Humberto Kishi

Association between air pollution and ischemic cardiovascular emergency room visits

This study observed the relationship between air pollutants and ischemic cardiac diseases such as angina and acute myocardial infarction in a representative cardiovascular center emergency room in São Paulo, Brazil. Daily emergency room admissions to the Institute of the Heart of the University of São Paulo, as well as data concerning daily air pollutant levels and meteorological variables, were collected from January 1994 to August 1995. Generalized additive Poisson regressions were fitted to the logarithm of the expected values of total emergency room visits due to angina or acute myocardial infarction, controlling for smooth functions of season and weather and indicators for days of the week. All investigated pollutants were positively associated with ischemic cardiovascular disease emergency room visits, and the time lags were relatively short, but only CO presented an effect that was statistically significant. An interquartile range increase in CO was associated with an increase of 6.4% (95% CI: 0.7-12.1) in daily angina or acute myocardial infarction emergency room visits. This result did not change when estimates were done using linear models and natural cubic splines. This study showed that air pollution has a role in cardiovascular morbidity in São Paulo, reinforcing the necessity for air pollutant emission-controlling polices in urban areas.

Air pollution and pediatric respiratory hospital admissions in São Paulo, Brazil

In order to investigate the relation between air pollution and child morbidity in Sao Paulo, a time-series study was carried out. Daily records of hospital admissions for children under 13 years old were obtained at the Health State Secretary, covering 112 hospitals in the period from October 1992 to October 1993. Daily levels of PM10, ozone, SO2, CO and NO2 were obtained from the environmental state agency (CETESB), while both CETESB and the Institute of Astronomy and Geophysics (IAG) of the University of Sao Paulo provided daily measures of temperature and relative humidity. Daily counts of child respiratory admissions (RESP) were considered as the dependent variable of pollutants in regression models, controlled for months of the year, days of the week, weather factors, and the daily number of non respiratory admissions (NORESP). PM10 and ozone were the pollutants that exhibited the most robust association with RESP. The mean levels of PM10observed during the period of study (70 μg m−3) were associated with an increase of 12% in RESP. The association between air pollution and RESP was significant within a time lag between 1 to 7 days and was dose-dependent. This result indicates that air pollution represents a significant pediatric health problem in Sao Paulo. Copyright

Predictive Factors for Local Recurrence and Incomplete Resection of Early Gastric Cancer Treated by Endoscopic Resection: A Western Experience

BACKGROUND Early gastric cancer (EGC) is defined as adenocarcinoma limited to the mucosa or submucosa regardless of lymph node involvement. Local EGC recurrence rates have been described in up to 6% of cases. OBJECTIVES To evaluate predictive factors for incomplete resection and local recurrence of EGC treated by endoscopic mucosal resection (EMR) that was followed up for at least one year. METHODS From June 1994 to December 2005, 46 patients with EGC underwent EMR. Possible predictive factors for incomplete endoscopic resection and local recurrence were identified by medical chart analysis. Demographic, endoscopic and histopathological data were retrospectively evaluated. EMR was considered complete or incomplete. Patients from the complete resection group were divided into subgroups (with and without local EGC recurrence). RESULTS Complete resection was possible in 36 cases (76.6%). Predictive factors for incomplete resection were tumour location (P=0.035), histological type (P=0.021), lesion size (P=0.022) and number of resected fragments (P=0.013). On multivariate analysis, undifferentiated histological type (OR 0.8; 95% CI 0.036 to 0.897) and number of resected fragments (OR 7.34; 95% CI 1.266 to 42.629) were independent predictive factors for incomplete resection. In the complete resection group, a larger lesion size was associated with a higher the number of resected fragments (P=0.018). Local recurrence occurred in nine cases (25%). Use of the cap technique was the only predictive factor for local recurrence in five of seven cases (71.4%) (P=0.006). CONCLUSIONS A larger lesion size was associated with a higher number of resected fragments. Undifferentiated adenocarcinoma and piecemeal resection were predictive factors for incomplete resection. Technique type was a predictive factor for local EGC recurrence.

CHARACTERIZATION OF THE MUCIN PHENOTYPE CAN PREDICT GASTRIC CANCER RECURRENCE AFTER ENDOSCOPIC MUCOSAL RESECTION

BACKGROUND Endoscopic mucosal resection is still considered an accepted treatment for early gastric cancer for selected cases. Histopathologic criteria for curative endoscopic resection are intramucosal well-differentiated adenocarcinoma, lateral and deep margins free of tumor, no histological ulceration, and no venous or lymphatic embolism. A 5% local recurrence rate has been described even when all the above-mentioned criteria are met. On the other hand, antigen expression by tumoral cells has been related to the biological behavior of several tumors. OBJECTIVE To evaluate whether early gastric cancer mucin immunoexpression, p53 and Ki-67, can predict recurrence after endoscopic mucosal resection, even when standard histopathologic criteria for curative measures have been attempted. METHODS Twenty-two patients with early gastric cancer were considered to have been completely resected by endoscopic mucosal resection. Local recurrence occurred in 5/22 (22.7%). Immunohistochemical study was possible in 18 (81.8%) resected specimens. Patients were divided in two groups: those with and those without local recurrence. They were compared across demographic, endoscopic, histologic data, and immunohistochemical factors for MUC2, MUC5a, CD10, p53, and Ki-67. RESULTS Mucin immunoexpression allowed a reclassification of gastric adenocarcinoma in intestinal (10), gastric (2), mixed (4), and null phenotypes (2). Mixed phenotype (positive for both MUC2 and MUC5a) was found in 80% of cases in the local recurrence group, while the intestinal type (positive MUC2 and negative MUC5a) was found in 76.9% of cases without local recurrence (P=0.004). Other observed features did not correlate with neoplastic recurrence. CONCLUSION The mixed phenotype of early gastric adenocarcinoma is associated with a higher probability of local recurrence after endoscopic mucosal resection.

Risk factors for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis: a prospective, single-center study

Background and study aims  To determine the clinical features associated with advanced duodenal and ampullary adenomas in familial adenomatous polyposis. Secondarily, we describe the prevalence and clinical significance of jejunal polyposis. Patients and methods  This is a single center, prospective study of 62 patients with familial adenomatous polyposis. Duodenal polyposis was classified according to Spigelman and ampullary adenomas were identified. Patients with Spigelman III and IV duodenal polyposis underwent balloon assisted enteroscopy. Predefined groups according to Spigelman and presence or not of ampullary adenomas were related to the clinical variables: gender, age, family history of familial adenomatous polyposis, type of colorectal surgery, and type of colorectal polyposis. Results  Advanced duodenal polyposis was present in 13 patients (21 %; 9 male) at a mean age of 37.61 ± 13.9 years. There was a statistically significant association between family history of the disease and groups according to Spigelman ( P  = 0.03). Seven unrelated patients (6 male) presented ampullary adenomas at a mean age of 36.14 ± 14.2 years. The association between ampullary adenomas and extraintestinal manifestations was statistically significant in multivariate analysis ( P  = 0.009). Five endoscopic types of non-ampullary adenoma were identified, showing that lesions larger than 10 mm or with a central depression presented foci of high grade dysplasia. Among 28 patients in 12 different families, a similar Spigelman score was identified; 10/12 patients (83.3 %) who underwent enteroscopy presented small tubular adenomas with low grade dysplasia in the proximal jejunum. Conclusions  Advanced duodenal polyposis phenotype may be predictable from disease severity in a first-degree relative. Ampullary adenomas were independently associated with the presence of extraintestinal manifestations.

Avaliação de refluxo ultra-distal com pHmetria de múltiplos canais

RACIONAL: Displasia e adenocarcinoma esofagico surge em pacientes com esofago de Barrett submetidos a tratamento cirurgico (fundoplicatura) com pHmetria esofagica sem evidencia de acidez, o que sugere existir refluxo distal ao cateter de pHmetria convencional. OBJETIVO: Desenvolver metodologia para avaliar refluxo ultra-distal (1 cm acima da borda superior de esfincter inferior do esofago). METODO: Foram selecionados 11 pacientes com esofago de Barrett previamente submetidos a fundoplicatura a Nissen, sem sintomas de refluxo, com endoscopia e estudo contrastado de esofago sem sinais de recidiva. Foi realizada manometria esofagica para avaliar a localizacao e a extensao do esfincter esofagico inferior (EIE). Realizou-se entao pHmetria esofagica com quatro canais: canal A a 5 cm acima da borda superior do EIE; canal B a 1 cm acima; canal C intraesfincteriano; canal D intragastrico. Avaliou-se o escore de DeMeester no canal A. Comparou-se o numero de episodios de refluxo acido, o numero de episodios de refluxo prolongado e a fracao de tempo com pH<4,0 nos canais A e B. Comparou-se a fracao de tempo de pH<4,0 nos canais B e C. A fracao de tempo com pH<4,0 acima de 50% no canal D foi usada como parâmetro para nao migracao proximal do cateter. RESULTADOS: Houve aumento significativo do numero de episodios de refluxo e da fracao de tempo com pH<4,0 no canal B em relacao ao canal A. Houve reducao do tempo de pH<4,0 no canal B em comparacao ao canal C. Dois casos de adenocarcinoma esofagico foram diagnosticados nos pacientes do grupo estudado. CONCLUSOES: A regiao 1 cm acima da borda superior do EIE esta mais exposta a acidez do que a regiao 5 cm acima, embora em niveis reduzidos. A regiao 1 cm acima da borda superior do EIE esta menos exposta a acidez do que a regiao intraesfincteriana, demonstrando eficacia da fundoplicatura.