Publications by authors named "Fernando Gomes Romeiro"

44 Publications

Two-year risedronate treatment for osteoporosis in patients with esophageal varices: a non-randomized clinical trial.

Hepatol Int 2022 Jun 29. Epub 2022 Jun 29.

Internal Medicine Department, Botucatu Medical School, Gastroenterology Division-São Paulo State University (UNESP), Rubião Júnior s/n, Botucatu, SP, CEP 18618-687, Brazil.

Background: Bisphosphonates are the mainstay of osteoporosis treatment, but their use for patients with esophageal varices has been avoided due to the risk of esophagitis, which may cause variceal bleeding. Since most clinical trials assessing osteoporosis treatment last 2-3 years, this study aimed to evaluate a 2-year risedronate treatment for patients with esophageal varices and liver cirrhosis.

Methods: The study received Institutional Review Board approval, and the sample was divided into two groups according to bone mineral density (BMD). Cirrhosis severity and endoscopic findings at baseline were similar between the groups. The intervention group had 51 patients with osteoporosis, who received oral risedronate 35 mg weekly plus calcium and vitamin D supplements. The control group had 51 patients with osteopenia, receiving only the supplements. Scheduled esophagogastroduodenoscopies and BMD measurements were carried out.

Results: The adjusted esophagitis risk was higher in the intervention group; however, none of the subjects had digestive bleeding. Lumbar spine BMD increased in the intervention group (- 3.06 ± 0.71 to - 2.33 ± 0.90; p < 0.001) and in the control group (- 1.38 ± 0.77 to - 1.10 ± 1.05; p = 0.012). Femoral neck BMD did not change in the intervention group (- 1.64 ± 0.91 to - 1.71 ± 0.95; p = 0.220), but tended to decrease in the control group (- 1.00 ± 0.74 to - 1.09 ± 0.82; p = 0.053).

Conclusion: Oral risedronate was effective and did not cause gastrointestinal bleeding in cirrhotic patients with esophageal varices under endoscopic surveillance.
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http://dx.doi.org/10.1007/s12072-022-10366-zDOI Listing
June 2022

Factors associated with hepatitis C treatment adherence: an integrative review.

Cien Saude Colet 2022 Apr 15;27(4):1359-1376. Epub 2021 May 15.

Departamento de Neurologia, Psicologia e Psiquiatria, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP). Av. Prof. Mário Rubens Guimarães Montenegro s/n, Distrito de Rubião Júnior. 18618-970 Botucatu SP Brasil.

This integrative review examined factors associated with hepatitis C treatment adherence. The articles included were published in English, Spanish and Portuguese in the Lilacs, Medline, PsycINFO, Web of Science, Scopus and CINAHL databases, between 2000 and 2019. Initially, 540 publications were found and, after applying the study inclusion criteria, 22 articles were selected. Percentage non-adherence to treatment ranged from 12% to 32%. The variables identified as facilitating adherence were: receiving treatment for psychiatric disorders identified during treatment; knowing about medications and disease; receiving less complex treatment with greater likelihood of cure; fewer adverse events; social support; doctor-patient communication; and/or being in relationships. Barriers to adherence identified were: presence of depressive symptoms and other mental disorders; abuse of alcohol and psychoactive substances; education; age; ethnicity; unemployment; not having a steady partner; stigma; distance from health services; and the complexity and adverse effects of treatment. This review identified gaps in research on adherence.
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http://dx.doi.org/10.1590/1413-81232022274.06942021DOI Listing
April 2022

Model for establishing a new liver transplantation center through mentorship from a university with transplantation expertise.

PLoS One 2022 30;17(3):e0266361. Epub 2022 Mar 30.

Liver and Digestive Organs Transplantation Division, Gastroenterology Department, Clinical Hospital of São Paulo University - HCFMUSP, São Paulo Faculty of Medicine, Universidade de São Paulo - USP, São Paulo, São Paulo, Brazil.

Background: Setting up new liver transplant (LT) centers is essential for countries with organ shortages. However, good outcomes require experience, because LT learning depends on a high number of surgeries. This study aims to describe how a new center was set up from a partnership between the new center and an experienced one. The step-by-step preparation process, the time needed and the results of the new center are depicted.

Material And Methods: The mentoring process lasted 40 months, in which half of the 52 patients included on the transplant list received LT. After the mentorship, a 22-month period was also analyzed, in which 46 new patients were added to the waiting list and nine were operated on.

Results: The 30-day survival rates during (92.3%) and after (66.7%) the partnership were similar to the other LT centers in the same region, as well as the rates of longer periods. The waiting time on the LT list, the characteristics of the donors and the ischemia times did not differ during or after the mentorship.

Conclusion: The partnership between universities is a suitable way to set up LT centers, achieving good results for the institutions and the patients involved.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266361PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8967004PMC
March 2022

Adherence to Non-Selective Beta Blockers for Prevention of Variceal Bleeding in Cirrhotic Patients.

Int J Gen Med 2021 13;14:6713-6724. Epub 2021 Oct 13.

Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, 110840, People's Republic of China.

Background And Aim: Long-term use of non-selective beta blockers (NSBBs) is essential for the prevention of esophageal variceal bleeding in liver cirrhosis but may impair the patient's adherence. The present study aimed to investigate the adherence to NSBBs to prevent variceal bleeding in cirrhotic patients.

Methods: All patients who had an indication of NSBBs for the prophylaxis of variceal bleeding between February 2018 and June 2019 were screened. Clinical pharmacists gave pre-medication education and recorded the adherence to NSBBs during the patients' hospitalizations. Factors associated with poor adherence were evaluated by univariate logistic regression analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. The relationship between poor adherence during follow-up and variceal bleeding after discharge was also evaluated.

Results: Overall, 108 patients were screened, of whom 12 were intolerant to NSBBs. Among the 96 remaining patients who could take NSBBs, the average change of heart rate after NSBBs was -10.49 b.p.m. Twenty-two (22.9%) patients had poor adherence to NSBBs due to their refusal to take NSBBs (n = 2), complete forgetfulness to take NSBBs (n = 10), and refusal or forgetfulness to monitor heart rate (n = 10). Univariate logistic regression analysis demonstrated that only older age was significantly associated with poor adherence (OR: 1.065, 95% CI: 1.019-1.114, P = 0.005). Patients with poor adherence during follow-up were more likely to develop variceal bleeding after discharge.

Conclusion: A significant proportion of cirrhotic patients had poor adherence to NSBBs during their hospitalizations. Further studies should explore how to improve the patient's adherence to NSBBs.
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http://dx.doi.org/10.2147/IJGM.S326192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8520848PMC
October 2021

Evolution of Nonmalignant Portal Vein Thrombosis in Liver Cirrhosis: A Pictorial Review.

Clin Transl Gastroenterol 2021 10 1;12(10):e00409. Epub 2021 Oct 1.

Liver Cirrhosis Study Group, Department of Gastroenterology, The General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China.

Portal vein thrombosis (PVT) is a common complication in liver cirrhosis, especially in advanced cirrhosis. It may be related to a higher risk of liver-related events and liver function deterioration. Imaging examinations can not only provide an accurate diagnosis of PVT, such as the extent of thrombus involvement and the degree of lumen occupied, but also identify the nature of thrombus (i.e., benign/malignant and acute/chronic). Evolution of PVT, mainly including development, recanalization, progression, stability, and recurrence, could also be assessed based on the imaging examinations. This article briefly reviews the pathophysiology, diagnosis, classification, and evolution of PVT with an emphasis on their computed tomography imaging features.
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http://dx.doi.org/10.14309/ctg.0000000000000409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8483868PMC
October 2021

Pharmacotherapy for the Treatment of Gastric Antral Vascular Ectasia: A Narrative Review.

Adv Ther 2021 10 15;38(10):5065-5077. Epub 2021 Sep 15.

Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China.

Gastric antral vascular ectasia (GAVE) is an uncommon clinical entity leading to recurrent gastrointestinal bleeding. There is no consensus regarding treatment of GAVE. Endoscopic therapy is the preferred treatment option, but has a fairly high recurrence rate. Surgical resection can completely resolve GAVE, but is invasive with a relatively high risk of postoperative complications. Recently, the role of pharmacotherapy for GAVE has been recognized. However, the evidence is limited to scattered case reports or small case series. This review comprehensively summarizes the efficacy and side effects of drugs commonly used for the treatment of GAVE, including octreotide, cyproheptadine, cyclophosphamide, prednisolone, estrogen-progesterone, thalidomide, bevacizumab, and tranexamic acid.
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http://dx.doi.org/10.1007/s12325-021-01912-6DOI Listing
October 2021

Mixed and disseminated paracoccidioidomycosis after liver transplantation: Case report.

Med Mycol Case Rep 2021 Jun 23;32:25-29. Epub 2021 Feb 23.

Department of Internal Medicine, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, Rubião Júnior S/N, 18618-970, São Paulo, Brazil.

Paracoccidioidomycosis (PCM) is a systemic granulomatous fungal infection rarely associated with solid organ transplantation. We report the second case of PCM in an adult after liver transplantation. A 47-year-old woman who had undergone liver transplantation was hospitalized for flu-like symptoms and multiple erythematous ulcerated skin papules. There was lymphadenopathy, pulmonary compromise, and quickly progression to septic shock. PCM was confirmed by skin biopsy and serologic tests, and a satisfactory response to amphotericin B was achieved.
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http://dx.doi.org/10.1016/j.mmcr.2021.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7921753PMC
June 2021

How Much Time Should Be Waited and What Are the Main Findings to Evaluate the Hepatocellular Carcinoma Response to Regorafenib? A Real-Life Experience.

Can J Gastroenterol Hepatol 2021 10;2021:6219896. Epub 2021 Jan 10.

Gastroenterology Division, Department of Internal Medicine, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), São Paulo, Brazil.

Background: Hepatocellular carcinoma is a relevant cause of mortality worldwide, mainly among patients who have a prior liver disease. In spite of clear recommendations regarding surveillance and screening methods, most patients are still diagnosed only when they are no longer candidates to curative treatment modalities, while others do not achieve the goals of such treatments, thus increasing the need of anticancer drugs. Moreover, when cirrhotic patients begin to receive these drugs, many types of adverse events are seen as a reason to withdrawal, even when there are findings suggesting a good response to the treatment. . This case report is about a cirrhotic patient who received many types of treatment, from surgery and chemoembolization during early stages to first- and second-line systemic therapy when the disease turned to be advanced. Since he had no signs of liver dysfunction and suffered tumor progression during sorafenib treatment, regorafenib was initiated. The main findings that make this case important are the adverse events after taking this second-line agent, which would certainly be considered unacceptable and would lead to the drug withdrawal. The reasons why regorafenib was maintained are explained based on clinical and imaging findings, showing how this decision led to an excellent response.

Conclusions: The knowledge of the main adverse events described in the pilot clinical trials can avoid unnecessary withdrawal of regorafenib. In addition, some clinical and imaging findings can be deemed as predictors of good response to tyrosine kinase inhibitors.
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http://dx.doi.org/10.1155/2021/6219896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7878098PMC
August 2021

Refining dual-energy x-ray absorptiometry data to predict mortality among cirrhotic outpatients: A retrospective study.

Nutrition 2021 05 31;85:111132. Epub 2020 Dec 31.

Gastroenterology Division, Department of Internal Medicine, Faculdade de Medicina de Botucatu, Univ Estadual Paulista, São Paulo, Brazil. Electronic address:

Objective: The aim of this study was to compare the effects of muscle wasting according to measures obtained by different limb muscle mass indexes, to find the best mortality predictor among outpatients with cirrhosis.

Methods: Patients with liver cirrhosis (N = 210) were submitted to dual-energy x-ray absorptiometry (DXA). Appendicular muscle mass (AMM), AMM index (AMMI), upper limb muscle mass (ULMM), and ULMM index (ULMMI) were calculated. The Model for End-Stage Liver Disease, anthropometric measures, and the presence of ascites and edema were also registered. Multiple logistic regressions were performed to determine mortality predictors; the area under the receiver operating characteristic curve was used to establish the best cutoff point to predict mortality.

Results: The mean follow-up duration was 49 ± 15.59 mo. ULMM and ULMMI were clearly associated with mortality (P = 0.007 and 0.001, respectively), whereas AMM and AMMI were not. After calculating the cutoff points for men and women, the presence of a depleted ULMMI as a categorical variable was associated with a mortality risk 2.5 times higher.

Conclusions: The results suggest that using ULMMI is better than AMMI for predicting mortality of outpatients with cirrhosis, thus offering a better measure to detect muscle wasting in this population using DXA.
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http://dx.doi.org/10.1016/j.nut.2020.111132DOI Listing
May 2021

Risk Factors for Hepatocellular Carcinoma Recurrence and Survival after Liver Transplantation in Patients with HCV-Related Cirrhosis.

Biomed Res Int 2020 17;2020:1487593. Epub 2020 Oct 17.

Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro (UFRJ), Rua Rodolpho Paulo Rocco, 255-Cidade Universitária, Ilha do Fundão, Rio de Janeiro, RJ, Brazil 21941-902.

Purpose: We aimed to identify prognostic factors for survival and recurrence of hepatocellular carcinoma (HCC) after liver transplantation (LT) for patients with HCC and hepatitis C virus-related cirrhosis (HCV-cirrhosis).

Methods: This retrospective cohort study followed all adult patients with HCV-cirrhosis who underwent LT because of HCC or had incidental HCC identified through pathologic examination of the explanted liver at a university hospital in Rio de Janeiro, Brazil, over 11 years (1998-2008). We used Cox regression models to assess the following risk factors regarding HCC recurrence or death after LT: age, Model for End-stage Liver Disease score, Child-Pugh classification, alpha-fetoprotein (AFP), whether patients had undergone locoregional treatment before transplantation, the number of packed red blood cell units (PRBCU) transfused during surgery, the number and size of HCC lesions in the explanted liver, and the presence of microvascular invasion and necrotic areas within HCC lesions.

Results: Seventy-six patients were followed up for a median (interquartile range (IQR)) of 4.4 (0.7-6.6) years. Thirteen (17%) patients had HCC recurrence during the follow-up period, and 26 (34%) died. The median survival time was 6.6 years (95% CI: 2.4-12.0), and the 5-year survival was 52.5% (95% CI: 42.3-65.0%). The final regression model for overall survival included four variables: age (hazard ratio (HR): 1.02, 95% CI: 0.96-1.08, = 0.603), transplantation waiting time (HR: 1.00, 95% CI: 1.00-1.00, = 0.190), preoperative AFP serum levels (HR: 1.01, 95% CI: 1.00-1.02, = 0.006), and whether >4 PRBCU were transfused during surgery (HR: 1.15, 95% CI: 1.05-1.25, = 0.001). The final cause-specific Cox regression model for HCC recurrence included only microvascular invasion (HR: 14.86, 95% CI: 4.47-49.39, < 0.001).

Conclusion: In this study of LT for HCV-cirrhosis, preoperative AFP levels and the number of PRBCU transfused during surgery were associated with overall survival, whereas microvascular invasion with HCC recurrence.
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http://dx.doi.org/10.1155/2020/1487593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591978PMC
May 2021

Correlation of Serum Cardiac Markers with Acute Decompensating Events in Liver Cirrhosis.

Gastroenterol Res Pract 2020 24;2020:4019289. Epub 2020 Sep 24.

Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang, China.

Methods: Cirrhotic patients who were consecutively hospitalized between January 2016 and March 2019 were screened. Serum cardiac biomarkers at admission, including N-Terminal pro-B-type natriuretic peptide (NT-pro BNP), high-sensitivity cardiac troponin T (hs-cTnT), creatine kinase (CK), creatine kinase MB (CK-MB), and lactate dehydrogenase (LDH), were collected. Acute decompensating events at admission, primarily including ascites, acute gastrointestinal hemorrhage, and acute-on-chronic liver failure (ACLF), were recorded.

Results: The NT-pro BNP level was significantly higher in cirrhotic patients with acute decompensating events than in those without any decompensating events (median: 140.75 pg/mL versus 41.86 pg/mL, < 0.001). The NT-pro BNP level significantly correlated with ascites, acute gastrointestinal hemorrhage, and ACLF. The hs-cTnT level was significantly higher in cirrhotic patients with acute decompensating events than in those without decompensating events (median: 0.008 ng/mL versus 0.006 ng/mL, = 0.007). The hs-cTnT level significantly correlated with acute gastrointestinal hemorrhage, but not ascites or ACLF. LDH (185.0 U/L versus 173.5 U/L, = 0.281), CK (71 U/L versus 84 U/L, = 0.157), and CK-MB (29.5 U/L versus 33.0 U/L, = 0.604) levels were not significantly different between cirrhotic patients with and without acute decompensating events.

Conclusion: The elevated NT-pro BNP level seems to be closely related to the development of acute decompensating events in liver cirrhosis.
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http://dx.doi.org/10.1155/2020/4019289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532360PMC
September 2020

Use of iron sucrose injection in anemia patients with reduced serum iron concentration during hospitalizations of digestive and liver diseases.

Ann Palliat Med 2021 Feb 15;10(2):1145-1153. Epub 2020 Sep 15.

Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang, China.

Background: Anemia is one of the most common disorders in the world. Serum iron is an essential element for the synthesis of hemoglobin and contribution of the oxygen-carrying ability of red blood cells (RBCs). Iron sucrose injection may effectively correct iron deficiency, increase iron storage, and then improve anemia. The aim of the present study was to evaluate the therapeutic effect of iron sucrose injection in anemia patients with reduced serum iron concentration.

Methods: Overall, 95 anemia patients with digestive and/or liver diseases were included. They were divided according to the infusion of iron sucrose injection during hospitalization. The paired sample t test was used for comparison between last and baseline hemoglobin concentration. The independent sample t test was used for comparison of a dynamic change of hemoglobin concentration between patients who received and did not receive infusion of iron sucrose injection.

Results: Iron sucrose injection was infused in 74 (77.90%) patients. Mean hemoglobin concentration after infusion of iron sucrose injection was significantly increased (91.61 vs. 94.98 g/L, P=0.011). Δ Hemoglobin concentration was significantly different between patients who received and did not receive infusion of iron sucrose injection (P=0.007). Mean hemoglobin concentration after infusion of iron sucrose injection remained significantly increased in subgroup analyses of patients with cirrhosis (88.30 vs. 91.98 g/L, P=0.035) and gastrointestinal bleeding (85.70 vs. 92.63 g/L, P<0.01).

Conclusions: Iron sucrose injection can significantly increase the hemoglobin concentration in anemia patients with serum iron concentration below the lower limit of the normal range.
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http://dx.doi.org/10.21037/apm-19-499DOI Listing
February 2021

Incidence, risk factors, and prognosis of abnormal liver biochemical tests in COVID-19 patients: a systematic review and meta-analysis.

Hepatol Int 2020 Sep 24;14(5):621-637. Epub 2020 Jul 24.

Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning Province, People's Republic of China.

Background And Aims: Coronavirus disease 2019 (COVID-19) pandemic is ongoing. Except for lung injury, it is possible that COVID-19 patients develop liver injury. Thus, we conducted a systematic review and meta-analysis to explore the incidence, risk factors, and prognosis of abnormal liver biochemical tests in COVID-19 patients.

Methods: PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang databases were searched. The incidence of abnormal liver biochemical tests, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), total bilirubin (TBIL), and albumin (ALB), was pooled. Risk ratio (RR) was calculated to explore the association of abnormal liver biochemical tests with severity and prognosis of COVID-19 patients.

Results: Forty-five studies were included. The pooled incidence of any abnormal liver biochemical indicator at admission and during hospitalization was 27.2% and 36%, respectively. Among the abnormal liver biochemical indicators observed at admission, abnormal ALB was the most common, followed by GGT, AST, ALT, TBIL, and ALP (39.8%, 35.8%, 21.8%, 20.4%, 8.8%, and 4.7%). Among the abnormal liver biochemical indicators observed during hospitalization, abnormal ALT was more common than AST and TBIL (38.4%, 28.1%, and 23.2%). Severe and/or critical patients had a significantly higher pooled incidence of abnormal liver biochemical indicators at admission than mild and/or moderate patients. Non-survivors had a significantly higher incidence of abnormal liver biochemical indicators than survivors (RR = 1.34, p = 0.04).

Conclusions: Abnormal liver biochemical tests are common in COVID-19 patients. Liver biochemical indicators are closely related to the severity and prognosis of COVID-19 patients.
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http://dx.doi.org/10.1007/s12072-020-10074-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380163PMC
September 2020

No Benefit of Hemostatic Drugs on Acute Upper Gastrointestinal Bleeding in Cirrhosis.

Biomed Res Int 2020 26;2020:4097170. Epub 2020 Jun 26.

Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China.

Background And Aims: Acute upper gastrointestinal bleeding (AUGIB) is one of the most life-threatening emergency conditions. Hemostatic drugs are often prescribed to control AUGIB in clinical practice but have not been recommended by major guidelines and consensus. The aim of this study was to investigate the therapeutic effect of hemostatic drugs on AUGIB in cirrhosis.

Methods: All cirrhotic patients with AUGIB who were admitted to our hospital from January 2010 to June 2014 were retrospectively included. Patients were divided into hemostatic drugs and no hemostatic drug groups. A 1 : 1 propensity score matching (PSM) analysis was performed by adjusting age, gender, etiology of liver disease, Child-Pugh score, MELD score, hematemesis, red blood cell transfusion, vasoactive drugs, antibiotics, proton pump inhibitors, and endoscopic variceal therapy. Primary outcomes included 5-day rebleeding and in-hospital mortality.

Results: Overall, 982 cirrhotic patients with AUGIB were included (870 in hemostatic drugs group and 112 in no hemostatic drug group). In overall analyses, hemostatic drugs group had a significantly higher 5-day rebleeding rate (18.10% versus 5.40%, = 0.001) than no hemostatic drug group; in-hospital mortality was not significantly different between them (7.10% versus 4.50%, = 0.293). In PSM analyses, 172 patients were included (86 patients in each group). Hemostatic drugs group still had a significantly higher 5-day rebleeding rate (15.10% versus 5.80%, = 0.046); in-hospital mortality remained not significantly different (7.00% versus 3.50%, = 0.304) between them. Statistical results remained in PSM analyses according to the type of hemostatic drugs.

Conclusions: The use of hemostatic drugs did not improve the in-hospital outcomes of cirrhotic patients with AUGIB.
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http://dx.doi.org/10.1155/2020/4097170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336197PMC
April 2021

Effect of terlipressin on renal function in cirrhotic patients with acute upper gastrointestinal bleeding.

Ann Transl Med 2020 Mar;8(6):340

Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China.

Background: Renal dysfunction is a serious morbidity in cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB). Terlipressin is the first-line treatment choice for acute variceal bleeding and hepatorenal syndrome (HRS). This study aimed to assess the effect of terlipressin on renal function in patients with liver cirrhosis and AUGIB.

Methods: We retrospectively reviewed 40 cirrhotic patients with AUGIB treated with terlipressin by an attending physician between January 2016 and June 2018. We analyzed the change of renal function parameters, including cystatin C (CysC) and creatinine (Cr), during the use of terlipressin and after terlipressin was stopped. We also identified the factors associated with renal function improvement in patients without active bleeding during the use of terlipressin.

Results: During the use of terlipressin, CysC value was significantly reduced (1.3±0.8 1.1±0.7, P=0.001); Cr value was reduced, but the reduction was not statistically significant (68.8±24 65.5±23, P=0.817); the rate of CysC reduction was significantly higher in patients treated with terlipressin than those treated with somatostatin/octreotide (73.1% 0%, P=0.005); the rate of Cr reduction was not significantly different between patients treated with terlipressin and somatostatin/octreotide (61.5% 20%, P=0.148); no factor associated with CysC reduction was identified; higher hemoglobin, red blood cell, and platelet and lower prothrombin time and international normalized ratio at baseline were significantly associated with Cr reduction. After terlipressin was stopped, neither CysC nor Cr value was significantly reduced (P=0.852 and P=0.296).

Conclusions: Terlipressin may be beneficial on preventing renal function impairment in cirrhotic patients with AUGIB.
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http://dx.doi.org/10.21037/atm.2020.02.135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186671PMC
March 2020

Gastrointestinal Bleeding due to Pancreatic Disease-Related Portal Hypertension.

Gastroenterol Res Pract 2020 27;2020:3825186. Epub 2020 Mar 27.

Department of Gastroenterology, General Hospital of Northern Theater Command (Formerly General Hospital of Shenyang Military Area), Shenyang 110840, China.

Background And Aims: Left-sided portal hypertension (LSPH) is a rare type of portal hypertension, which occurs due to obstruction, stenosis, or thrombosis within the splenic vein. Pancreatic diseases are the most common etiology of LSPH. This study is aimed at reporting our experiences and discussing the presentation, management, and prognosis of LSPH secondary to pancreatic diseases. . We retrospectively reviewed five patients who were diagnosed with LSPH secondary to pancreatic diseases at our department. We collected the demographic information, history, comorbidities, clinical presentations, laboratory tests, esophagogastroduodenoscopy (EGD), images, and outcome data.

Results: Three elderly patients (>60 years old) were diagnosed with pancreatic cancer, of whom one underwent laparoscopic radical distal pancreatectomy and splenectomy, one received chemotherapy, and another one chose conservative management due to multiple systemic metastases. Two younger patients (<40 years old) were diagnosed with acute recurrent pancreatitis and chronic pancreatitis. Four of these five included patients presented with hematemesis and/or melena at our admission. All patients had gastric varices, and one of them also had esophageal varices. One elderly patient with metastatic pancreatic cancer underwent endoscopic variceal treatment as a rescue therapy but finally died of refractory gastrointestinal (GI) bleeding; another younger patient with chronic pancreatitis died of massive GI bleeding; and the remaining three patients survived at their last follow-up.

Conclusions: LSPH should be seriously taken into consideration in patients with pancreatic diseases who develop upper GI bleeding. Clinicians should individualize the treatment strategy of LSPH according to the patients' clinical conditions and nature of pancreatic diseases.
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http://dx.doi.org/10.1155/2020/3825186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140141PMC
March 2020

Should we introduce a feeding tube before assessing the risk of variceal bleeding?

Clin Nutr 2020 04 14;39(4):1304. Epub 2020 Feb 14.

Internal Medicine Department, Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, Brazil.

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http://dx.doi.org/10.1016/j.clnu.2020.02.005DOI Listing
April 2020

Safety and efficacy of risedronate for patients with esophageal varices and liver cirrhosis: a non-randomized clinical trial.

Sci Rep 2019 12 12;9(1):18958. Epub 2019 Dec 12.

Internal Medicine Department, Gastroenterology Division - São Paulo State University (UNESP), Botucatu Medical School, São Paulo, Brazil.

Despite the high prevalence of osteoporosis in liver cirrhosis, the indication of bisphosphonates for patients with esophageal varices has been avoided due to risk of digestive mucosal damage. Therefore, this study aimed to evaluate the safety profile of risedronate treatment for patients with osteoporosis, liver cirrhosis and esophageal varices with low risk of bleeding. A total of 120 patients were allocated into two groups according to their bone mineral density measured by dual-energy X-ray absorptiometry. In the intervention group, 57 subjects with osteoporosis received oral risedronate at 35 mg weekly plus daily calcium and vitamin D supplementation. In the control group, 63 subjects with osteopenia received only calcium and vitamin D. The groups received the treatment for one year and underwent surveillance endoscopies at six and 12 months, as well as a control dual-energy X-ray absorptiometry after a 12-month follow-up. The study received Institutional Review Board approval. The groups had not only comparable Model for End-stage Liver Disease score and esophageal varices degree, but also similar incidence of digestive adverse effects. A significant improvement was achieved in the intervention group in the lumbar spine T score (p < 0.001). The results suggest that risedronate may be safely used in liver cirrhosis and esophageal varices with low bleeding risk under endoscopic surveillance, thus allowing bone mass recovery.
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http://dx.doi.org/10.1038/s41598-019-55603-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908659PMC
December 2019

A New Rodent Model of Non-Alcoholic Steatohepatitis and Metabolic Syndrome.

Arq Bras Cardiol 2019 11;113(5):903-904

Universidade Estadual Paulista (UNESP), Botucatu, SP - Brazil.

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http://dx.doi.org/10.5935/abc.20190219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7020952PMC
November 2019

Efficacy and safety of external-beam radiation therapy for hepatocellular carcinoma: An overview of current evidence according to the different target population.

Biosci Trends 2019 Mar 24;13(1):10-22. Epub 2019 Feb 24.

Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area).

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. During the recent years, external-beam radiation therapy (EBRT) has been safely and effectively employed for the management of HCC. We overviewed the current evidence regarding the efficacy and safety of EBRT for HCC according to the different target population. PubMed database was searched for identifying English-language full-text articles regarding EBRT for the treatment of HCC. Search items were "hepatocellular carcinoma AND radiation therapy". Until now, preliminary evidence has suggested the following role of EBRT for HCC. 1) EBRT, especially stereotactic body radiation therapy, is an emerging choice of therapy for small HCC. 2) EBRT combined with non-surgical treatment can achieve an excellent intrahepatic tumor control and a potential survival benefit for huge HCC. 3)Adjunctive EBRT may improve the efficacy of transarterial chemoembolization for HCC with portal vein tumor thrombosis. 4) EBRT can relieve the pain and improve the quality of life for patients with extrahepatic metastases. 5) EBRT may be a bridge to liver transplantation by minimizing the tumor progression. 6) Adjunctive EBRT may reduce the tumor recurrence and improve the survival after resection. In summary, EBRT is a promising choice of treatment of HCC. However, more high-quality evidence is needed to further establish the status of EBRT for the management of HCC.
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http://dx.doi.org/10.5582/bst.2018.01261DOI Listing
March 2019

A systematic review and meta-analysis of treatment for hepatorenal syndrome with traditional Chinese medicine.

Transl Gastroenterol Hepatol 2018 22;3:57. Epub 2018 Aug 22.

Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110016, China.

Background: Hepatorenal syndrome (HRS) is a life-threatening complication of end-stage liver diseases. It has been reported that traditional Chinese medicine (TCM) may improve liver function, delay disease progression, alleviate symptoms, and improve quality of life in HRS patients. The study aims to systematically review the efficacy of TCM for the treatment of HRS.

Methods: Publications were searched electronically from China National Knowledge Infrastructure (CNKI), Wanfang, VIP, PubMed, and EMBASE databases. Odds ratio (OR) and standardized mean difference (SMD) with 95% confidence interval (CI) were calculated. Heterogeneity was assessed. The Cochrane Collaboration's tool was used to assess the risk of bias.

Results: Fourteen randomized controlled trials involving 788 patients with HRS were included. Random generation sequence was reported in only two studies. Blinding was not used in any study. Compared to conventional treatment without TCM, TCM led to a significant survival benefit during hospitalization (OR: 0.18; 95% CI: 0.08-0.39; P<0.0001), a significantly higher complete response (OR: 3.20; 95% CI: 2.06-4.97; P<0.00001), and a significantly lower no response (OR: 0.20; 95% CI: 0.14-0.30; P<0.00001). Partial response was not significantly different between the two groups (OR: 1.39; 95% CI: 0.90-2.15; P=0.14). Regardless of TCM, blood urea nitrogen and abdominal circumference were significantly decreased, and urine volume was significantly increased after treatment. Compared to conventional treatment without TCM, TCM led to a significantly lower serum creatinine, blood urea nitrogen, bilirubin, plasma ammonia, and abdominal circumference and significantly higher urine volume after treatment. There was significant heterogeneity.

Conclusions: TCM might have a better survival and a higher complete response in patients with HRS. However, the quality of published studies was unsatisfactory.
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http://dx.doi.org/10.21037/tgh.2018.08.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6131225PMC
August 2018

Which of the branched-chain amino acids increases cerebral blood flow in hepatic encephalopathy? A double-blind randomized trial.

Neuroimage Clin 2018 28;19:302-310. Epub 2018 Mar 28.

Department of Neurology, Psychology and Psychiatry, Botucatu Medical School, UNESP - Univ Estadual Paulista, Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, São Paulo 18618-687, Brazil. Electronic address:

Branched-chain amino acids increase the brain perfusion of patients with hepatic encephalopathy (HE), but the amino acid and the mechanisms involved are still unknown. This study compared brain perfusion and clinical improvement during leucine or isoleucine supplementation. After randomization, 27 subjects with cirrhosis and HE received leucine or isoleucine supplements for one year. Brain single Photon Emission Computed Tomography (SPECT) and dynamic brain scintigraphy (DBS) were performed pretreatment and at 1, 8 and 12 months of supplementation. Brain perfusion was increased only in the isoleucine group at 8 months of treatment by both SPECT and DBS ( < 0.001 and  = 0.05, respectively) and by SPECT at the 12th month ( < 0.05). This was associated with hepatic encephalopathy improvement at 8 and 12 months ( = 0.008 and 0.004, respectively), which was not observed in the leucine group ( = 0.313 and 0.055, respectively). Isoleucine supplementation achieved a better impact on brain perfusion restoration in HE.
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http://dx.doi.org/10.1016/j.nicl.2018.03.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044187PMC
January 2019

Selection of treatment modalities for hepatocellular carcinoma at stages T1 and T2: A preliminary analysis based on the Surveillance, Epidemiology, and End Results registry database.

J BUON 2018 May-Jun;23(3):611-621

Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, Liaoning Province, China.

Purpose: To explore the selection of treatment modalities for hepatocellular carcinoma (HCC) at stages T1 and/or T2 and to compare the survival of patients treated with surgery alone vs radiation therapy (RT) alone.

Methods: Surveillance, Epidemiology, and End Results (SEER) database was used to identify the patients diagnosed with HCC between 2004 and 2013. The tumor-nodemetastasis (TNM) stage was established according to the American Joint Committee on Cancer (AJCC) Staging. After age, sex, TNM stage, and tumor extension were matched, the survival was further compared between patients undergoing surgery alone vs RT alone.

Results: Of 11967 patients at stages T1 (n=7829) and T2 (n=4138), 10449 (87.31%) underwent surgery alone, 1241 (10.37%) RT alone, and 277 (2.32%) surgery combined with RT. Compared with those treated with RT alone and in combination with surgery, patients treated with surgery alone were younger, with smaller tumor size, higher proportion of females, single lesion, and AJCC stage I/II, and lower proportion of regional and distant lymph nodes, bone, brain, and lung invasion. Among them, 758 pairs (surgery alone and RT alone) at stage T1 and 430 pairs (surgery alone and RT alone) at stage T2 were matched. Regardless of stage T1 or T2, patients undergoing surgery alone had a significantly better cumulative survival than those undergoing RT alone (p<0.001).

Conclusion: The treatment selection of HCC was dependent on the age, sex, tumor size, number of lesions, and extrahepatic invasion. Surgery alone should be the preferred treatment modality of HCC at stages T1 and T2.
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September 2019

Xuebijing Injection Combined with Antibiotics for the Treatment of Spontaneous Bacterial Peritonitis in Liver Cirrhosis: A Meta-Analysis.

Evid Based Complement Alternat Med 2018 19;2018:2989846. Epub 2018 Mar 19.

Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.

Background And Aim: Spontaneous bacterial peritonitis (SBP) is one of the most common complications of liver cirrhosis. Antibiotics are the main treatment regimen of SBP. Traditional Chinese medicine Xuebijing injection has been used in such patients. Our study aimed to overview the efficacy of Xuebijing injection combined with antibiotics for the treatment of SBP.

Method: We searched the PubMed, Embase, China National Knowledge Infrastructure, VIP, and Wanfang databases. The search items included "Xuebijing", "peritonitis", "liver cirrhosis", and "random" to identify all relevant randomized controlled trials (RCTs). The Cochrane risk of bias tool was used to assess the study quality. The odd ratios (ORs) with 95% confidence intervals (CIs) were calculated by using a random-effect model. Heterogeneity was also calculated.

Results: A total of 9 RCTs were included. The study quality was unsatisfied. The overall (OR = 2.95, 95% CI = 1.97-4.42, < 0.00001) and complete (OR = 2.18, 95% CI = 1.57-3.04, < 0.00001) responses were significantly higher in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. The incidence of cirrhosis related complications, including hepatic encephalopathy and hepatorenal syndrome, was lower in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. No significant heterogeneity was observed among studies.

Conclusion: Additional use of Xuebijing injection may improve the efficacy of antibiotics for the treatment of SBP in liver cirrhosis. However, due to a low level of current evidence, we did not establish any recommendation regarding the use of Xuebijing injection for the treatment of SBP.
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http://dx.doi.org/10.1155/2018/2989846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5884321PMC
March 2018

Albumin-to-bilirubin score for assessing the in-hospital death in cirrhosis.

Transl Gastroenterol Hepatol 2017 7;2:88. Epub 2017 Nov 7.

Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang 110000, China.

Background: To evaluate the ability of albumin-to-bilirubin (ALBI) score for assessing the in-hospital death in cirrhotic patients.

Methods: Overall, 1,067 cirrhotic patients admitted between January 2009 and December 2014 were retrospectively enrolled. We calculated the Child-Pugh, model for end-stage liver disease (MELD), and ALBI scores. We performed receiver operating characteristic curve (ROC) analyses to assess the in-hospital death. We calculated the area under the ROC curve (AUC).

Results: In the overall analysis, all of the three scores can significantly assess the in-hospital death (Child-Pugh score AUC =0.750, 95% CI: 0.713-0.784, P<0.0001; MELD score AUC =0.728, 95% CI: 0.689-0.765, P<0.0001; ALBI score AUC =0.698, 95% CI: 0.667-0.727, P<0.0001). In the subgroup analysis of hepatitis B virus, Child-Pugh and ALBI scores were suitable to assess in-hospital death (Child-Pugh score AUC =0.752, 95% CI: 0.679-0.816, P<0.0001; ALBI score AUC =0.803, 95% CI: 0.751-0.849, P=0.0002) and both were superior to the MELD score (AUC=0.564, 95% CI: 0.483-0.643, P=0.5357). In the subgroup analysis of alcohol abuse, Child-Pugh and MELD scores properly assessed in-hospital death (Child-Pugh score AUC =0.791, 95% CI: 0.727-0.846, P<0.0001; MELD score AUC =0.720, 95% CI: 0.647-0.786, P=0.0023), rather than ALBI score (AUC =0.646, 95% CI: 0.588-0.702, P=0.1360).

Conclusions: ALBI score might be an alternative index for assessing the in-hospital death in patients with liver cirrhosis.
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http://dx.doi.org/10.21037/tgh.2017.09.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5723748PMC
November 2017

Who should receive endoscopic variceal ligation after recovering from acute variceal bleeding?

Hepatology 2018 05;67(5):2057-2058

Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China.

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http://dx.doi.org/10.1002/hep.29684DOI Listing
May 2018

Should Serum Protein Electrophoresis Be a Surrogate for Liver Biopsy in Some Cases of Alpha Antitrypsin Deficiency?

Case Reports Hepatol 2017 28;2017:2705131. Epub 2017 Sep 28.

Internal Medicine Department, Gastroenterology Division, Botucatu Medical School, Universidade Estadual Paulista (UNESP), Botucatu, SP, Brazil.

Most patients with alpha antitrypsin deficiency do not receive this diagnosis until developing severe complications, in particular when respiratory symptoms are absent. This is a reason for making alpha antitrypsin deficiency a possible diagnosis among patients with cryptogenic cirrhosis or other conditions of liver disease without a clear etiology. In this report, a case of cryptogenic cirrhosis is presented, showing the role of serum protein electrophoresis in the diagnosis, which was made before liver biopsy. Therefore, the possibility of using a typical pattern of serum protein electrophoresis as a surrogate for liver biopsy in alpha antitrypsin deficiency is discussed.
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http://dx.doi.org/10.1155/2017/2705131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637832PMC
September 2017

Occupational exposures to biological material among health professionals of Bauru Base Hospital: preventive and post-exposure measures.

Rev Bras Med Trab 2017 1;15(3):194-199. Epub 2017 Sep 1.

Department of Internal Medicine, School of Medicine of Botuctatu, Júlio de Mesquita Filho State University (Universidade Estadual Paulista "Júlio de Mesquita Filho" - UNESP) - Botucatu (SP), Brazil.

Background: Exposure to biological materials is common among hospital workers, even when preventive measures are suggested. Few studies assessed the incidence of this type of exposure and the impact of preventive measures.

Objective: The aim of the present study was to describe occupational exposure to biological materials at Base Hospital of Bauru, São Paulo, Brazil, along one year.

Methods: Observational retrospective study conducted with data for 2014, which were analyzed according to epidemiological and occupational exposure characteristics before and after exposure, such as previous immunization and follow up of workers, respectively.

Results: Forty-two accidents involving biological materials were recorded; 85.7% affected the nursing staff, mainly nursing technicians. The incidence of accidents involving sharp materials was 83%; the upper limbs were the most frequently affected (81%) body part. Vaccination campaigns and specific care protocols achieved effective results, allowing to avoid disease transmission and reducing the costs associated with the follow up of affected healthcare professionals. Few accidents (17%) occurred during emergency procedures, which shows that most instances of exposure might be prevented through safety measures.

Conclusion: The study revealed some aspects of the workers involved, exposure type and follow up after accidents with biological materials at the investigated hospital and discusses measures likely to reduce risk.
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http://dx.doi.org/10.5327/Z1679443520170001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104850PMC
September 2017

Prognostic Assessment and Management of Liver Cirrhosis.

Biomed Res Int 2017;2017:5326898. Epub 2017 Aug 1.

Faculdade de Medicina de Botucatu, UNESP, Campus de Botucatu, s/n, Botucatu, SP, Brazil.

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http://dx.doi.org/10.1155/2017/5326898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556990PMC
October 2018
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