Joana Nunes

Eradication of Hepatitis C Virus Reduces the Risk of Hepatocellular Carcinoma in Patients with Compensated Cirrhosis

BackgroundThe effect of a sustained virological response (SVR) to interferon (IFN) on clinical outcomes of hepatitis C virus (HCV)–related cirrhosis is controversial. Aims: Evaluate the effect of SVR to IFN on the incidence of hepatocellular carcinoma (HCC) and mortality in patients with compensated HCV-induced cirrhosis.MethodsA cohort of 130 consecutive patients (92 men, mean age 51.7xa0years) with histologically proven cirrhosis who received one or more courses of IFN monotherapy or combination therapy with ribavirin were analyzed. SVR was defined as undetectable serum HCV RNA by real-time polymerase chain reaction (PCR) 24xa0weeks after IFN discontinuation. HCC was assessed by alfa-fetoprotein and ultrasound every 6xa0months. Predictors of clinical outcomes, defined as HCC, orthotopic liver transplantation (OLT) and mortality, were assessed by Cox regression analysis.ResultsThe mean follow-up was 6.4xa0±xa04.0xa0years (range 1–18). HCC developed in 21 patients: one with SVR versus 20 with non-SVR (Pxa0=xa00.017). Logistic regression analysis showed that non-SVR (odds ratio [OR]xa0=xa027.0; confidence interval [CI], 1.6–452.1), male (ORxa0=xa011.6; CI, 1.8–75.4), and greater number of treatments (ORxa0=xa04.7; CI, 1.4–16.0) increased the probability of HCC development. Multivariate analysis found that SVR was associated with lower risk of HCC (HR 0.09; CI, 0.01–0.77), OLT (HR 0.04; CI, 0.003–0.63) and any event (HR 0.11; CI, 0.02–0.46) as compared to non-SVR.ConclusionsIn compensated HCV-related cirrhosis, SVR markedly reduces the risk of HCC and improves survival. Clearance of the virus should be intensively attempted in these patients.

The burden of alcoholism in fifteen years of cirrhosis hospital admissions in Portugal.

Deploying a longitudinal perspective, we observe how cirrhosis caused mortality rates in Portugal are converging with the levels reported in the European Union (15 countries). However, we still lack analysis of the burden of alcoholic cirrhosis in terms of hospital admissions and associated mortality. As Portugal may be considered a paradigmatic case in Europe, our aim was to characterize the evolution of hospital admissions for alcoholic cirrhosis between 1993 and 2008 and draw conclusions for other countries.

Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low risk patients: results of a noninferiority randomized controlled trial

BACKGROUND AND STUDY AIMSnPropofol provides the best sedation in colonoscopy. The safety of non-anesthesiologist administration of propofol (NAAP) is still a matter of debate. The aim of the current study was to evaluate sedation safety, colonoscopy quality, and patient satisfaction with NAAP.nnnPATIENTS AND METHODSnThe study was a single-blinded, noninferiority, randomized controlled trial comparing NAAP (Group A) with anesthesiologist-administered sedation (Group B) performed at a single academic institution. Patients (18u200a-u200a80 years) who underwent colonoscopy and were at low anesthetic risk (American Society of Anesthesiologists class Iu200a-u200aII) were included. The primary end point was the incidence of adverse events. Secondary end points were propofol dose, patient satisfaction and pain, colonoscopy quality indicators, and procedure and recovery times.nnnRESULTSnA total of 277 patients were included in the analysis. The incidence of adverse events was 39.3u200a% in Group A and 39.0u200a% in Group B (absolute difference -u200a0.3u200a%, 95u200a% confidence interval [CI]u200a-u200a12.0u200a% to 11.4u200a%; Pu200a=u200a0.959). There were no sentinel adverse events. The following interventions (Group A vs. Group B) were necessary: atropine administration (0u200a% vs. 5.5u200a%; Pu200a=u200a0.004); airway repositioning (8.7u200a% vs. 4.7u200a%; Pu200a=u200a0.196); increased oxygen administration (6.7u200a% vs. 3.9u200a%; Pu200a=u200a0.317), and increased fluid rate (2.7u200a% vs. 0.8u200a%; Pu200a=u200a0.379). There were no differences in cecal intubation and adenoma detection rates. Recovery times were longer in Group B (58u200a±u200a33 vs. 67u200a±u200a29 minutes; Pu200a=u200a0.032). There were no differences in mean propofol dose, withdrawal time, painless colonoscopy, satisfaction, and amnesia. All but two patients (Group B) were willing to repeat the colonoscopy.nnnCONCLUSIONSnNAAP is equivalent to anesthesiologist-administered sedation in the rate of adverse events in a low risk population.nnnTRIAL REGISTRATIONnClinicalTrials.gov (NCT02067065).

Cerebral venous thrombosis: an unexpected complication from spinal surgery

PurposeTo provide new insights into the pathophysiology, prevention and diagnosis of cerebral venous thrombosis (CVT) associated with iatrogenic cerebrospinal fluid (CSF) leaks and/or external CSF drainage.MethodsCase report and literature review.ResultsWe describe the case of a 30-year-old woman who developed a CSF fistula after lumbar spinal surgery. The treatment included rest, hydration, caffeine, and continuous lumbar CSF drainage. After closure of the fistula, the patient complained of severe orthostatic headache. Thrombosis involving the superior sagittal sinus, the right transverse sinus, the right sigmoid sinus, and the right jugular vein was diagnosed after neurological deterioration.ConclusionA few reports have associated CVT with various forms of spinal meningeal injury. However, it has been rarely documented following spinal surgery complicated by accidental durotomy and/or external lumbar CSF drainage. CSF hypovolemia may precipitate CVT in patients having prothrombotic risk factors. Patients who have or had CSF leaks and/or lumbar CSF drains who present with symptoms of intracranial CSF hypotension should remain in the horizontal position to prevent CVT. In that context, the diagnosis of CVT depends on a high degree of suspicion.

Adenoma Detection Rate: I Will Show You Mine if You Show Me Yours

Background: Colorectal cancer (CRC) is the first cause of cancer-related mortality in Portugal. CRC screening reduces disease-specific mortality. Colonoscopy is currently the preferred method for screening as it may contribute to the reduction of CRC incidence. This beneficial effect is strongly associated with the adenoma detection rate (ADR). Aim: Our aim was to evaluate the quality of colonoscopy at our unit by measuring the currently accepted quality parameters and publish them as benchmarking indicators. Methods: From 5,860 colonoscopies, 654 screening procedures (with and without previous fecal occult blood testing) were analyzed. Results: The mean age of the patients was 66.4 ± 7.8 years, and the gender distribution was 1:1. The overall ADR was 36% (95% confidence interval [CI] 32-39), the mean number of adenomas per colonoscopy was 0.66 (95% CI 0.56-0.77), and the sessile serrate lesion detection rate was 1% (95% CI 0-2). The bowel preparation was rated as adequate in 496 (76%) patients. The adjusted cecal intubation rate (CIR) was 93.7% (95% CI 91.7-95.8). Most colonoscopies were performed under monitored anesthesia care (53%), and 35% were unsedated. The use of sedation (propofol or midazolam based) was associated with a higher CIR with an odds ratio of 3.60 (95% CI 2.02-6.40, p < 0.001). Conclusion: Our data show an above-standard ADR. The frequency of poor bowel preparation and the low sessile serrated lesion detection rate were acknowledged, and actions were implemented to improve both indicators. Quality auditing in colonoscopy should be compulsory, and while many units may do so internally, this is the first national report from a high-throughput endoscopy unit.