageal mucosa that persisted despite water irrigation. Biopsy specimens from positively stained and negatively stained mucosa were obtained and compared.All specimens were independently examined by two pathologists. The mean lenght of BE was 5.7 cm(range 2 to 14)and 18 subjects had long barretts and 12 with short barretts. We obtained 296 endoscopic biopsy specimens from stained and nonstained ares(medium 9.86 biopsies/patient, see table). The sensitivity, specificity, positive predictive value and negative predictive value of MB staining for detecting IM was 73%, 59%, 93% and 21% respectively. Conclusion: In patients previously diagnosed to have Barretts esophagus MB had good sensitivity but a hight frequency of false negatives.

IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION

Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.

3534 High grade dysplasias are present in normal appearing esophageal mucosa in subjects at risk for squamous cell carcinoma in southern brazil.

Objectives: Subjects at risk for squamous cell carcinoma of the esophagus were examined for mucosal abnormalities that could contain high grade dysplasias and/or early cancer with upper gastrointestinal endoscopy. Methods: Individuals found with cytology atypias at a screening program using esophageal balloon were submitted to esophagoscopy and the mucosa examined before and after Lugol spraying and biopsies obtained from unstained and stained areas. Results: 1495 subjects were screened and 122 underwent endoscopy. Their mean age was 57,8 and 75 (61.5%) were males. They were exposed, daily, to known risk factors as hot mate infusion drinking (91%), cigarrette smoking (51.6%) and alcohol drinking (19.7%). Conventional esophagoscopy visualized minute mucosal lesions (focal hyperemia, erosion, ulceration, nodule, depression / elevation, white plaque, red focal area) in 78 (63.9%) subjects but it was normal in 44 (36.1%). After Lugol spraying unstained areas were seen in 82 (67.2 %) individuals, 61 of which localized in mucosa with normal appearance with biopsies disclosing 10 dysplasias ( 5 high and 5 low grade) while 21, coincident with visible abnormalities had adenocarcinoma in one and a low grade dysplasia in another. Stained mucosa were also biopsied randomly in all subjects and 2 dysplasias were found (1 high and 1 low grade). Lugol esophagoscopy unstained areas had sensitivity of 83.3%, specificity of 61.1 %, positive predictive value of 6.09% and negative predictive value of 99.1% to detect high grade dysplasias ( p = 0.03, Fishers exact test). All high grade dysplasias were present in normal appearing esophageal mucosa. Conclusions: High grade dysplasias were occult in normal appearing mucosa and most were detected only after addition of Lugol staining to the esophageal mucosa.