Introduction: Inflammatory bowel disease (IBD) patients do not appear to be more susceptible to SARS-CoV-2 infection, including those on biologic treatment. Nonetheless, the rate of immunity to the coronavirus in these patients is currently unknown. This study was designed to assess the seroprevalence of COVID-19 in IBD patients undergoing biological treatment, including those who have already been vaccinated. Methods: All adult patients with IBD undergoing biologic therapy in a major referral center were invited to perform a serological test (BioPlex 2200 SARS-CoV-2 IgG Panel, BIO-RAD, USA). On the day of the blood sample collection, they were asked to complete a questionnaire exploring a previous diagnosis of SARS-CoV-2 infection and vaccination. Results: A total of 221 patients agreed to participate in the study, the majority females (55.2%), with a median age of 42 years old (IQR 32-54). IBD diagnosis included Crohn’s disease (76.8%) and ulcerative colitis (23.2%). The proportions of patients receiving anti-tumor necrosis factor (anti-TNF), vedolizumab and ustekinumab were 73.8%, 11.8% and 14.5%, respectively. Twenty-four patients (10.9%) had been diagnosed with COVID-19, with only 2 requiring hospitalization. Two thirds of these individuals had positive anti-SARS-CoV-2 IgG. Of the remaining 197 patients, 10 (5.1%) had antibodies compatible with a previous asymptomatic infection. This cohort also included 48 vaccinated patients (57.1% Pfizer-BioNTech, 14.3% Moderna, 28.6% AstraZeneca), 12 (25.0%) of whom had already received two doses. Full vaccination status was associated with a SARS-CoV-2 seroprevalence of 100%, while the seroprevalence of those who received one dose is 72.2%. There were no association between biologic therapies and positive SARS-CoV-2 serology (anti-TNF 86.2%, vedolizumab 72.7%, ustekinumab 62.5%; p=0.287). No patient was diagnosed with COVID-19 after vaccination. Conclusion: In this cohort, 5.1% of patients had asymptomatic SARS-CoV-2 infection, which supports the idea that immunosuppression is not an additional risk factor for the development of severe forms of COVID-19 in IBD. Vaccination against SARS-CoV-2 seems to be effective, even in these immunocompromised individuals.
LINKED CONTENT This article is linked to Garrido et al and Nathwani et al papers. To view these articles, visit https://doi.org/10.1111/apt.15813 and https://doi.org/10.1111/apt.15872 .
Introduction Liver biopsy is a technique frequently performed in clinical practice. However, the recommended surveillance period after the procedure is not established in the guidelines. The aim of this study was to assess the safety and patient satisfaction of hospital discharge 2 h after a percutaneous liver biopsy. Methods Prospective monocentric study which included all patients who underwent percutaneous liver biopsy between December 2020 and November 2022. Individuals were discharged 2 h after the procedure according to a protocol that was implemented in our institution. Results A total of 200 patients were included, the majority male (52.0%), with a median age of 52 years old (interquartile range (IQR) 40–60). Forty-two (21.0%) individuals had mild adverse events at the time of or within 2 h of the procedure. Most (90.4%) occurred in the first hour after the liver biopsy. Only 5 (2.5%) patients were kept under observation for 4 h due to abdominal/shoulder pain. There were no serious complications and no patient required subsequent admission. The majority of patients reported being satisfied/very satisfied (99.4%) and felt safe (98.9%) with this protocol. Most of the individuals showed a preference for early hospital discharge (97.3%). Conclusion We showed that patients requiring percutaneous liver biopsy can be safely discharged 2 h after the procedure.
INTRODUCTION: The association of antimitochondrial antibodies (AMA) with primary biliary cirrhosis (PBC) is well established. Indeed, PBC is diagnosed when there is a positive AMA test associated with elevated alkaline phosphatase levels or compatible liver histology. However, little is known about the clinical relevance of these antibodies in patients with disorders other than PBC. Thus, the purpose of this study was to review all individuals with positive AMA and to identify associated pathologic conditions. METHODS: We collected data retrospectively from adult patients with AMA at a titer of 1:40 or higher between January 2010 and December 2019 at Centro Hospitalar e Universitário de São João, Portugal. RESULTS: A total of 214 AMA-positive patients were included in the study. Most individuals were females (78.0%) and with a mean age of 58 years old (standard deviation 14 years). A diagnosis of PBC was established in 148 (69.2%) patients, 143 of whom were identified right from the beginning and 5 individuals were diagnosed during the follow-up. When analyzed the antibodies specificities, we noted that patients with PBC had positive AMA-M2 (63.5%), AMA-M4 (5.4%) and AMA-M9 (4.1%). There were also 36 (16.8%) patients with overlap syndrome with autoimmune hepatitis, 9 (4.2%) with viral hepatitis, 4 (1.9%) with drug-induced liver injury and 2 (0.9%) with autoimmune hepatitis. Beyond autoimmune hepatobiliary diseases, further 91 patients had conditions known to be associated with autoimmunity (Table 1). In 30 patients, routine liver function tests (serum transaminases, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, albumin and coagulation tests) were entirely normal. Finally, AMA were found in only 7 individuals without any pathologic conditions. CONCLUSION: Too few healthy individuals with positive AMA have been identified. Indeed, these antibodies are often associated with pathologic conditions, usually autoimmune disorders. Clinicals must be alert and maintain close monitoring on AMA-positive patients as they can develop conditions other than PBC that requires timely diagnosis and treatment during follow-up. Further studies should focus on antibodies specificities, which could provide useful diagnostic and prognostic information.Table 1.: Positive antimitochondrial antibodies and associated conditions. An individual patient may have more than one pathologic condition. PBC - primary biliary cirrhosis, AIH -autoimmune hepatitis, ALD - alcoholic liver disease, NAFLD - non-alcoholic fatty liver disease, DILI - drug-induced liver injury, SLE - systemic lupus erythematosus.
An 82 year-old female performed upper digestive endoscopy for diagnostic work-up of iron-deficiency anemia, which revealed a giant pedunculated gastric polyp obstructing the pylorus with extension to the second part of the duodenum. Biopsies were consistent with tubular adenoma with high-grade dysplasia. After multidisciplinary discussion, endoscopic submucosal dissection was performed and the lesion was successfully resected en-bloc without adverse events. Histopathological analysis of the specimen confirmed complete curative resection. This case highlights the expanding role of endoscopic submucosal dissection, which allowed a careful, controlled en-bloc resection of a giant gastric adenomatous polyp producing ball-valve syndrome.
espanolEn las ultimas decadas se han logrado notables avances en la lucha contra la pobreza y en la reduccion de la desigualdad a escala global, que las dos grandes crisis de este siglo amenazan con revertir. Dadas sus responsabilidades y el ambito global de actuacion, el Fondo Monetario Internacional (FMI) ha sido un actor con influencia sobre las politicas para hacer frente a la desigualdad y a la pobreza en el mundo. El relato historico de la transformacion de las politicas del Fondo en sus 75 anos de vida desvela en que medida cada uno de sus agentes internos (gerencia, miembros y plantilla) ha influido en la evolucion de su posicion institucional respecto a estos retos. El analisis basado en la metodologia de «mineria de textos» de los documentos que articulan la posicion de cada uno de estos agentes permite contrastar la coherencia de sus discursos con la descripcion de los hechos historicos. EnglishSignificant progress has been made in recent decades in the fight against poverty and the reduction of inequality on a global scale, which this century’s two major crises have threatened to reverse. Given its responsibilities and global scope, the International Monetary Fund has been an influential actor in the policies to tackle inequality and poverty worldwide. The historical account of the transformation of the Fund’s policies over its 75-year history reveals the extent to which each of its internal agents (management, members and staff) has influenced the shifts in its institutional stance with respect to these challenges. A textmining- based analysis of the documents articulating each of these agents’ stances allows their discourse to be checked for consistency against historical events
The first patient with confirmed COVID-19 in Portugal was seen in our emergency department on March 2, 2020.[1]Direção-Geral da Saúde Comunicado da Diretora-Geral da Saúde com informação atualizada a 02/03/2020 | 17:28 - casos de infeção por novo Coronavírus (COVID-19).https://www.dgs.pt/a-direccao-geral-da-saude/comunicados-e-despachos-do-director-geral.aspxDate accessed: May 17, 2020Google Scholar Our hospital is located in one of the most hard-hit areas in the country and admitted more patients with COVID-19 than any other. However, the first case and subsequent beginning of the pandemic were recorded in Portugal with an average delay of 1 month compared to other neighboring western European countries. This delay allowed health authorities to initiate a series of public health measures and individual medical departments to delineate strategies to deal with patients with and without COVID-19. Our department is a high-volume hepatology center, as attested by 11,500 adult outpatient clinics/year, 3,000 of which are new referrals, and nearly 500 inpatient admissions/year; thus, even a slowdown in clinical services was likely to have a substantial impact on outcomes. We read with great interest the EASL-ESCMID position paper on the care of patients with liver disease during the COVID-19 pandemic first published in early April.[2]Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, et al. Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. JHEP Rep. 2020;2(3):100113.Google Scholar In particular, we share Boettler et al.'s concerns regarding cirrhotic patients. Our Gastroenterology and Hepatology department established strategies to prioritize the care of these patients in times of limited healthcare resources. By the 13th of March, based on the limited literature available by then and on the experience with previous pandemics, these measures were outlined in a well-defined protocol, aiming to prevent SARS-CoV-2 infection, guarantee the best treatment to avoid hepatic decompensation, reduce loss to follow-up and avoid delayed medical referrals. The protocol was implemented in our practice by 18th of March and was in course until the end of state emergency on 2nd of May. Interestingly, some of the measures that were taken are also reflected in the aforementioned position paper.[2]Boettler T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Cornberg M, et al. Care of patients with liver disease during the COVID-19 pandemic: EASL-ESCMID position paper. JHEP Rep. 2020;2(3):100113.Google Scholar However, and because our protocol was approved before the publication of this position paper, some of them were not included. In addition, it only focused on patients with cirrhosis. Herein, we briefly describe the strategies implemented by our department and the obtained outcomes. All outpatient clinics for patients with compensated cirrhosis were made by phone, ensuring that essential medications were available. Directed therapies for different etiologies were maintained. However, in case of SARS-CoV-2 infection, therapeutic adjustments were made (Fig. 1). Non-invasive methods were used for the screening and surveillance of esophageal varices, namely through platelet count. Upper endoscopy was reserved for patients at high risk of bleeding, particularly if there was a history of previous bleed or signs of significant portal hypertension. In cirrhotic patients with COVID-19, endoscopy was performed only in life-threatening conditions. All patients proposed for endoscopic procedures were previously tested for SARS-CoV-2, through an RT-PCR nasopharyngeal swab test, and health professionals always used protective equipment during procedures. For primary prophylaxis beta-blockers were preferred instead of endoscopic band ligation, unless large varices or bleeding stigmata were discovered in an emergent endoscopy. Prophylaxis of spontaneous bacterial peritonitis and hepatic encephalopathy were maintained.[3]European Association for the Study of the LiverEASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.J Hepatol. 2018; 69: 406-460Abstract Full Text Full Text PDF PubMed Scopus (1517) Google Scholar Hepatocellular carcinoma (HCC) screening by ultrasonography has been delayed. Computed tomography and magnetic resonance imaging were performed with no delay if malignancy was suspected. Liver biopsy was reserved for marked elevation in aminotransferase levels of unknown etiology and suspicious liver nodules. Liver biopsies were postponed in patients with COVID-19. A weekly hepato-biliary multidisciplinary cancer group meeting was maintained using a local web-platform. In case of HCC, systemic treatments were maintained according to guidelines.[4]European Association for the Study of the LiverEASL Clinical Practice Guidelines: management of hepatocellular carcinoma.J Hepatol. 2018; 69: 182-236Abstract Full Text Full Text PDF PubMed Scopus (4886) Google Scholar However, general precautions were in place, such as systematic screening for symptoms and fever before treatments. In patients with COVID-19, locoregional and immune checkpoint inhibitor therapies were temporarily withdrawn until symptom resolution or when SARS-CoV-2 re-testing was negative. We created a "COVID-19 free" area in our day-hospital for patients who are going for therapeutic paracentesis or phlebotomy. Waiting rooms have been remodeled to allow sufficient distance between individuals and procedures were scheduled to reduce waiting times. Lastly, a set of measures to prevent SARS-CoV-2 infection during hospitalizations were implemented, namely forbidding visits and strengthening cleaning services. In addition, all patients who were admitted had been tested for SARS-CoV-2, through an RT-PCR nasopharyngeal swab test, allowing the creation of COVID-19 and COVID-19-free wards. Patients with cirrhosis who tested positive for SARS-CoV-2 were admitted for inpatient care if another poor prognostic factor was present, such as cardiovascular diseases, Child B/C or HCC and they were managed in COVID-19 units by multidisciplinary teams. In-ward patients infected with SARS-CoV-2 were treated with 5-day hydroxychloroquine (400 mg bid on day 1 followed by 200 mg bid on day 2-5). During the state of emergency, there were 37 hospital admissions due to decompensated cirrhosis (portosystemic encephalopathy [55%], ascites [13%] and variceal bleeding [10%]); compared to the same period last year, there was no significant increase in the rate of hospital admissions. In addition, 3 patients were admitted for locoregional therapy for HCC, which corresponds to 20% of the expected elective admissions. Only 2 elective endoscopic band ligations and 1 liver biopsy were performed, an overwhelming reduction on the number of elective procedures compared to the same period last year. We achieved a rate of almost 95% of medical appointments by telemedicine and therapeutic compliance in 90% of cases (assessed both by questioning and by the uptake of medicines in hospital pharmacy). In-person visits were restricted to 10 patients with decompensated cirrhosis. None of our patients were lost to follow-up. During the lockdown period, our hospital admitted 756 patients with COVID-19, 6 (0.8%) of whom had cirrhosis. Two of these cirrhotic patients had developed nosocomial COVID-19 infection. This protocol, mostly mirroring the EASL position paper, shows that the level of care for cirrhotic patients can be maintained during the pandemic. Although laborious, it allowed a high level of patient adherence without an increase in frequency of cirrhotic complications. The impact of the strategies implemented by our Department during the lockdown period should be re-evaluated in the near future, so they may inform anticipatory changes in resource allocation during future pandemics. The authors received no financial support to produce this manuscript. Isabel Garrido drafted the manuscript. Isabel Garrido, Rodrigo Liberal, Rui Gaspar and Guilherme Macedo have critically revised and finalized the manuscript. All authors have approved the final version of the manuscript. Guarantor of the article: Isabel Garrido. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. Download .pdf (2.54 MB) Help with pdf files disclosures.pdf
Introducción: El tamizaje de los Trastornos del Espectro Autista (TEA) mediante el Modified Checklist for Autism in Toddlers - Revised with Follow Up (M-CHAT-R/F) aumenta la detección precoz, posibilitando intervenciones tempranas y mejorando el pronóstico. Este instrumento es parte del algoritmo de manejo ante la sospecha de TEA en diversas guías clínicas. El objetivo fue realizar la validación concurrente, discriminante y el análisis de confiabilidad del M-CHAT-R/F en una población chilena.Pacientes y Método: Esta es la segunda etapa de la adaptación transcultural, de diseño transversal. Se aplicó M-CHAT-R/F a una muestra de 20 niños con sospecha de TEA y 100 niños de control sano seleccionados al azar, de 16-30 meses de edad. Se aplicó Autism Diagnostic Observation Schedule (ADOS-2), considerado como referencia, a los 20 pacientes de la muestra clínica, a 20 niños de la muestra de control sano y a aquellos casos de la muestra de control sano con M-CHAT-R/F positivo. Se calculó alfa de Cronbach, análisis de correlación de M-CHAT-R/F y ADOS-2 y sensibilidad y especificidad.Resultados: En el grupo de control sano, M-CHAT-R/F resultó alterado en 2 pacientes, siendo uno positivo y otro negativo para TEA con ADOS-2. En muestra clínica el M-CHAT-R/F fue positivo en todos, con test de ADOS-2 negativo en 3 casos. La confiabilidad Alfa del M-CHATR/F fue =0,889, la sensibilidad y especificidad discriminante de 100 y 98% y la concurrente 100% y 87,5% respectivamente.Conclusión: M-CHAT-R/F en su versión chilena resultó fiable, sensible y específico de manera similar al original, lo cual abre la posibilidad de su utilización en población clínica y para investigación. La validación es un proceso continuo que se debe profundizar.
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