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Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients' individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient's characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.

Background and Aims Buried bumper syndrome (BBS) is a rare adverse event of percutaneous endoscopic gastrostomy (PEG) placement in which the internal bumper migrates through the stomal tract to become embedded within the gastric wall. Excessive tension between the internal and external bumpers, causing ischemic necrosis of the gastric wall, is believed to be the main etiologic factor. Several techniques for endoscopic management of BBS have been described using off-label devices. The Flamingo set is a novel, sphincterotome-like device specifically designed for BBS management. We aimed to evaluate the effectiveness of the Flamingo device in a large, homogeneous cohort of patients with BBS. Methods A guidewire was inserted through the external access of the PEG tube into the gastric lumen. The Flamingo device was then introduced into the stomach over the guidewire. This dedicated tool can be flexed by 180 degrees, exposing a sphincterotome-like cutting wire, which is used to incise the overgrown tissue until the PEG bumper is exposed. A retrospective, international, multicenter cohort study was conducted on 54 patients between December 2016 and February 2019. Results The buried bumper was successfully removed in 53 of 55 procedures (96.4%). The median time for the endoscopic removal of the buried bumper was 22 minutes (range, 5-60). Periprocedural endoscopic adverse events occurred in 7 procedures (12.7%) and were successfully managed endoscopically. A median follow-up of 150 days (range, 33-593) was performed in 29 patients (52.7%), during which no significant adverse events occurred. Conclusions Through our experience, we found this dedicated novel device to be safe, quick, and effective for minimally invasive, endoscopic management of BBS.

O objetivo deste estudo foi caracterizar o perfil dos casais inférteis submetidos à técnica de reprodução humana assistida (RHA) no município de Salvador, Bahia. Trata-se de um estudo de caráter retrospectivo, observacional, baseado em dados secundários, obtidos mediante consulta aos prontuários eletrônicos dos pacientes cadastrados em uma clínica particular de RHA durante o ano de 2017. As variáveis categóricas e quantitativas foram apresentadas em valor absoluto e relativo, média ± desvio-padrão, respectivamente. Posteriormente, analisadas por meio de um software estatístico. Dos 496 pacientes atendidos na clínica de reprodução, 360 (72,6%) foram diagnosticados com infertilidade. A causa compartilhada (n=224; 62,2%) foi mais prevalente do que a isolada por sexo. Entre as mulheres, observa-se que a idade avançada (30,8%) e endometriose (26,5%) representam as principais causas de infertilidade. Nos homens, a teratozoospermia (36,9%) e a varicocele (33,6%) foram os fatores que mais comprometeram a fertilidade. A qualidade do gameta feminino e masculino é severamente comprometida em pacientes que tem como causa de infertilidade a falência ovariana (62,5%) e oligoastenoteratozoospermia (56,5%), respectivamente. No entanto, observa-se que nas mulheres, a baixa qualidade embrionária está mais associada à obstrução tubária (47,7%), enquanto que nos homens, o mesmo fator associado a baixa qualidade seminal é também responsável pelo desenvolvimento insatisfatório dos embriões (69,2%). Por fim, conclui-se que a infertilidade acomete, em maior proporção, homens e mulheres simultaneamente. Nas mulheres, a infertilidade associa-se a idade avançada e endometriose, enquanto que nos homens a teratozoospermia e varicocele. Essas causas, além de impactarem na qualidade dos gametas, também afetam a qualidade e desenvolvimento embrionário.

O presente trabalho tem como objetivo estudar a relação entre a mãe e o bebê e verificar quais os desdobramentos dessa relação na inserção do bebê na creche. Nesse sentido, busca-se analisar as primeiras relações materno-infantis a partir de três proposições teóricas: a relação mãe-bebê, o conceito da mãe suficientemente boa e a análise do acolhimento do bebê na creche, por meio da abordagem Winnicottiana. A metodologia utilizada foi a revisão da literatura. Grande parte da revisão bibliográfica foi realizada por meio das obras de Donald W. Winnicott e de seus colaboradores. Pôde-se verificar que, para Winnicott, cada ser humano traz um potencial inato para amadurecer, para se integrar, no entanto não é o ambiente que faz o bebê crescer, nem determina o sentido desse crescimento, mas apenas facilita, se for suficientemente bom. Para que o bebê se desenvolva de forma saudável, ele precisa de uma mãe dedicada, tanto do ponto de vista físico, como psicológico. Essa dedicação deve se dar por meio de uma relação empática e da adaptação sensível da mãe às necessidades do bebê. Quando o bebê sai do núcleo familiar e passa a frequentar espaços coletivos, ele enfrenta um momento estressante. Nesse sentido, é fundamental que os profissionais da Educação Infantil busquem estratégias de acolhimento do bebê e de sua família.

Lipomas of the gastrointestinal (GI) tract are common, benign and usually present as innocuous findings. Larger ones (>2 cm in diameter), particularly those involving the ileum, may present with clinical symptoms such as abdominal pain (caused by intussusception) and iron deficiency anaemia (IDA) or obscure GI bleeding (OGIB) (caused by overlying mucosal ulceration); these cases warrant intervention and often end up being referred for surgery. We describe a minimally invasive endoscopic alternative to surgical resection for the management of these lesions. A 60-year-old man presented with recurrent, cramping abdominal pain and OGIB. A magnetic resonance enterography (MRE) revealed a 2.5 cm submucosal lesion in the distal ileum, in keeping with a large lipoma. In light of these findings and the clinical presentation, we perform a saline-immersion retrograde DBE under conscious sedation, for further evaluation and minimally invasive, definitive endotherapy. At DBE the lesion was identified at around 40 cm proximal to the ileocaecal valve. The endoscopic appearances revealed a 2.5 cm sessile submucosal, lumen-filling lesion with a positive ‘pillow sign’. Although the overlying mucosa appeared mostly unremarkable, a small, healed ulcer (which would account for the patient’s IDA and OGIB) was identified on the medial surface of the lesion. Endotherapy was deemed feasible and this was facilitated by the buoyancy properties provided by SITE. In order to reduce the risk of perforation and bleeding, an endoscopic loop ligating device was first deployed tightly at the base of the lesion. A ball-tip, needle-type endoscopic submucosal dissection (ESD) knife was then used to incise and unroof the lesion. This allowed for exposure and spontaneous extrusion of the lipomatous tissue (already under pressure from the loop-lighting device). Saline-immersion allowed for maintenance of a clear visual field, through avoidance of clouding of the endoscopic lens and flotation of extruded micelles of fatty tissue. A submucosal tattoo and a clip were placed as endoscopic and radiological markers, respectively. The procedure was performed under antibiotic cover. No significant immediate, early or late adverse events were encountered. Histopathological examination of retrieved tissue showed mature adipocytes with fibrofatty submucosal changes, in keeping with a submucosal lipoma. No dysplasia or sarcomatous transformation was identified. The patient’s symptoms have resolved completely post-endotherapy. Our case demonstrates the safety and usefulness of minimally invasive endotherapy of symptomatic large ileal lipomas. The combination of DBE with SITE-facilitated unroofing, after securing the lipoma’s base with a loop-ligation device, allows for safe, spontaneous extrusion of the benign lipomatous tissue and avoids the need for operative surgery in symptomatic patients.

Optimisation of patient care though multidisciplinary team (MDT) meetings is now established as the standard of care in cancer pathways. Cases presented at MDTs are discussed by a panel of experts in order to provide optimal management. An ‘Advanced-endoscopy MDT’ may help to achieve consensus on decision-making, clinical outcomes and patient satisfaction. In our tertiary referral institution, we developed and adopted an ‘Advanced-Endoscopy MDT’ to evaluate complex cases. A bi-weekly meeting was established with the presence of expert interventional endoscopists, radiologists, histopathologists, dedicated gastrointestinal surgeons and nurse endoscopists. Depending on the cases discussed, additional experts were also in attendance. Endoscopic images, radiological scans and histopathology reports were assessed in order to decide treatment options and surveillance intervals. We retrospectively reviewed all patients that were discussed. Demographic, clinical, endoscopic findings and outcome data were analysed. Over 20 months, 35 meetings were conducted; 463 cases were discussed for a total of 323 patients. The main reasons for MDT referral were for consideration of double-balloon enteroscopy (DBE) (107 patients) and for appropriate endoscopic or surgical management of mucosal/submucosal GI lesions. Through MDT discussion, 9 patients were referred for surgical management; 34 patients were treated with endoscopic submucosal dissection (ESD) and 72 patients with endoscopic mucosal resection (EMR). One ESD procedure was abandoned due to high suspicion of deep invasion and was referred for surgery. From the remaining 33 cases, R0 margins were reported for 32/33 patients. Eight patients referred for DBE did not require endoscopic input and 29 cases were reviewed twice as additional radiological investigations or small bowel capsule endoscopy were deemed necessary. No major adverse event including perforation, severe delayed GI bleed or sepsis occurred after any endoscopic procedure discussed at the MDT. Based on our preliminary experience of an ‘Advanced-Endoscopy MDT’ is a useful platform for the safe, effective and efficient management of complex advanced endoscopic procedures.

Background and study aims COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

Among the various economic activities that impact the environment, the fish agroindustry sector stands out. This activity that generates a large amount of waste in the stages of the production process, from the capture to the commercialization of the fish. In view of the above, this study aimed to learn about solid waste management in some fish agribusinesses located in the municipality of Coremas - PB, as well as to propose environmental control measures to subsidize future management plans for this type of establishment. To carry out the study, agro-industries were selected, for which field visits were made and a questionnaire was applied, in order to learn about the management of solid waste, identify the environmental impacts associated with it and the environmental perception of its owners and employees. Additionally, measures were proposed for the environmentally sound management of agro-industrial waste. Based on the results, it was observed that the vast majority of agro-industries had an environmentally inadequate management of solid waste, which has caused several negative environmental impacts associated, mainly, with the quantity and form of destination of the fish residues. It was also verified that it is necessary to elaborate and execute solid waste management plans, according to the applicable legislation (Law no. 12,305 / 2010), to regularize agro-industries and contribute to the environmental balance of the region. Finally, it is expected that the measures proposed in this study document serve as a basis for structuring solid waste management plans for small fish farming agro-industries located in Coremas - PB. Entre las diversas actividades económicas que impactan al medio ambiente, se destaca el sector de la agroindustria pesquera. Esta actividad que genera una gran cantidad de residuos en las etapas del proceso productivo, desde la captura hasta la comercialización del pescado. Por lo anterior, este estudio tuvo como objetivo conocer el manejo de residuos sólidos en algunas agroindustrias pesqueras ubicadas en el municipio de Coremas - PB, así como proponer medidas de control ambiental para subsidiar futuros planes de manejo para este tipo de establecimientos. Para la realización del estudio se seleccionaron agroindustrias, para lo cual se realizaron visitas de campo y se aplicó un cuestionario, con el fin de conocer sobre el manejo de los residuos sólidos, identificar los impactos ambientales asociados al mismo y la percepción ambiental de sus propietarios. y empleados. Además, se propusieron medidas para la gestión ambientalmente racional de los desechos agroindustriales. Con base en los resultados, se observó que la gran mayoría de las agroindustrias tuvieron un manejo ambientalmente inadecuado de los residuos sólidos, lo que ha provocado varios impactos ambientales negativos asociados, principalmente, a la cantidad y forma de destino de los residuos pesqueros. También se verificó que es necesario elaborar y ejecutar planes de manejo de residuos sólidos, de acuerdo con la legislación aplicable (Ley No. 12.305 / 2010), para regularizar las agroindustrias y contribuir al equilibrio ambiental de la región. Finalmente, se espera que las medidas propuestas en este documento de estudio sirvan de base para estructurar planes de manejo de residuos sólidos para las pequeñas agroindustrias piscícolas ubicadas en Coremas - PB. Entre as diversas atividades econômicas que causam impactos ao meio ambiente, destaca-se o setor da agroindústria de pescado. Esta atividade que gera grande quantidade de resíduos nas etapas do processo produtivo, desde a captura até à comercialização do pescado. Diante do exposto, neste trabalho teve-se por objetivo conhecer o gerenciamento de resíduos sólidos em algumas agroindústrias de pescado localizadas no município de Coremas - PB, bem como propor medidas de controle ambiental para subsidiar futuros planos de gerenciamento para este tipo de estabelecimento. Para execução do estudo, foram selecionadas agroindústrias, para as quais realizaram-se visitas de campo e aplicou-se um questionário, com a finalidade de conhecer o gerenciamento dos resíduos sólidos, identificar os impactos ambientais a este associados e a percepção ambiental dos seus proprietários e funcionários. Adicionalmente, propuseram-se medidas para o gerenciamento ambientalmente adequado dos resíduos agroindustriais. Com base nos resultados, observou-se que a grande maioria das agroindústrias apresentou um gerenciamento ambientalmente inadequado dos resíduos sólidos, o que tem acarretado diversos impactos ambientais negativos associados, principalmente, à quantidade e forma de destinação dos resíduos do pescado. Verificou-se, ainda, que é necessária a elaboração e execução de planos de gerenciamento de resíduos sólidos, segundo a legislação aplicável (Lei n. 12.305/2010), para regularizar as agroindústrias e contribuir com o equilíbrio ambiental da região. Por fim, espera-se que as medidas propostas neste estudo documento sirvam como base para estruturação de planos de gerenciamento de resíduos sólidos para as pequenas agroindústrias de piscicultura situada em Coremas – PB.

Entre as diversas atividades econômicas que causam impactos ao meio ambiente, destaca-se o setor da agroindústria de pescado. Esta atividade que gera grande quantidade de resíduos nas etapas do processo produtivo, desde a captura até à comercialização do pescado. Diante do exposto, neste trabalho teve-se por objetivo conhecer o gerenciamento de resíduos sólidos em algumas agroindústrias de pescado localizadas no município de Coremas - PB, bem como propor medidas de controle ambiental para subsidiar futuros planos de gerenciamento para este tipo de estabelecimento. Para execução do estudo, foram selecionadas agroindústrias, para as quais realizaram-se visitas de campo e aplicou-se um questionário, com a finalidade de conhecer o gerenciamento dos resíduos sólidos, identificar os impactos ambientais a este associados e a percepção ambiental dos seus proprietários e funcionários. Adicionalmente, propuseram-se medidas para o gerenciamento ambientalmente adequado dos resíduos agroindustriais. Com base nos resultados, observou-se que a grande maioria das agroindústrias apresentou um gerenciamento ambientalmente inadequado dos resíduos sólidos, o que tem acarretado diversos impactos ambientais negativos associados, principalmente, à quantidade e forma de destinação dos resíduos do pescado. Verificou-se, ainda, que é necessária a elaboração e execução de planos de gerenciamento de resíduos sólidos, segundo a legislação aplicável (Lei n. 12.305/2010), para regularizar as agroindústrias e contribuir com o equilíbrio ambiental da região. Por fim, espera-se que as medidas propostas neste estudo documento sirvam como base para estruturação de planos de gerenciamento de resíduos sólidos para as pequenas agroindústrias de piscicultura situada em Coremas – PB.

Erythrodiplax fusca (Rambur, 1842) é uma Odonata da família Libellulidae, que defendem seus territórios próxima de rios, lagos e áreas pântanosas. Disputas por acesso a fêmeas ou pelos locais de reprodução, geralmente ocorrem durante o voo. O objetivo neste trabalho foi analisar as disputas por territórios entre machos avaliar se o ganhador possuía maior peso. O estudo foi conduzido na Fazenda Experimental Morro Feio, localizada no município de Hidrolândia, estado de Goiás, Brasil. Inicialmente, foi realizada uma inspeção para encontrar pontos na margem do riacho que os machos comumente disputam para estabelecer seus territórios. Após a identificação destes pontos todas as disputas por território foram contabilizadas, ao final do conflito os dois machos foram coletados (vencedor e perdedor) e pesados. Foram coletados 74 indivíduos de E. fusca (37 vencedores e 37 perdedores). O peso fresco foi determinante para a vitória, com machos vitoriosos apresentando peso fresco 10% maior que os machos perdedores. Portanto, o presente trabalho corrobora a hipótese de que o peso dos machos de E. fusca está relacionado à vitória em disputas por territórios.

Evidence indicates that neuroplasticity-based cognitive training can improve cognition in patients with schizophrenia, but the individual response to training varies greatly between subjects. Hence, there is a need to understand the neurological underpinnings of cognitive training to reveal predictors of treatment response. D-serine is a crucial modulator of neuroplasticity, and decreased levels of D-serine may contribute to deficits in neuroplasticity in schizophrenia. Interestingly, we observed that training mice to identify auditory oddballs increased extracellular levels of D-serine in the hippocampus during training. Serine racemase (Srr) is the only source of brain D-serine; thus, it is possible that Srr may mediate the response to training. To test this hypothesis, we trained mice that have a mutated version of Srr (SrrY269*/SrrY269*) and reduced levels of D-serine in the same auditory training. SrrY269*/SrrY269* mice showed decreased performance during auditory training (defined as the capacity to discriminate an oddball during a sequence of tones). Importantly, auditory training improved prepulse inhibition (PPI) in SrrY269*/SrrY269* but not in wild-type mice. Finally, D-serine (100 mg/kg i.p.) given 30 min before training sessions to SrrY269*/SrrY269* mice improved training performance, but it did not enhance PPI. Taken together, our results show that D-serine is involved in the response to neuroplasticity-based auditory training and that PPI deficits can be improved by auditory oddball training even in the presence of neuroplasticity deficits.

Introduction Chicungunya fever, epidemic caused by Alphavirus (CHIKV) transmitted by mosquitoes of the genus Aedes, is characterized by highly debilitating joint pain and can cause atypical cardiac complications in 10% of patients. CHIKV produces direct damage to myofibrils (inflammation and infiltration) and secondary damage due to hypersensitivity and necrosis. Objective To evaluate, by echocardiography, the chronic cardiac alterations of the CHIKV infection. Methods Thirty-two patients were studied (mean age was 56 ± 14 years, 17 females) with CHIKV-confirmed infection and signs of cardiac involvement between 5 and 25 months of evolution. The dimensions and function of the ventricles were measured by two-dimensional and Doppler echocardiography. The global longitudinal strain (GLS) of the left ventricle (LV) and left atrial longitudinal strain (LALS) were evaluated. Patients were divided into Group A, with duration of CHIKV infection shorter than 12 months (12 patients) and Group B, with disease duration equal to or greater than 12 months (20 patients). Comparative statistical data were considered significant when p Results The diameters and volumes of LV, Left atrium (LA), right ventricular (RV) diameter and RV wall thickness were increased in Group B. LV ejection fraction (EF) was lower in Group B patients. The GLS was decreased in both Groups and the regression equation with EF were significant (r = 0.74, r ² = 0.55, p Conclusion Decreased EF of LV and SLG was observed in most patients with chronic CHIKV infection. In the first 12 months of evolution, the dimensions of the LV were normal, but after one year, most of the patients had dilatation of the cavity. LV concentric remodeling was more frequent in the first year and eccentric hypertrophy after one year of evolution. Segmental changes were observed in almost a quarter of the cases, as well as a high incidence of arrhythmias. All these findings suggest the progressive nature of the disease. Echocardiography plays an important role in the detection of cardiovascular alterations caused by Chicungunya fever and should be used after confirmation of infection, to initiate appropriate treatment already in the acute phase, which will probably minimize the deleterious effects of disease.

Resumo: Introdução: O momento da pandemia por Covid-19 tem um impacto direto na formação dos estudantes de Medicina, tanto pela modificação repentina na metodologia presencial para remota quanto pelo estresse e pela ansiedade gerados. A saúde mental dos estudantes necessita de estratégias de coping para que eles possam lidar com situações de extrema ansiedade. Relato de experiência: O grupo Estudo de Literatura e Arte na Medicina (Elam) criou, durante o período da pandemia, momentos de discussão de literatura por meio de produção textual e discussões em mídia social, e principalmente por meio de atividades artísticas com pintura em aquarela e artes plásticas, para lidar com os conflitos apresentados pelos alunos na quarentena. Foram 24 telas de aquarela, vídeos, telas de colagem em artes plásticas e textos de crônicas e poesias. Os temas abordados nos textos foram principalmente: amor (N = 2), envelhecer (N = 2), pecado e religiosidade (N = 4), ciclo da vida (N = 6), câncer, caos, sabedoria, mortalidade (N = 3), tempo, olhar e ver (N = 2) e regionalismo (N = 2). Discussão: O enfrentamento da Covid-19 impõe o isolamento social, o distanciamento físico e a restrição à mobilidade das pessoas como medidas fundamentais para evitar a rápida disseminação do vírus. Quando o jovem não dispõe de mecanismos para lidar com a situação estressante propiciada pela situação, pode haver o desencadeamento de uma série de psicopatologias, como depressão, ansiedade e distúrbios do humor. É uma tendência mais ampla na educação médica: cada vez mais, as escolas de Medicina estão investindo em currículo e programação em torno das artes, e, no momento atual, essa estratégia de coping se torna importante no enfrentamento da pandemia pelo estudante de Medicina. Conclusão: Atravessar esse momento de pandemia pela Covid-19 exigiu uma estratégia de coping para ajudar os alunos a vivenciar e extravasar seus medos, sendo a arte a melhor forma de expressão, o que foi atingido pelo grupo Elam.

Introduction According to the WHO, Chagas disease affects 8 to 10 million people, mainly in the Americas and in some European countries, with more than 10 thousand annual deaths. It presents an acute phase followed by a chronic, categorized as indeterminate, cardiac or digestive forms. After infestation, most patients remain asymptomatic, but 40% progress to symptomatic form at the rate of 1.8 to 5% patients/year. Evidence of myocardial fibrosis in 41% of these patients was found by magnetic resonance imaging. Objective To evaluate, by echocardiography, patients with Chagas disease, indeterminate phase, analysing dimensions, function and parameters of deformation and mechanical dispersion in left and right cardiac cavities. Method The study included 44 asymptomatic patients, 36 female, mean age 51 ± 10 years with positive Chagas serology and a control group of 44 healthy individuals, 35 female, mean age 52 ± 10 years. Left and right cavitary dimensions were evaluated, systolic and diastolic function, global myocardial deformation and mechanical dispersion. The groups were compared by the paired "t" test with significance level Results Demographic data (age, body surface area) with no significant differences. Left ventricular (LV) diameters (p Conclusion Asymptomatic patients with Chagas disease (undetermined phase), when compared with healthy individuals of the same age group, presented larger cavitary diameters, diastolic disfunction and, deformation parameters of the left and right ventricles, with increased mechanical dispersion in both chambers. These data seem to corroborate recent results obtained by magnetic resonance imaging with gadolinium, suggesting areas of myocardial fibrosis in these patients.

Objetivo: Avaliar o perfil e os fatores associados ao uso de anticoncepcionais orais combinados (AOC) em regimes de pausa (intermitente) ou estendido (contínuo) em mulheres férteis atendidas em um centro de planejamento familiar. Métodos: Trata-se de um estudo transversal, realizado no Centro de Pesquisa e Assistência em Reprodução Humana (CEPARH), Salvador, Bahia. Resultados: Entre julho e setembro de 2017, 210 mulheres atendidas, consecutivamente, no CEPARH foram entrevistadas. Dessas, 69 (32,8%) fazem uso de algum AOC, das quais 32 (46,4%) utilizam-no em regimes estendidos. Mulheres que trabalham têm 1,89 vezes mais chances de usarem AOC do que as que não trabalham (IC95%: 1,04-3,42; p=0,039). Nenhuma diferença significativa foi observada nas características entre as que fazem uso de AOC em regime de pausa ou estendido (p>0,05). Conclusão: Os resultados indicam que mulheres que trabalham adiam a concepção e utilizam com mais frequência a pílula contraceptiva, independentemente da forma de administração (forma contínua ou intermitente). Ademais, não há nenhum fator que contribua, significativamente, para que as mulheres façam uso estendido das cartelas de AOC.

Introduction Although endoscopic submucosal dissection (ESD) of gastrointestinal (GI) neuroendocrine tumor (NETs) is an increasingly performed minimally invasive technique allowing complete en-bloc resection of mucosal and submucosal lesions, efficacy and safety outcome is limited. The aim of this study is to review two European centers experience of endoscopic treatment of superficial GI NET by ESD. Methods Clinical and technical data of patients treated by ESD from two tertiary European centers were prospectively collected from October 2014 to February 2019. Complete resection (R0) was defined as clear lateral and vertical margins. Results Twenty-four ESDs of NET were performed in 22 patients (females 59%), mean age of 54.8 years. Fifteen NETs (66%) were removed from the stomach, 6 from the rectum (25%), 1 from the esophagus (4%) and 1 from the duodenum (4%). 87.5% of gastric NETs were associated with atrophic gastritis (86.6% of which of autoimmune etiology) and 56% with previous history of multiples NETs. En-bloc resection was achieved in all patients (100%). R0 resection rate was 75% (91.6% clear lateral and 79% clear vertical margins). Lymphovascular infiltration was seen in one case (4%). Median ESD duration time was 77 min (20–240). Two cases presented small perforations, treated conservatively by antibiotics and clip closure. The median specimen size was of 25 mm (12–50). Pathological examination showed 58.3% grade 1, 37.5% grade 2 and 4% grade 3 NETs. Sixteen lesions were characterized as pT1 (72.7%). Three patients were candidates for additional treatment: one had endoscopic mucosal resection for additional known lesions, one underwent surgery with oncological lymph node resection (finally pT2N1) and one refused systemic therapy. At the end of a median follow-up of 18 months, two cases of recurrence were identified: one was managed endoscopically, the second refused treatment. Conclusions Our series of ESD for selected GI NETs showed favorable results in term of efficacy and safety. However, further studies are needed to determine the role of ESD compared to other resection modalities.

Introduction Small bowel diverticula are a rare cause of gastrointestinal (GI) bleeding. Their pathogenesis is still unclear and can be found in up to 1–2% of the general population. Although these lesions are usually asymptomatic, mid-gut bleeding from diverticula in the jejunum or ileum could lead to a life-threatening situation, warranting emergency invasive therapy and often abdominal surgery. Aims and Methods Our aim was to demonstrate the usefulness of the double-balloon enteroscopy (DBE) in the setting of an acute, severe small bowel diverticular bleed. A 79-year-old woman with hypertension and type II diabetes mellitus was referred to our institution with melaena and severe anaemia requiring urgent, repeat blood transfusions. Bidirectional conventional endoscopy did not reveal the cause of bleeding. Small bowel capsule endoscopy (SBCE) showed multiple diverticula within the jejunum and ileum. Emergency computed tomography (CT) mesenteric angiography demonstrated a faint ‘blush’ at one of the jejunal lesions. Results Once the patient w as haemodynamically stable, emergency anterograde DBE was performed under general anaesthesia (GA) in our main operating theatres. The enteroscope was inserted into the jejunum, approximately 1.5 meters post-pylorus. The culprit cause of the bleeding was identified within a large (5 cm orifice) diverticulum, where a large, adherent, pulsating blood clot was seen. In the first instance, peri-lesion, quadrantic injection of a total of 20 mls of adrenaline solution (1 in 10,000 dilution) was performed. The clot was then cautiously removed with a long endoclip to reveal the actively bleeding vessel which was then promptly clipped. A total of 3 clips were placed for effective haemostasis and a submucosal tattoo was placed adjacent to the bleeding point for future reference. The patient remained stable after the procedure and did not require any further blood transfusion. Conclusion DBE facilitated endotherapy is a precise, safe and minimally invasive approach to the effective management of severe bleeding caused by small bowel diverticula.

Introduction Sporadic laterally spreading nonampullary duodenal adenomas (SLSNDA) are an uncommon incidental finding during oesophagogastroduodenoscopy. Endoscopic mucosal resection (EMR) in the duodenum is challenging due to increased risk of perforation and bleeding. Underwater EMR (UEMR) is a novel and effective endoscopic resection technique performed without submucosal injection. Saline-immersion therapeutic endoscopy (SITE) is an evolution of UEMR and saline solution is used instead of water to minimise the risk of water intoxication. Aims and methods Our aim was to evaluate the efficacy and safety of SITE-EMR for SLSNDA via a retrospective review of SLSNDA resected by SITE-EMR at our institution from May 2017 to October 2018. Demographic, clinical, endoscopic findings and follow-up data were analysed. Results Nine SLSNDA (median size 25 mm) were found in eight patients (4 male, median age: 69 year-old). One was located in D1, 4 in D2 and 4 in D3. En-bloc resection was achieved in two lesions (23%) while wide-field resection was performed in seven lesions (77%). Complete resection was achieved in seven patients (87.5%). A circumferential lesion involving the whole duodenal bulb was found in one case and SITE-EMR technique was not feasible as well as other alternative endoscopic resection techniques due to severe fibrosis; the patient was therefore referred for surgery and excluded from further analysis. Histological results revealed six (75%) tubulo-villous adenomas with low-grade dysplasia and two tubular adenomas low-grade dysplasia (25%). Immediate complications including perforation and bleeding did not occur. One patient (12.5%) presented with delayed GI bleeding 24hours post procedure and was treated successfully with endoclips. Three cases (37.5%) of recurrences were identified at 3 months follow-up requiring further endoscopic treatment. No further recurrence was identified at 6 and 12 months follow-up in any patient. Conclusion SITE-EMR of SLSNDA appears to be a safe and effective management with low recurrence rates at long term follow-up.

Introduction Buried bumper syndrome (BBS) is an uncommon complication of percutaneous endoscopic gastrostomy (PEG) placement, with an incidence of 1%. Several techniques for endoscopic management of BBS have been described, given the absence of a dedicated device to date. Methods A 94-year-old man presented with fever and PEG obstruction. A PEG had been placed in 2014 for enteral feeding in the context of dysphagia, secondary to Parkinson’s disease. On examination, the cutaneous side of the PEG tract appeared erythematous and oedematous, with seepage of purulent mucus; any attempt to mobilise the PEG tube though external manipulation proved futile. Results At upper gastrointestinal (GI) endoscopy, a 4 cm elevated area of granulomatous tissue with a central depression was identified on the proximal anterior wall of the gastric antrum, confirming the suspected diagnosis of BBS. A 2.5 mm ball-tip, needle-type knife was initially used to incise the granulomatous tissue, allowing intra-gastric passage of a guidewire, pushed through the cutaneous aspect of the PEG tract. The use of a novel, sphincterotome-like, dedicated device, designed for radial incision of BBS-related intra-gastric granulomatous tissue (Flamingo Set, Medwork, Hochstadt, Germany) was then applied. This device was inserted over the guidewire into the stomach, through the external aspect of the partially cut PEG tube. The guidewire was subsequently withdrawn and the distal part of the Flamingo device was flexed by 180°, exposing the bow-string, sphincterotome-like, cutting wire. External traction was then applied to the Flamingo device from the cutaneous side of the PEG tract. Optimal apposition of the cutting wire and the granulomatous tissue was achieved through direct endoscopic visualisation. The overgrown tissue was then incised by a series of radial cuts until the plastic bumper was exposed. The PEG bumper and remnant of the externally cut PEG tube was then released into the gastric lumen through gentle, external manipulation. As a pre-cautionary measure, the excision site was partially closed by deployment of through-the-scope endoclips. The whole procedure was performed under conscious sedation and broad-spectrum, intravenous antibiotic prophylaxis; no immediate, early or late adverse events were encountered. A new PEG insertion was successfully achieved at an alternative site, 2 weeks later. Conclusions To the best of our knowledge, this is the first use of the ‘Flamingo Set’ for BBS. Through our preliminary experience, this novel, dedicated device appears to be user-friendly, safe, quick and effective for minimally invasive, endoscopic management of BBS and warrants further study.

Introduction Colorectal endoscopic submucosal dissection (ESD) is a well-established minimally invasive resection technique. When the so-called muscle-retracting (MR) sign is encountered during ESD, complete resection may not be feasible. The pocket creation method (PCM) allows easier recognition of the submucosal space in the context of fibrosis and MR sign. To date, both magnifying endoscopy and endoscopic ultrasound may not be able to show invasive cancer, especially for lateral spreading tumor (LST) with a large nodule. Therefore it may be difficult to predict if any MR sign is caused by fibrosis or deep submucosal invasion. Methods Our aim was to highlight the characteristics of deep submucosal invasion during PCM-ESD. A 74-year-old man had a colonoscopy due to haematochezia and a large granular, mixed-nodular LST was identified in the proximal rectum. Endoscopic assessment of the lesion with near focus, indigo carmine and narrow band imaging (NBI) did not reveal any sign of Kudo pit pattern Vn, JNET type 3 surface findings, or any other definitive sign of intramucosal or deeply invasive cancer. For this reason we proceeded with saline-immersion therapeutic endoscopy (SITE) facilitated PCM-ESD. Results After dissection of the distal part of the lesion, the MR sign was encountered within the submucosal pocket, underneath a large nodule. Despite continuing dissecting this severely fibrotic submucosal area using the PCM technique, increasing severity of submucosal fibrosis and repeated bleeding from convergent, irregular submucosal neovascularisation around the MR site (with an appearance akin to ‘solar flares’), impeded further resection. ESD was therefore discontinued due to high suspicion for submucosal invasion. Histopathological analysis of biopsies taken from the MR area confirmed deep submucosal invasion. Conclusions Our findings reinforce the suspicion that a flare of neovascularisation convergent onto the MR area is suggestive of deep submucosal invasion. In this scenario ESD could be discontinued and surgical options should be considered.

Introduction Blue rubber bleb nevus syndrome (BRBNS) is an extremely rare systemic vascular disorder characterised by multiple cutaneous and gastrointestinal venous malformations. Patients present with fatigue, iron deficiency anaemia (IDA) and occult or overt gastrointestinal (GI) bleeding. Patients are usually treated with conservative management including iron supplementation and blood transfusions. However, endoscopic (argon plasma coagulation, sclerotherapy, polypectomy, band ligation etc), radiological and surgical approaches are preferred for severe cases. Aims and Methods A 7-year-old female patient with iron deficiency anaemia and multiple cutaneous lesions was diagnosed with BRBNS at a local hospital. The patient was referred to our institution for further management due to blood transfusions dependence and PR bleeding. A small bowel capsule endoscopy (SBCE) revealed two vascular lesions in the small bowel. Results An anterograde double-balloon enteroscopy (DBE) was the performed under general anaesthesia. Two 20 mm vascular lesions were identified in the gastric body. A loop ligating device (Olympus, Tokyo, Japan) was applied around the base of each lesion then tightened and completely detached. No further vascular malformations were found in the duodenum, jejunum and proximal ileum. Although the number of units of blood transfusion decreased over the next 6 months a follow-up retrograde DBE was performed due to persistent anaemia. Six lesions were identified in the transverse colon (2), caecum (1) and distal ileum (3). Ligation loop was used for 2 colonic lesions while two ileac rubber blub lesions were treated with both ligation loop and metallic clips. Since the 2 remaining lesions were flat and floppy, loop ligation was not technically feasible. No immediate and post procedural complications (including delayed bleeding) occurred. Conclusion DBE facilitated loop ligation appears to be a safe and minimally invasive option in patients affected by BRBNS reducing the blood transfusion dependence.

BACKGROUND AND OBJECTIVES: Palliative care is a set of practices that encompasses patients with life-threatening diseases which approach is no longer curative, but comforting, including care for the family. The objective of this study was to verify the epidemiological profile of cancer patients in palliative care. METHODS: We interviewed 100 cancer patients in palliative care, as well as the sociodemographic and biopsychosocial variables, using the Karnofsky index, Palliative Performance Scale and Edmonton Symptom Assessment Scale. RESULTS: The prevalent age group was between 51-60 years (34%), more than half female (77%), incomplete elementary school (40%) and resident in the interior of Maranhão (73%). Concerning the use of pain drugs, 52% reported not forgetting to take their pain drug, while 56% took drug on their own. As to the diagnosis, only 13% of the interviewees were aware of a palliative diagnosis, and more than half of them were aware of primary or oncological diagnosis (65%). Regarding the evaluation of functional capacity, 52% had the Karnofskys index between 70 and 90%; Palliative Performance Scale, 62% between 80 and 90%, and Edmonton Symptom Assessment Scale the following most significant variables in tiredness, (60%); sadness, (84%); anxiety, (73%); lack of appetite, (51%) and absence of well-being (79%). CONCLUSION: Knowing the profile of patients is key to identify the obstacles to the effective implementation of palliative care, making it possible to implement targeted measures. RESUMO JUSTIFICATIVA E OBJETIVOS: Os cuidados paliativos são um conjunto de práticas que abrangem pacientes portadores de doenças ameaçadoras da vida e cuja abordagem deixa de ser curativa e passa a ser baseada em conforto, incluindo cuidados com a família. O objetivo deste estudo foi verificar o perfil epidemiológico de pacientes oncológicos em cuidados paliativos. MÉTODOS: Foram entrevistados 100 pacientes oncológicos em cuidados paliativos quanto às variáveis sociodemográficas e biopsicossociais, utilizando-se o índice de Karnofsky, a Escala de Performance Paliativa e a Escala de Avaliação de Sintomas de Edmonton. RESULTADOS: Observou-se faixa etária mais prevalente entre 51 e 60 anos (34%), mais da metade do sexo feminino (77%), nível escolar fundamental incompleto (40%) e residente no interior do Maranhão (73%). Quanto ao uso de analgésicos, 52% relataram não esquecer de tomar o fármaco para dor; enquanto 56% tomam fármaco por conta própria. Quanto ao diagnóstico, apenas 13% dos entrevistados conhecem o diagnóstico paliativo, e mais da metade conhece o diagnóstico primário ou oncológico (65%). Quanto à avaliação da capacidade funcional, 52% tem índice de Karnofsky avaliado entre 70 e 90%; Escala de Performance Paliativa, 62% estão entre 80 e 90% e Escala de Avaliação de Sintomas de Edmonton as seguintes variáveis mais significantes em cansaço, (60%); tristeza, (84%); ansiedade, (73%); falta de apetite, (51%) e ausência de bem-estar (79%). CONCLUSÃO: Conhecer o perfil de pacientes é relevante para a identificação pontual de obstáculos na implementação efetiva dos cuidados paliativos. Possibilitando assim, a implementação de medidas direcionadas.

Background and Aims Self-expandable metal stents (SEMSs) are used for palliation of malignant gastric outlet obstruction (GOO). Studies comparing covered SEMSs (C-SEMSs) and uncovered SEMSs (U-SEMSs) have led to inconclusive results. We compared efficacy and safety of C-SEMSs versus U-SEMSs in patients with GOO. Methods We searched MEDLINE, EMBASE, and Cochrane Library from 2000 to 2019 to identify available studies comparing C-SEMSs versus U-SEMSs in patients with GOO. Primary outcomes were stent survival and patient survival, whereas secondary outcomes were clinical and technical success, Gastric Outlet Obstruction Score System (GOOSS) score after the procedure, overall adverse events, reintervention rate, dysfunction rate, stent occlusion, and stent migration. Results Overall, 7 randomized controlled trials and 9 observational studies were identified that included 1741 patients. C-SEMSs were associated with higher stent survival (hazard ratio, .68; 95% confidence interval [CI], .48-.96), whereas patient survival did not statistically significantly differ between C-SEMS and U-SEMS groups (hazard ratio, .96; 95% CI, .75-1.23). Clinical and technical success were not statistically different between groups (odds ratios, 1.1 [95% CI, .76-1.61] and .69 [95% CI, .21-2.3], respectively). There were no differences in terms of overall adverse events, reintervention rate, dysfunction rate, and GOOSS rate ≥2 after SEMS placement. U-SEMSs were associated with a higher rate of occlusion (odds ratio, .34; 95% CI, .21-.53) and C-SEMSs with a higher rate of migration (odds ratio, 4.28; 95% CI, 2.79-6.57). Conclusions C-SEMSs were associated with higher stent survival (time between stent deployment and stent dysfunction) compared with U-SEMSs, whereas no differences in terms of patient survival (time between stent deployment and patient's death) emerged. However, U-SEMSs were associated with higher risk of occlusion and C-SEMSs with higher risk of migration. Further studies using new C-SEMSs with an antimigration system are needed.

1558 Background: Cervical cancer (CC) still represents a public health priority in Brazil, with estimated incidence of 15,43 cases per 100.000 women. CC is the most frequent cause of cancer and cancer-related mortality in women in the state of Maranhão. The Brazilian national screening program recommends cervical cytology (Pap test) every 3 years in women 25-64 years old. Although of public access, the screening program continues to be non-organized. This was a real-life CC screening intervention through a mobile screening unit (MSU) in communities of São Luis, Maranhão. Methods: Prospective, intervention-based, analytic study, from April to August, 2018. Women in the assisted communities were offered Pap tests. Tests were collected and results were retrieved within 4 weeks along with further screening recommendations. Quality control and monitoring of the test were done. A structured questionnaire was applied. Results: 960 tests were collected and 545 women answered the questionnaire. Median age: 43 (34 – 52), with 88.2% of women within the target age. Socioeconomic charachteristics: 47.3% completed high school education; 37.8% were housewives, 16.1% were unemployed; 56.3% were married; 59.8% had a monthly family-income up to 1 minimum wage ($ 250,00). Previous Pap tests and difficulties: 94.1% had at least one previous test; 78,2% had a test within the past 3 years; 48.4% referred to dificculties to scheduling, 23.3% time constraints, 11.2% being ashamed, and 10.4% financial restrains. There were 65 (6.9%) abnormal results (LSIL in 3%, HSIL in 0.7%, and in situ adenocarcinoma in 1 case), for whom further investigation was recommended. Follow-up was possible in 31 of these cases. More than 50% were still awaiting for additional screening tests at time of contact (>6 month interval). Conclusions: MSU strategy faccilitated the access to Pap tests, their results and recommendations. Although Pap test was easily available, the non-organized process of invitation, follow-up and referal of positive cases for further investigation, as offered by the Brazilian public health services, limit screening efficacy and CC control.