Rifaximin on epigenetics and autophagy in animal model of hepatocellular carcinoma secondary to metabolic-dysfunction associated steatotic liver disease

BACKGROUND Prevalence of hepatocellular carcinoma(HCC)is increasing,especially in patients with metabolic dysfunctionassociated steatotic liver disease(MASLD).AIM To investigate rifaximin(RIF)effects on epigenetic/autophagy markers in animals.METHODS Adult Sprague-Dawley rats were randomly assigned(n=8,each)and treated from 5-16 wk:Control[standard diet,water plus gavage with vehicle(Veh)],HCC[high-fat choline deficient diet(HFCD),diethylnitrosamine(DEN)in drinking water and Veh gavage],and RIF[HFCD,DEN and RIF(50 mg/kg/d)gavage].Gene expression of epigenetic/autophagy markers and circulating miRNAs were obtained.RESULTS All HCC and RIF animals developed metabolic-dysfunction associated steatohepatitis fibrosis,and cirrhosis,but three RIF-group did not develop HCC.Comparing animals who developed HCC with those who did not,miR-122,miR-34a,tubulin alpha-1c(Tuba-1c),metalloproteinases-2(Mmp2),and metalloproteinases-9(Mmp9)were significantly higher in the HCC-group.The opposite occurred with Becn1,coactivator associated arginine methyltransferase-1(Carm1),enhancer of zeste homolog-2(Ezh2),autophagy-related factor LC3A/B(Map1 Lc3b),and p62/sequestosome-1(p62/SQSTM1)-protein.Comparing with controls,Map1 Lc3b,Becn1 and Ezh2 were lower in HCC and RIF-groups(P<0.05).Carm1 was lower in HCC compared to RIF(P<0.05).Hepatic expression of Mmp9 was higher in HCC in relation to the control;the opposite was observed for p62/Sqstm1(P<0.05).Expression of p62/SQSTM1 protein was lower in the RIF-group compared to the control(P=0.024).There was no difference among groups for Tuba-1c,Aldolase-B,alpha-fetoprotein,and Mmp2(P>0.05).miR-122 was higher in HCC,and miR-34a in RIF compared to controls(P<0.05).miR-26b was lower in HCC compared to RIF,and the inverse was observed for miR-224(P<0.05).There was no difference among groups regarding miR-33a,miR-143,miR-155,miR-375 and miR-21(P>0.05).CONCLUSION RIF might have a possible beneficial effect on preventing/delaying liver carcinogenesis through epigenetic modulation in a rat model of MASLD-HCC.

Glucose-6-phosphate-dehydrogenase deficiency and its correlation with other risk factors in jaundiced newborns in Southern Brazil

Objective:To evaluate the correlation between glucose-6-phosphate-dehydrogenase(G6PD) deficiency and neonatal jaundice.Methods:Prospective,observational case-control study was conducted on 490 newborns admitted to Hospital de Clinicas de Porto Alegre for phototherapy, who all experienced 35 or more weeks of gestation,from March to December 2007.Enzymatic screening of G6PD activity was performed,followed by PCR.Results:There was prevalence of 4.6% and a boy-girl ratio of 3:1 in jaundiced newborns.No jaundiced neonate with ABO incompatibility presented G6PD deficiency,and no Mediterranean mutation was found.A higher proportion of deficiency was observed in Afro-descendants.There was no association with UGT1A1 variants. Conclusions:G6PD deficiency is not related to severe hyperbilirubinemia and considering the high miscegenation in this area of Brazil,other gene interactions should be investigated.

Bone-marrow derived cells participate in extramedullary hematopoiesis in a model of acetaminophen-induced acute liver failure in rats

Adult derived mononuclear bone marrow cells are a good alternative as cell therapy. These cells are capable of significantly improve survival rate of Wistar rats with acetaminophen (APAP) induced acute liver failure in ten days. However, long term of cell therapy is not deeply studied in the literature. Here, we report an extramedullary hematopoiesis process derived from transplanted mononuclear bone marrow cells in the liver of rats 10 days after APAP injection. This result indicates that liver maintains an adequate microenvironment for the occurrence of extramedullary hematopoiesis process. The consequence of this finding deserves more studies.

Hereditary Angioedema in Pregnancy and Management without Recombinant Human C1-INH

A pregnant woman diagnosed with type 1 angioedema seeks care at a public hospital for planning the delivery. This report presents ways to prevent and manage an acute HAE crisis during childbirth and early postpartum without the availability of first-line medications, such as plasma-derived human C1-INH concentrate.

Correlation between Endocervical Length in the First Trimester and Spontaneous Preterm Delivery

Introduction: Prematurity is a public health problem in Brazil, with 12% of deliveries occurring before 37 weeks of gestation. The measurement of the cervix in the second trimester is already established as a method of screening for prematurity and some studies point out advantages to start this screening in the first trimester. Objective: To define the correlation between the length of the endocervix by transvaginal ultrasound in the first trimester (11 to 14 weeks) with spontaneous early deliveries. Method: A prospective and observational study realized in a suplementar and private ultrasound clinic and hospital of Porto Alegre, Brazil between 2019-2020. Ultrasound screening of cervix was performed in singleton pregnancies in first and second trimester of pregnancy and correlated with age of delivery. Results: 142 pregnant women were studied, 80% were in the first pregnancy. The average age was 33.8 years. The rate of prematurity was 18% before 37 weeks and 4% before 34 weeks. The average of cervix measured in the first and second trimesters in deliveries before 34 weeks was 32.7 mm and 29.3 mm, respectively. In term deliveries the median cervical length was 38.8 mm and 37.8 mm, respectively. When analyzing the measurements of the cervix in the second trimester, the cervix was smaller (p = 0.008) among deliveries below 34 weeks (29 mm) than deliveries after 37 weeks. No statistically related differences were found between preterm birth and first trimester cervix measurements. Conclusions: In this study, we did not observe a statistically significant relationship between first trimester cervix measurement and prematurity. More studies are needed to evaluate this finding. However, the measurement of the cervix in the second trimester is different from that found in the literature. This suggests a possible new cut-off point that increases the sensitivity of transvaginal ultrasound as a method of preventing prematurity.

Real-world disease activity and sociodemographic,clinical and treatment characteristics of moderate-to-severe inflammatory bowel disease in Brazil

BACKGROUND Understanding the treatment landscape of inflammatory bowel diseases(IBD)is essential for improving disease management and patient outcomes.Brazil is the largest Latin American country,and it presents socioeconomic and health care differences across its geographical regions.This country has the highest increase in IBD incidence and prevalence in Latin America,but information about the clinical and treatment characteristics of IBD is scarce.AIM To describe the sociodemographic,clinical,and treatment characteristics of IBD outpatients in Brazil overall and in the Southeast,South and Northeast/Midwest regions.METHODS Multicenter,cross-sectional study with a 3-year retrospective chart review component.Patients with moderate-to-severe Crohn’s disease(CD)or ulcerative colitis(UC)were consecutively enrolled between October 2016 and February 2017.Active CD at enrollment was defined as a Harvey Bradshaw Index≥8 or a CD Activity Index≥220 or a calprotectin level>200μg/g or an active result based on colonoscopy suggestive of inadequate control during the previous year;active UC was defined as a partial Mayo score≥5.Descriptive statistics were used to analyze all variables.RESULTS In a total of 407 included patients,CD was more frequent than UC,both overall(264 CD/143 UC patients)and by region(CD:UC ratios of 2.1 in the Southeast,1.6 in the South and 1.2 in the Northeast/Midwest).The majority of patients were female(54.2%of CD;56.6%of UC),and the mean ages were 45.9±13.8 years(CD)and 42.9±13.0 years(UC).The median disease duration was 10.0(range:0.5-45)years for both IBD types.At enrollment,44.7%[95%confidence interval(CI):38.7-50.7]of CD patients and 25.2%(95%CI:18.1-32.3)of UC patients presented with active disease.More than 95%of IBD patients were receiving treatment at enrollment;CD patients were commonly treated with biologics(71.6%)and immunosuppressors(67.4%),and UC patients were commonly treated with mesalazine[5-Aminosalicylic acid(5-ASA)]derivates(69.9%)and immunosuppressors(44.1%).More than 50%of the CD patients had ileocolonic disease,and 41.7%presented with stricturing disease.One-quarter of CD patients had undergone CD-related surgery in the past 3 years,and this proportion was lower in the Northeast/Midwest region(2.9%).CONCLUSION In Brazil,there are regional variations in IBD management.CD outweighs UC in both frequency and disease activity.However,one-quarter of UC patients have active disease,and most are receiving 5-ASA treatment.

Study on little active and sedentary women: Comparison between protocols and prospects for admission in physical activity program

The aim of this work was to study little active and sedentary women through physical assessments using anthropometric measurements and exercise testing using the Naughton and Bruce protocols. Approximately 53 women were evaluated: Group 1—comprised of 17 completely sedentary women, aged 25-58 years, mean age 44.4 years, and Group 2—comprised of 36 women who answered doing physical activities once or twice a week (low active), aged 28-54 years, mean age 39.5 years. The results Group 1— high weight, body mass index showing overweight, heart rate above the target areas of your training, i.e., above 85% effort. Systolic blood pressure reached a high level in the seventh stage with 21 minutes of effort (177.3) and diastolic (92.7). Group 2—normal weight, body mass index recorded is considered thin, heart rate heart zones above the target of your training, i.e., above 85% effort also. Systolic blood pressure reached the highest level in phase 1 recovery (156.75). Diastolic blood pressure recorded pressure levels considered normal for the type of work done by the group. The values reported for the double product are considered normal for the type of effort made by both groups. Conclusion: The participants from group 1 are able to join physical activity programs from the results presented, specifically due to weight, BMI, heart rate and blood pressure. The participants from group 2 require more days of practice of physical activities and longer hours to improve the levels of heart rate and blood pressure.

Evolving treatment strategies for colorectal cancer: A critical review of current therapeutic options

Management of rectal cancer has markedly evolved over the last two decades.New technologies of staging have allowed a more precise definition of tumor extension.Refinements in surgical concepts and techniques have resulted in higher rates of sphincter preservation and better functional outcome for patients with this malignancy.Although,preoperative chemoradiotherapy followed by total mesorectal excision has become the standard of care for locally advanced tumors,many controversial matters in management of rectal cancer still need to be defined.These include the feasibility of a non-surgical approach after a favorable response to neoadjuvant therapy,the ideal margins of surgical resection for sphincter preservation and the adequacy of minimally invasive techniques of tumor resection.In this article,after an extensive search in PubMed and Embase databases,we critically review the current strategies and the most debatable matters in treatment of rectal cancer.

Liver preservation prior to transplantation: Past, present, and future

Since Dr. Thomas Starzl performed the first series of successful liver transplants(LTs), important advances have been made in immunosuppression, operative techniques, and postoperative care. In 1988, Belzer's group reported the first successful LT using the University of Wisconsin preservation solution(UW).Since then, UW has replaced EuroCollins solution and allowed prolonged and safer preservation of liver, kidney, and pancreas allografts, thus contributing to the improvement of transplant outcomes. Although UW is still considered the standard of care in the United States and in several countries worldwide, a recent meta-analysis revealed similar LT outcomes among UW, Celsior solution, and the Institut Georges Lopez-1 preservation solution, which were slightly superior to those obtained with histidine-tryptophan-ketoglutarate preservation solution.Dynamic preservation has been recently developed, and liver allografts are preserved mainly through the following methods: hypothermic machine perfusion, normothermic machine perfusion, and subnormothermic machine perfusion. Their use has the potential advantage of improving clinical results in LT involving extended criteria donor allografts. Although associated with increased costs, techniques employing machine perfusion of liver allografts have been considered clinically feasible. This editorial focuses on recent advances and future perspectives in liver allograft preservation.

Endothelial dysfunction as a predictor of cardiovascular disease in type 1 diabetes

Macro and microvascular disease are the main cause of morbi-mortality in type 1 diabetes(T1DM).Although there is a clear association between endothelial dysfunction and atherosclerosis in type 2 diabetes,a cause-effect relationship is less clear in T1 DM.Although endothelial dysfunction(ED) precedes atherosclerosis,it is not clear weather,in recent onset T1 DM,it may progress to clinical macrovascular disease.Moreover,endothelial dysfunction may either be reversed spontaneously or in response to intensive glycemic control,long-term exercise training and use of statins.Acute,long-term and post-prandial hyperglycemia as well as duration of diabetes and microalbuminuria are all conditions associated with ED in T1 DM.The pathogenesis of endothelial dysfunction is closely related to oxidative-stress.NAD(P)H oxidase over activity induces excessive superoxide production inside the mitochondrial oxidative chain of endothelial cells,thus reducing nitric oxide bioavailability and resulting in peroxynitrite formation,a potent oxidant agent.Moreover,oxidative stress also uncouples endothelial nitric oxide synthase,which becomes dysfunctional,inducing formation of superoxide.Other important mechanisms are the activation of both the polyol and protein kinase C pathways as well as the presence of advanced glycation end-products.Future studies are needed to evaluate the potential clinical applicability of endothelial dysfunction as a marker for early vascular complications in T1 DM.

Contribution of endoscopy in the management of eosinophilic esophagitis

Eosinophilic esophagitis (EoE) is a clinicopathological entity characterized by a set of symptoms similar to gastroesophageal reflux disease and eosinophilic infi ltration of the esophageal epithelium. EoE is an emerging worldwide disease as documented in many countries. Recent reports indicate that EoE is increasingly diagnosed in both pediatric and adult patients although the epidemiology of this new disease entity remains unclear. It is unclear whether EoE is a new disease or a new classification of an old esophageal disorder. Esophagogastroduodenoscopy (EGD) and biopsies with histological examination of esophageal mucosa are required to establish the diagnosis of EoE, verify response to therapy, assess disease remission, document and dilate strictures and evaluate symptom recurrence of EoE. Repeated endoscopies with biopsies are necessary for monitoring of disease progression and treatment effi cacy. EGD has a fundamental role in the diagnosis and management of EoE, forming an essential part of the investigation and follow-up of this condition. EoE is now considered a systemic disorder and not only a local condition with an important immunological back-ground. One of the aims of research in EoE is to study non-invasive markers, such as immune indicators found in plasma, that correlate with local presence of EoE in esophageal tissues. Studies over the next few years will provide new information about diagnosis, pathogenesis, endoscopic/histologic criteria, non-invasive markers, novel and more eff icacious treatments, as well as establishing natural history. Randomized clinical trials are urgently called for to inform non-invasive diagnostic tests, hallmarks of natural history and more eff icacious treatment approaches for patients with EoE. The collaboration between pediatric and adult clinical and experimental studies will be paramount in the understanding and management of this disease.

Exercise manual for liver disease patients

AIM: To increase inspiratory muscle strength and improve the quality of life of candidates for liver transplantation.METHODS: Twenty-three candidates for liver transplantation participated in the control group and 14 made up the intervention group. The control group consisted of 18 men and 5 women, body mass index(BMI) 27.3 ± 4.5 kg/m2 and Model for End-Stage Liver Disease(MELD) 18.2 ± 6.1. The intervention group consisted of 11 men and 3 women, BMI 28.6 ± 5.4 kg/m2 and MELD 18 ± 4.5. The presence or absence of ascites was identified in the first patient evaluation and after three months. We evaluated maximal inspiratory pressure(MIP) and maximal expiratory pressure, spirometry, root mean square(RMS) of diaphragm and rectus abdominis, and the quality of life. The exercises were performed daily by patients at home for three months and were supervised at distance monthly. The manual consisted of diaphragmatic breathing exercises, diaphragmatic isometric exercise, Threshold IMT&#174;, lifting upper limbs with a bat and strengthening the abdomen. RESULTS: There was significant difference(P = 0.01) between the first(initial) and the third month(final) MIP in the control group and in the intervention group, but there was no difference(P = 0.45) between the groups.The RMS of the diaphragm was lower(P = 0.001) and the functional capacity was higher(P = 0.006) in the intervention group compared to the control. The general health and mental health domains received higher scores after three months in the control group(P = 0.01) and the intervention group(P = 0.004), but there was no significant difference between them. The comparison between the presence of initial ascites with the presence of ascites was performed after three months in the control group(P = 0.083) and intervention group(P = 0.31). There was no significant difference, in relation to the presence of ascites after three months between groups(P = 0.21). In the intervention group, patients with ascites at the end of the time period had decreased scores on the social aspects SF-36 domain(P = 0.023) compared to those who had no ascites. CONCLUSION: The proposed exercises provide an increase in the inspiratory muscle strength and improve functional capacity, consequently bettering the quality of life of liver disease patients.

Parkin protein expression and its impact on survival of patients with advanced colorectal cancer

Objective:Features of colorectal cancer such as natural history,molecular,chromosomal,and epigenetic alterations have been well described.However,there is still a lack of accurate prognostic markers,which is evident by the lower overall survival rates of patients with advanced cancer.Although alterations in parkin protein expression have been described in colorectal cancer,the functional significance of this protein remains unknown.The present study aimed to investigate the involvement of parkin expression in colorectal adenocarcinoma development and progression by evaluating the association between its expression,clinicopathological parameters,and expression of known proteins involved in colorectal cancer.Methods:Tissue microarrays consisting of 73 tumor and 64 normal tissue samples were generated to examine parkin expression and localization by immunohistochemistry.Results:A positive correlation of parkin and APC expression was observed in the superficial,intermediate,and profound regions of all cases(ρ=0.37;P=0.001).Parkin expression was also significantly associated with tumors in men(P=0.049),those of the mucinous subtype(P=0.028),and of advanced stage(III+IV,P=0.041).In addition,increased parkin expression was observed in the invasive front tumor region(P=0.013).More importantly,a positive correlation was found between parkin expression and the overall survival of patients with advanced colorectal cancer(P=0.019).Multivariate analysis showed that parkin expression was independent of any of the clinicopathological parameters evaluated in relation to patient survival.Conclusions:These results suggest that parkin expression status can be used as a potential independent prognostic marker of survival in advanced colorectal cancer.

New approaches for patients with advanced radioiodine-refractory thyroid cancer

The cumulative evidence over the past decades has shown that the incidence of differentiated thyroid carcinoma(DTC)has exponentially increased.Approximately 10%of patients with DTC exhibit recurrent or metastatic disease,and about two-thirds of the latter will be defined as refractory to radioactive iodine(RAIR)treatment.Since this condition implies 10-year survival rates less than 10% after detection,using available treatments,such as systemic and targeted therapies,have become increasingly relevant.The initiation of these treatments aims to reach stabilization,tumor volume reduction,and/or symptom improvement and it should be decided by highly specialized endocrinologists/oncologists on the basis of patient’s features.Considering that despite enlarged progression-free survival was proven,multikinase inhibitors remain non-curative,their benefits last for a limited time and the side effects potentially cause harm and quality of life reduction.In this context,molecular testing of cancer cells provides a promising spectrum of targeted therapies that offer increased compatibility with individual patient needs by improving efficacy,progression free survival,overall survival and adverse events profile.This review article aims to provide a summary of the current therapeutic strategies in advanced RAIR-DTC,including approved target therapies as well as those for off-label use,RAI resensitization agents,and immunotherapy.

Corticosteroids for severe influenza pneumonia: A critical appraisal

Influenza pneumonia is associated with high number of severe cases requiring hospital and intensive care unit(ICU) admissions with high mortality. Systemic steroids are proposed as a valid therapeutic option even though its effects are still controversial. Heterogeneity of published data regarding study design, population demographics, severity of illness, dosing, type and timing of corticosteroids administered constitute an important limitation for drawing robust conclusions. However, it is reasonable to admit that, as it was not found any advantage of corticosteroid therapy in so diverse conditions, such beneficial effects do not exist at all. Its administration is likely to increase overall mortality and such trend is consistent regardless of the quality as well as the sample size of studies. Moreover it was shown that corticosteroids might be associated with higher incidence of hospital-acquired pneumonia and longer duration of mechanical ventilation and ICU stay. Finally, it is reasonable to conclude that corticosteroids failed to demonstrate any beneficial effects in the treatment of patients with severe influenza infection. Thus its current use in s evere influenza pneumonia should be restricted to very selected cases and in the setting of clinical trials.

Quality of life, work productivity impairment and healthcare resources in inflammatory bowel diseases in Brazil

BACKGROUND Inflammatory bowel diseases(IBD)have been associated with a low quality of life(QoL)and a negative impact on work productivity compared to the general population.Information about disease control,patient-reported outcomes(PROs),treatment patterns and use of healthcare resources is relevant to optimizing IBD management.AIM To describe QoL and work productivity and activity impairment(WPAI),treatment patterns and use of healthcare resources among IBD patients in Brazil.METHODS A multicenter cross-sectional study included adult outpatients who were previously diagnosed with moderate to severe Crohn’s disease(CD)or ulcerative colitis(UC).At enrolment,active CD and UC were defined as having a Harvey Bradshaw Index≥8 or a CD Activity Index≥220 or calprotectin>200μg/g or previous colonoscopy results suggestive of inadequate control(per investigator criteria)and a 9-point partial Mayo score≥5,respectively.The PRO assessment included the QoL questionnaires SF-36 and EQ-5D-5L,the Inflammatory Bowel Disease Questionnaire(IBDQ),and the WPAI questionnaire.Information about healthcare resources and treatment during the previous 3 years was collected from medical records.Chi-square,Fisher’s exact and Student’s t-/Mann-Whitney U tests were used to compare PROs,treatment patterns and the use of healthcare resources by disease activity(α=0.05).RESULTS Of the 407 patients in this study(CD/UC:64.9%/35.1%,mean age 42.9/45.9 years,54.2%/56.6%female,38.3%/37.1%employed),44.7%/25.2%presented moderate-to-severe CD/UC activity,respectively,at baseline.Expressed in median values for CD/UC,respectively,the SF-36 physical component was 46.6/44.7 and the mental component was 45.2/44.2,the EQ-visual analog scale score was 80.0/70.0,and the IBDQ overall score was 164.0/165.0.Moderate to severe activity,female gender,being unemployed,a lower educational level and lower income were associated with lower QoL(P<0.05).Median work productivity impairment was 20%and 5%for CD and UC patients,respectively,and activity impairment was 30%,the latter being higher among patients with moderate to severe disease activity compared to patients with mild or no disease activity(75.0%vs 10.0%,P<0.001).For CD/UC patients,respectively,25.4%/2.8%had at least one surgery,38.3%/19.6%were hospitalized,and 70.7%/77.6%changed IBD treatment at least once during the last 3 years.The most common treatments at baseline were biologics(75.3%)and immunosuppressants(70.9%)for CD patients and 5-ASA compounds(77.5%)for UC patients.CONCLUSION Moderate to severe IBD activity,especially among CD patients,is associated with a substantial impact on QoL,work productivity impairment and an increased number of IBD surgeries and hospitalizations in Brazil.

Esophagogastric junction outflow obstruction successfully treated with laparoscopic Heller myotomy and Dor fundoplication: First case report in the literature

BACKGROUND Esophagogastric junction outflow obstruction(EGJOO) is a rare syndrome,characterized by an elevation of the integrated relaxation pressure of the lower esophageal sphincter, not accompanied by alterations in esophageal motility that may lead to the criteria for achalasia. We were unable to find any prior report of the combination of Heller myotomy with anterior partial fundoplication(Dor) as the treatment for EGJOO. We herein report a case of EGJOO treated with laparoscopic Heller myotomy combined with Dor fundoplication.CASE SUMMARY A 26-year-old man presented with a 3-year history of solid dysphagia and a 30-kg weight loss. He was treated with oral nifedipine, isosorbide, and omeprazole,without resolution of symptoms. An upper gastrointestinal series(barium swallow) revealed a "bird's beak" sign. Esophagogastroduodenoscopy was positive for Los Angeles grade A peptic esophagitis. High-resolution esophageal manometry was compatible with EGJOO. Esophageal pH monitoring showed pathological acid reflux both in orthostatic and decubitus position. An 8-cm laparoscopic Heller myotomy combined with an anterior 220° Dor fundoplication was performed. Solid diet was introduced on postoperative day 2, and the patient was discharged home the same day. At 17-mo follow-up, he reported no symptoms. Barium swallow was compatible with complete radiologic resolution.Both esophageal manometry and upper endoscopy showed normal findings 9 mo after the operation.CONCLUSION Surgical treatment with Heller myotomy and Dor fundoplication is a potential treatment option for EGJOO refractory to medical treatment.

Multiple-Organ Extracorporeal Support Therapies in Critically Ill Patients

The critically ill patient is capable of presenting a multiple organ dysfunction syndrome (MODS) caused by different diseases, which can be infectious (sepsis, septic shock) as well as non-infectious (pancreatitis, large surgeries, traumatic injuries, burn patients and brain injuries), this syndrome is characterized by global hemodynamic and organ perfusion alterations accompanied by an uncontrolled and marked inflammatory response unresponsive to pharmacological treatment due to which extracorporeal organ support can be a viable option. Acute renal lesion can occur in up to 60% of patients receiving intensive care, and close to 10% - 20% require renal replacement therapy (RRT) globally this can be provided as peritoneal dialysis (PD) or intermittent hemodialysis (IHD), continuous renal replacement therapy (CRRT), hybrid therapies known as sustained slow efficiency dialysis (SLED), which combines the benefits IHD and CRRT, slow continuous ultrafiltration (SCUF). Extracorporeal membrane oxygenation (ECMO) and extracorporeal elimination of CO2, have been used more frequently lately, these are temporal artificial support used for respiratory and/or cardiac insufficiency that is refractory to conventional treatment. Acute liver failure in adults has a mortality rate close to 50% furthermore one-third of patients hospitalized for cirrhosis are likely to progress to acute liver failure which will drastically increase its mortality. Based on concepts of albumin dialysis, one of its most known is the following: Molecular Adsorbent Recirculating System (MARS), Fractionated Plasma Separation and Absorption—FPSA (Prometheus®) and also, hemoperfusion with different cartridges used in different extracorporeal therapies, used in liver failure, rhabdomyolysis, cytokine release syndrome and more in the context of the pandemic covid19. The objective of this review is to know the different extracorporeal therapies and the therapeutic utility in critical patients.

Managing gastroesophageal reflux disease in children: The role of endoscopy

Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.

Spectrum and visual outcomes of Vogt-Koyanagi-Harada disease in Argentina

AIM： To review all cases of Vogt-Koyanagi-Harada （VKH） disease in an Inflammatory Eye Disease Service in Argentina and to describe the clinical profile and outcomes of treatment.METHODS： The records from patients with VKH disease between January 1980 and December 2008 were retrospectively analyzed for clinical profile, complications, and treatment. Patients were classified according to their initial treatment in group 1： high corticosteroid dose [≥1 mg/（kg·d）] within 2wk of illness onset; group 2： high corticosteroid dose, 2 to 4wk of onset and group 3： patients who received the high dose after 1mo of illness onset, patients who received lower oral doses than 1 mg/（kg·d） without regarding the time of beginning of the disease.RESULTS： A total of 210 eyes of 105 patients were included. The mean age at presentation was 32.6±13y （range： 10-74y）, and 86.7% were female. The mean duration of follow up was 144±96.6mo. Patients in the group 1 had significantly higher visual acuity than the other groups （P〈0.0001）, none had （loss of, or no） light perception at the end of follow up, whereas 24.7% patients in group 3 ended in light perception （P〈0.004）.CONCLUSION： Patients with early high dose corticosteroid treatment have better visual acuity and fewer complications. Proper timing in referral and treatment is critical for better visual outcome in VKH disease.