No abstract

Background: Colonic volvulus, mainly from the sigmoid, is a relatively common cause of intestinal obstruction, particularly in the elderly and in patients with debilitating conditions. The high morbi-mortality of emergency surgery places the endoscopic approach as the first-line treatment for the resolution of this acute obstructive condition. Objectives: To assess the importance of endoscopic treatment for the resolution of colonic volvulus in a debilitated population. Method: This is a retrospective analysis of emergency lower gastrointestinal endoscopies in patients with colonic volvulus as diagnosis, performed over a 9-year period (2009-2018), as well as population characterization and follow-up after the first exam. Results: We performed 88 procedures in 52 patients (56.4% males, median age 83 years, range 33-94). Endoscopic resolution was effective in 86.4% (76/88) of the exams, without procedure complications. Eighty-one percent of patients presented with volvulus recurrence, 50% of which occurred during the 3 months after the initial procedure. Twenty-one were submitted to surgery, 12 of which were emergency procedures after endoscopic failure as the primary treatment (5 of which had mucosal necrosis at en-doscopy). There was no mortality in elective surgery. In the emergency plus necrosis group, mortality was 60% (3/5) and 14.3% (1/7) in the emergency without necrosis group. Conclusions: Despite the high recurrence of volvulus after endoscopic treatment, it seems to be an adequate and low-risk first-line therapy for sigmoid volvulus in debilitated patients, allowing improvement of surgical conditions. Terapêutica endoscópica do volvo sigmoideu numa população debilitada -qual a relevância? Palavras ChaveVolvo · Sigmoideia · Idoso · Endoscopia · Cirurgia Resumo Introdução: O volvo cólico, particularmente da sigmoideia, é uma causa relativamente comum de obstrução intestinal, sobretudo em idosos ou doentes com condições debilitantes. A elevada morbi-mortalidade do procedimento cirúrgico de urgência coloca a abordagem endoscópica como primeira linha na tentativa de resolução tica endoscópica parece apresentar-se como uma opção de primeira linha adequada e de baixo risco na resolução de volvo cólico em doentes debilitados, permitindo melhorar condições clínicas para a realização de intervenção cirúrgica eletiva.

Introduction: Recent studies assessed the predictive value of liver transient elastography, combined or not with platelet count, for the presence of esophageal varices in patients with liver cirrhosis, and multiple cutoffs have been proposed. The Baveno VI consensus states that patients with compensated advanced chronic liver disease, liver stiffness <20 kPa, and a platelet count >150,000 have a very low risk of having varices requiring treatment and can avoid screening endoscopy. We aimed to validate this recommendation in a cohort of cirrhotic patients. Methods: Retrospective analysis of all patients evaluated at the Gastroenterology Department (Centro Hospitalar de Lisboa Central) between September 2009 and October 2015 with a liver stiffness (FibroScan®) compatible with liver cirrhosis as well as upper endoscopy and blood tests within 12 months from elastography. Patients on propranolol ≥80 mg/day or carvedilol ≥12.5 mg/day, as well as those with previous variceal bleeding, variceal endoscopic treatments, or cirrhosis decompensations were excluded. We validated the new Baveno VI recommendation and explored alternative cutoffs. Results: Ninety-seven patients were analyzed, 76.3% (74/97) male, mean age 54.3 ± 11.2 years. Most patients (55.7%) had no varices and 14.4% had varices requiring treatment. Most patients (78.4%) had cirrhosis related to chronic hepatitis C. If the new Baveno VI recommendation had been applied to this cohort, upper endoscopy would have been avoided in 11.3% (11/97) of patients, none of them with esophageal varices requiring treatment: specificity 100%, sensitivity 13.3%, positive predictive value 100%, and negative predictive value 16.3% for absence of varices requiring treatment. If screening endoscopy had been avoided in those patients with liver stiffness <30 kPa and platelet count ≥120,000, endoscopy would have been avoided in 27.8% (27/97) of patients, none of whom with esophageal varices requiring treatment: specificity 100%, sensitivity 32.5%, positive predictive value 100%, and negative predictive value 20% for absence of varices requiring treatment. Conclusions: The new Baveno VI criteria identified compensated cirrhotic patients without varices requiring treatment in whom screening endoscopy could have been avoided safely. Further studies are needed to confirm these findings and potentially explore more ambitious but still safe cutoffs for those criteria.

Ozone is an important disinfecting agent, however its influence on enamel adhesion has not yet been clarified.Objective:Evaluate the influence of ozone pretreatment on the shear strength of an etch-and-rinse and a self-etch system to enamel and analyze the respective failure modes.Material and Methods:Sixty sound bovine incisors were used. Specimens were randomly assigned to four experimental groups (n=15): Group G1 (Excite® with ozone) and group G3 (AdheSE® with ozone) were prepared with ozone gas from the HealOzone unit (Kavo®) for 20 s prior to adhesion, and groups G2 (Excite®) and G4 (AdheSE®) were used as control. Teeth were bisected and polished to simulate a smear layer just before the application of the adhesive systems. The adhesives were applied according to the manufacturer's instructions to a standardized 3 mm diameter surface, and a composite (Synergy D6, Coltene Whaledent) cylinder with 2 mm increments was build. Specimens were stored in 100% humidity for 24 h at 37º C and then subjected to a thermal cycling regimen of 500 cycles. Shear bond tests were performed with a Watanabe device in a universal testing machine at 5 mm/min. The failure mode was analyzed under scanning electron microscope. Means and standard deviation of shear bond strength (SBS) were calculated and difference between the groups was analyzed using ANOVA, Kolmogorov-Smirnov, Levene and Bonferroni. Chi-squared statistical tests were used to evaluate the failure modes. Results:Mean bond strength values and failure modes were as follows: G1- 26.85±6.18 MPa (33.3% of adhesive cohesive failure); G2 - 27.95±5.58 MPa (53.8% of adhesive failures between enamel and adhesive); G3 - 15.0±3.84 MPa (77.8% of adhesive failures between enamel and adhesive) and G4 - 13.1±3.68 MPa (36.4% of adhesive failures between enamel and adhesive).Conclusions:Shear bond strength values of both adhesives tested on enamel were not influenced by the previous application of ozone gas.

Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Agents that suppress gastric acid are commonly prescribed to reduce the incidence of clinically important stress ulcer-related gastrointestinal bleeding. However, the indiscriminate use of stress ulcer prophylaxis in all patients admitted to the intensive care unit is not warranted and can have potential adverse clinical effects and cost implications. The present guidelines from the Sociedade Portuguesa de Cuidados Intensivos summarizes the current evidence and gives six clinical statements and an algorithm aiming to provide a standardized prescribing policy for the use of stress ulcer prophylaxis in the intensive care unit.