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Stricture formation is common in Crohn's disease, and endoscopic intervention plays an increasingly important role in managing these strictures. A 61-year-old man with biological aortic prosthesis and a 30-year history of ileocolonic stricturing Crohn's disease, managed with azathioprine and infliximab, presented with marked occlusive symptoms. Colonoscopy revealed a descending colon stricture, prompting endoscopic balloon dilation. At the time of the procedure, no prophylactic antibiotic was given. Subsequently, he developed Streptococcus gallolyticus endocarditis, necessitating aortic valve replacement. The authors present a case of late Streptococcus gallolyticus endocarditis associated with endoscopic balloon dilation of a Crohn-related colonic stricture., (© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Climate change can have direct and indirect effects on human health. Direct effects can include an increase in extreme weather events, such as heatwaves and floods, as well as an increase in the spread of vector-borne and infectious diseases, which may lead to a set of health problems and diseases. Indirect effects can include changes in air quality, water availability, and food production and distribution. These changes can lead to an increase in respiratory problems, malnutrition, and increased food insecurity. There is a perceived need to investigate the extent to which Higher Education Institutions (HEIs) are engaged in efforts to foster a greater understanding of the connections between climate change and health. In this context, this preliminary investigation offers an overview of the relationships between climate change and health. By means of a survey among teaching staff and researchers at HEIs from 42 countries across all continents working on the connection between climate change and health. The study has investigated the extent to which current provisions for education and training on the connection between climate change and health are being considered and how current needs in terms of policy development, research, and training are being met. A series of case studies illustrate how universities worldwide are actively developing strategies and implementing measures to address climate change and health. The study concludes by providing specific recommendations aimed at facilitating the handling of issues related to climate change and health in a higher education context., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Leal Filho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Pancreatobiliary fistulas associated withntraductal Papillary Mucinous Neoplasm (IPMN) are rare and present therapeutic challenges. The authors describe the clinical course of an 81-year-old woman presenting with acute cholangitis, ultimately diagnosed with IPMN involving secondary ducts with focal high-grade dysplasia. Initial manifestations included elevated inflammatory markers, cholestasis, and imaging findings of a pancreatic lesion. Endoscopic retrograde cholangiopancreatography revealed dilation of both intrahepatic and extrahepatic bile ducts, along a cystic cluster originating from the pancreas, fistulizing into the common bile duct. Despite initial endoscopic interventions, recurrent cholestasis persisted. Subsequent multidisciplinary evaluation led to a cephalic duodenopancreatectomy. This case underscores the rarity of pancreatobiliary fistulas associated with IPMNs and the subsequent therapeutic challenges. The absence of standardized treatment algorithms for such intricate cases emphasizes the importance of individualized approaches. The fluoroscopy image displaying a cystic cluster originating from the pancreas and showing fistulization into the common bile duct is a rare image presented in our report, unique to this case.

Background: Considering the soaring health-related costs directed toward a growing, aging, and comorbid population, the health sector needs effective data-driven interventions while managing rising care costs. While health interventions using data mining have become more robust and adopted, they often demand high-quality big data. However, growing privacy concerns have hindered large-scale data sharing. In parallel, recently introduced legal instruments require complex implementations, especially when it comes to biomedical data. New privacy-preserving technologies, such as decentralized learning, make it possible to create health models without mobilizing data sets by using distributed computation principles. Several multinational partnerships, including a recent agreement between the United States and the European Union, are adopting these techniques for next-generation data science. While these approaches are promising, there is no clear and robust evidence synthesis of health care applications., Objective: The main aim is to compare the performance among health data models (eg, automated diagnosis and mortality prediction) developed using decentralized learning approaches (eg, federated and blockchain) to those using centralized or local methods. Secondary aims are comparing the privacy compromise and resource use among model architectures., Methods: We will conduct a systematic review using the first-ever registered research protocol for this topic following a robust search methodology, including several biomedical and computational databases. This work will compare health data models differing in development architecture, grouping them according to their clinical applications. For reporting purposes, a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 flow diagram will be presented. CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies)-based forms will be used for data extraction and to assess the risk of bias, alongside PROBAST (Prediction Model Risk of Bias Assessment Tool). All effect measures in the original studies will be reported., Results: The queries and data extractions are expected to start on February 28, 2023, and end by July 31, 2023. The research protocol was registered with PROSPERO, under the number 393126, on February 3, 2023. With this protocol, we detail how we will conduct the systematic review. With that study, we aim to summarize the progress and findings from state-of-the-art decentralized learning models in health care in comparison to their local and centralized counterparts. Results are expected to clarify the consensuses and heterogeneities reported and help guide the research and development of new robust and sustainable applications to address the health data privacy problem, with applicability in real-world settings., Conclusions: We expect to clearly present the status quo of these privacy-preserving technologies in health care. With this robust synthesis of the currently available scientific evidence, the review will inform health technology assessment and evidence-based decisions, from health professionals, data scientists, and policy makers alike. Importantly, it should also guide the development and application of new tools in service of patients' privacy and future research., Trial Registration: PROSPERO 393126; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=393126., International Registered Report Identifier (irrid): PRR1-10.2196/45823., (©José Miguel Diniz, Henrique Vasconcelos, Júlio Souza, Rita Rb-Silva, Carolina Ameijeiras-Rodriguez, Alberto Freitas. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 19.06.2023.)

An 84-year-old female, with history of endometrial and gallbladder adenocarcinomas, both submitted to curative surgeries, was admitted to the emergency room with obstructive jaundice. Computed tomography and subsequent magnetic resonance cholangiopancreatography revealed a common hepatic duct stenosis with intrahepatic biliary dilatation. She underwent percutaneous transhepatic cholangiography with successful biliary drainage. During the same admission, the patient experienced episodes of hematochezia. Rectosigmoidoscopy showed a 20 mm ulcer in the distal rectum and congestion of the rectal mucosa. Computed tomography revealed rectal wall circumferential thickening. Ulcer biopsies were compatible with a neoplasia of biliary origin.

Gastric heterotopia (GHT) is a medical condition where the gastric mucosa is found at a non-phyysiological part of the body. GHT can present itself anywhere in the gastrointestinal tract from the mouth to the anorectal area, as well as in the hepatobiliary system. However, it is relatively rare to find GHT in the rectum, with only around 50 documented cases reported in medical literature. We present the case of a 51-year-old man who underwent average-risk screening colonoscopy. He had no clinically significant comorbidities and was otherwise asymptomatic, with no family history. Notable findings included a pseudopolypoid lesion in the distal rectum, adjacent to the dentate line, measuring approximately 15 mm with regular-appearing mucosa under narrow-band-imaging. Biopsy specimens showed histological characteristics of oxyntic-type gastric mucosa without inflammation or dysplasia. GHT has the potential to progress to malignancy, although the rate of malignancy is currently unknown. Awareness of this entity is important given its frequency and potential for misdiagnosis.

Purpose: The purpose of this study was to evaluate rod-mediated function with two-color dark-adapted perimetry (2cDAP) in patients with RPE65-related retinopathy treated with voretigene neparvovec-rzyl., Methods: Following dilation and dark adaptation, 2cDAP and FST were performed. The 2cDAP was measured on an Octopus 900 perimeter (Haag-Streit) with cyan (500 nm wavelength) and red (650 nm wavelength) stimuli. Hill of vision (HOV) analysis was performed on 2cDAP perimetry with Visual Field Modeling and Analysis (VFMA). Full field threshold stimulus testing (FST) was also measured as a secondary measure of rod-mediated function, and assessed on a Diagnosys Espion with the ColorDome stimulator (Diagnosys LLC)., Results: Eight eyes from 4 patients who were treated with voretigene bilaterally had rod function assessed by 2cDAP testing at least 1 year after treatment. There was statistically significant improvement in 2cDAP following gene augmentation therapy. HOV VFMA analysis showed widespread improvements that extended beyond the treatment bleb and statistically significant improvement in HOV analysis volumetric measurements post-treatment to cyan and red stimuli. FST testing performed in six eyes from three patients demonstrated statistically significant improvement to all chromatic stimuli following treatment., Conclusions: These findings demonstrated statistically significant improvement in 2cDAP and FST following treatment with voretigene., Translational Relevance: These findings provide a sensitive method of assessing rod-mediated function in a topographic manner that may be useful in future clinical trials for inherited retinal dystrophies.

Introduction: Helicobacter pylori ( H. pylori ) infection is highly prevalent in Portugal and its eradication is formally recommended. However, the indiscriminate use of antimicrobials has led to a drastic rise in antibiotic resistance, with the failure of traditional eradication schemes. A single-capsule bismuth-based quadruple therapy became recently available in Portugal. This study aims to evaluate the efficacy and safety of a bismuth-based quadruple therapy as a second-line or rescue therapy., Patients and Methods: This was a multicentric study. All consecutive patients that were treated with bismuth-based quadruple therapy, as second-line or salvage treatment between July 2017 and April 2019 were enrolled. Their medical records were reviewed and clinical and laboratorial parameters, as well as data on treatment efficacy and adverse events were retrieved. Patients were also contacted by phone after treatment to confirm compliance, adverse events, and global satisfaction with this specific therapy., Results: A total of 151 subjects were included (female-68.9%; mean age-56 ± 13.5 years). Patients were previously submitted to 212 eradication schemes (Median-1; 1-5; IQR:4): 33.5% triple clarithromycin-based, 25% sequential, 7.5% concomitant, 5.2% others, and in 28.8% it was not possible to know the previous eradication scheme(s) followed by the patient. The PPI of choice was esomeprazole (39.7%), followed by omeprazole (27.8%). Compliance was achieved in 93.4% and the overall eradication rate was 90.1% (95% CI: 84.6-94.2). Treatment-related adverse effects were experienced by 63 patients (41.7%; 95% CI: 34-49.7), being mild in 29, moderate in 19, and severe in 15. The main drawbacks of the treatment, from the patient's perspective, were the high price (47%) and the adverse effects (16.6%). Failure to eradicate H. pylori was correlated with the following: previous rifabutin-based scheme (0 vs. 100%; p  = 0.010) and a higher number of previous treatment schemes (1.5 ± 0.7 vs. 2.3 ± 1.2; p  < 0.001)., Conclusion: In this South-European country a single-capsule bismuth-based quadruple therapy is an excellent option as a second-line or rescue therapy, with acceptable compliance and side effects.

Advances in vitreoretinal surgery provide greater safety, efficacy, and reliability in the management of the several vitreoretinal diseases that benefit from surgical treatment. The advances are divided into the following topics: scleral buckling using chandelier illumination guided by non-contact visualization systems; sclerotomy/valved trocar diameters; posterior vitrectomy systems and ergonomic vitrectomy probes; chromovitrectomy; vitreous substitutes; intraoperative visualization systems including three-dimensional technology, systems for intraoperative optical coherence tomography, new instrumentation in vitreoretinal surgery, anti-VEGF injection before vitrectomy and in eyes with proliferative diabetic retinopathy, and new surgical techniques; endoscopic surgery; the management of subretinal hemorrhages; gene therapy; alternative techniques for refractory macular hole; perspectives for stem cell therapy and the prevention of proliferative vitreoretinopathy; and, finally, the Port Delivery System. The main objective of this review is to update the reader on the latest changes in vitreoretinal surgery and to provide an understanding of how each has impacted the improvement of surgical outcomes.

Purpose: To report the first Brazilian patient with RPE65 deficiency-inherited retinal dystrophy ( RPE65 -IRD) treated with voretigene neparvovec-rzyl (VN)., Methods: An adult patient with Leber congenital amaurosis-2 with a homozygous mutation in the RPE65 gene (p.Phe83Leu) was treated bilaterally with VN. The clinical and surgical aspects are described. The baseline and 4-month postoperative ophthalmologic examinations included measurement of the best-corrected visual acuity (BCVA), full-field stimulus threshold (FST) test, Octopus 900 semiautomated kinetic visual fields (VFs), and microperimetry., Results: No complications developed in this patient. The BCVA remained stable. The full-field stimulus threshold test (FST) and VFs showed clinically significant improvements bilaterally. The patient reported significant improvements in the ability to perform daily activities, mainly for those requiring the VFs and vision in a low-luminescence environment., Conclusions: The treatments were beneficial for this patient who was homozygous for RPE65 p.Phe83Leu. The first VN treatments in an adult Brazilian patient in clinical practice showed measurable improvements in visual outcomes that were meaningful for the patient's daily activities., Translational Relevance: This case reinforces the clinical trial results and proves that the procedure is feasible in countries such as Brazil.

Introduction and Objectives: Neurohormonal blockade (NB)/modulation is the combination of two renin-angiotensin-aldosterone system inhibitors (RAASi) with a beta blocker. It is the core therapy for heart failure with reduced ejection fraction (HFrEF). While improving long term prognosis, it also induces hyperkalemia (serum K + >5.0 mEq/L) due to RAASi effects. This may cause lethal arrhythmias and increase mortality in the short term. Thus, hyperkalemia frequently leads to withholding or reducing the intensity of neurohormonal blockade/modulation, which is associated with worsening long term prognosis. We assessed the relevance of hyperkalemia as a limiting factor of neurohormonal blockade/modulation in real life clinical conditions., Methods: We reviewed the medical records of HFrEF patients attending a HF clinic at a tertiary Portuguese hospital during 2018 (n=240). The number of patients not tolerating maximal neurohormonal blockade/modulation due to hyperkalemia was determined. The incidence and characteristics of hyperkalemia episodes were also assessed., Results: Only six patients (3%) achieved maximal doses of neurohormonal blockade/modulation. Hyperkalemia was the limiting factor in 48 (20%) patients. A total of 185 hyperkalemia episodes occurred in 100 (42%) patients. Forty-five (24%) episodes were moderate or severe (serum K + >5.5 mEq/L). In these HFrEF patients, the co-existence of hypertension, diabetes or renal failure was associated with the occurrence of hyperkalemia., Conclusions: In daily clinical practice, hyperkalemia is frequent and limits neurohormonal blockade/modulation by leading to the withholding or reducing of the intensity of RAAS inhibition. Considering the negative prognostic impact associated with sub-optimal neurohormonal blockade/modulation, addressing hyperkalemia is an important issue when treating HFrEF patients., (Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Aim: Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival. This study aimed to analyze patients with colorectal liver metastasis (CRLM) submitted to hepatectomy in three centers from Rio de Janeiro, over the past 10 years, by comparing the morbidity of first hepatectomy and re-hepatectomy., Methods: From June 2009 to July 2020, 192 patients with CRLM underwent liver resection with curative intent in three hospitals from Rio de Janeiro Federal Health System. The data from patients, surgeries, and outcomes were collected from a prospectively maintained database. Patients submitted to first and re-hepatectomies were classified as Group 1 and Group 2, respectively. Data from groups were compared and value of p<0.05 was considered significant., Results: Among 192 patients, 16 were excluded. Of the remaining 176 patients, 148 were included in Group 1 and 28 were included in Group 2. Fifty-five (37.2%) patients in Group 1 and 13 (46.5%) in Group 2 presented postoperative complications. Comparing Groups 1 and 2, we found no statistical difference between the cases of postoperative complications (p=0.834), number of minor (p=0.266) or major (p=0.695) complications, and deaths (p=0.407)., Conclusions: No differences were recorded in morbidity or mortality between patients submitted to first and re-hepatectomies for CRLM, which reinforces that re-hepatectomy can be performed with outcomes comparable to first hepatectomy.

Background: Identification of Barrett's esophagus (BE) with the treatment of dysplasia is essential to prevent esophageal adenocarcinoma (EAC). Moreover, determination of BE prevalence is important to define subsequent management strategies. However, precise estimates on BE prevalence from several European countries are lacking. We aimed to determine BE prevalence in a Southern European country., Methods: A cross-sectional, multicenter study from November 2019 to February 2020 was performed defining BE as a columnar extent in the distal esophagus greater than or equal to 1 cm with intestinal metaplasia., Results: A total of 1550 individuals, 51% male with a mean age of 62 (SD = 15) years undergoing upper endoscopy were included. The overall BE prevalence was 1.29% (95% confidence interval: 0.73-1.85); significantly higher in men [2.05% (1.06-3.04)] vs. women [0.53% (0.01-1.04)]. Of the 20 BE patients, eight were newly diagnosed and 12 were under surveillance. The median extent was C3 (min 0; max 16) M4.5 (min 2; max 16). One patient each had EAC (0.06%) and high-grade dysplasia (0.06%) at the time of endoscopy. There was no difference in prevalence between geographical regions, centers, use of sedation or experience of endoscopists. Considering all reports, 93% used standardized terminology, 23% accurate photodocumentation and 69% photodocumented the esophagogastric junction (EGJ). Furthermore, 80% used Prague classification, 55% Seattle protocol, 60% distance to the squamocolumnar junction, 75% to the EGJ and 40% to the hiatal pinch. When considering only reports with EGJ photodocumentation or Prague classification, the prevalence was 1.78% (0.91-2.64) or 1.03% (0.53-1.53)., Conclusion: We report for the first time BE prevalence in Southern Europe and report a low overall prevalence in an unselected population. Future studies need to determine progression rates and how to improve quality metrics., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Heart failure (HF) is a growing public health problem. Sacubitril/valsartan is now recommended to be used in persistently symptomatic patients with left ventricular ejection fraction (LVEF) <40%, replacing angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs). In the present study, we aimed to characterise the challenges of sacubitril/valsartan use in everyday clinical practice., Methods: We assessed the medical records of patients with HF and reduced ejection fraction eligible for sacubitril/valsartan attending a HF clinic at a Portuguese University Hospital during 2018 (n=152). The number of eligible patients receiving the drug and the reasons for not prescribing sacubitril/valsartan were evaluated. Additionally, we assessed the tolerability of maximal doses of sacubitril/valsartan. New York Heart Association functional class (NYHA class) and LVEF before and after up-titration to maximal tolerated sacubitril/valsartan dose were compared. Median follow-up was 41 months., Results: Of the 152 included patients, 75 (49%) were prescribed the drug. The two main reasons for non-prescription were patient financial barriers (31%) and hypotension (27%). Only 33% of patients on sacubitril/valsartan did reach maximal dose. Hypotension was the main limiting factor for dose optimisation. Duration of sacubitril/valsartan treatment showed a positive association with LVEF improvement during follow-up (6.6% absolute LVEF increase/year). NYHA functional class improved significantly from baseline through the end of follow-up., Conclusions: In every-day clinical practice, although sacubitril/valsartan was associated with a marked improvement in NYHA class and in LVEF, important financial and clinical barriers to the implementation of this therapy were identified., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/cdt-21-312). All authors report that this work was supported by Novartis, via funding for third-party medical writing, review, and submission of this manuscript. AS has received speaker fees or advisory board participation fees from MSD, Merck Serono, Novartis, Servier, Bial and Pfizer outside of this work. BM has received speaker fees from AstraZeneca, Boehringer Ingelheim, Lilly, Servier, Novartis and Merck Serono outside of this work. JSC has received speaker and consultant fees, or advisory board participation fees from Abbott, AstraZeneca Pharmaceuticals, Bial, Boehringer Ingelheim, Menarini, Merck Serono, Merck Sharp & Dohme, Novartis, Orion, Pfizer, Sanofi, Servier, and Vifor Pharma outside of this work. The authors have no other conflicts of interest to declare., (2021 Cardiovascular Diagnosis and Therapy. All rights reserved.)