Mário Dinis-Ribeiro

Centre for Research in Health Technologies and Information Systems (CINTESIS), Oporto, Porto, Portugal

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Publications (124)413.46 Total impact

  • M. Serrano, I. Kikuste, M. Dinis-Ribeiro
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    ABSTRACT: The most immediate strategy for improving survival of gastric cancer patients is secondary prevention through diagnosis of early gastric cancer either through screening or follow-up of individuals at high risk. Endoscopy examination is therefore of paramount importance and two general steps are to be known in assessing gastric mucosa – detection and characterization. Over the past decade, the advent of advanced endoscopic imaging technology led to diverse descriptions of these modalities reporting them to be useful in this setting. In this review, we aim at summarizing the current evidence on the use of advance imaging in individuals at high-risk (ie, advance stages of gastric atrophy/intestinal metaplasia) and in those harboring neoplastic lesions, and address its potential usefulness providing the readers a framework to use in daily practice. Further research is also suggested.
    Baillière&#x027 s Best Practice and Research in Clinical Gastroenterology 12/2014; · 3.28 Impact Factor
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    ABSTRACT: A recent review of economic studies relating to gastric cancer revealed that authors use different tests to estimate utilities in patients with and without gastric cancer. Our aim was to determine the utilities of gastric premalignant conditions and adenocarcinoma with a single standardized health measure instrument. Cross-sectional nationwide study of patients undergoing upper endoscopy (n=1,434) using the EQ-5D-5L quality of life (QoL) questionnaire. According to EQ-5D-5L, utilities in individuals without gastric lesions were 0.78 (95% confidence interval: 0.76-0.80), with gastric premalignant conditions 0.79 (0.77-0.81), previously treated for gastric cancer 0.77 (0.73-0.81) and with present cancer 0.68 (0.55-0.81). Self-reported QoL according to the visual analogue scale (VAS) for the same groups were 0.67 (0.66-0.69), 0.67 (0.66-0.69), 0.62 (0.59-0.65) and 0.62 (0.54-0.70) respectively. Utilities were consistently lower in women versus men (no lesions 0.71 vs. 0.78; premalignant conditions 0.70 vs. 0.82; treated for cancer 0.72 vs. 0.78 and present cancer 0.66 vs. 0.70). The health-related QoL utilities of patients with premalignant conditions are similar to those without gastric diseases whereas patients with present cancer show decreased utilities. Moreover, women had consistently lower utilities than men. These results confirm that the use of a single standardized instrument such as the EQ-5D-5L for all stages of the gastric carcinogenesis cascade is feasible and that it captures differences between conditions and gender dissimilarities, being relevant information for authors pretending to conduct further cost-utility analysis.
    Journal of gastrointestinal and liver diseases: JGLD 12/2014; 23(4):371-8. · 1.85 Impact Factor
  • Matilde Monteiro-Soares, Dinis-Ribeiro M
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    ABSTRACT: Understanding the quality of diabetic foot care delivery is essential. The Eurodiale consortium addressed subjects’ characteristics, diabetic foot ulcer prognostic predictors and clinical outcomes, in 10 European countries. We analyzed the results of a specialized Portuguese diabetic foot clinic at the light of the ones from Eurodiale.
    Diabetes Research and Clinical Practice 10/2014; · 2.54 Impact Factor
  • Miguel Areia, Mário Dinis-Ribeiro, Francisco Rocha Gonçalves
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    ABSTRACT: Progression of extensive gastric premalignant conditions to cancer might warrant surveillance programms. Recent guidelines suggest a 3-yearly endoscopic follow-up for these patients. Our aim was to determine the cost utility of endoscopic surveillance of patients with extensive gastric premalignant conditions such as extensive atrophy or intestinal metaplasia.
    Helicobacter 08/2014; · 2.99 Impact Factor
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    ABSTRACT: Background and study aims: Although endoscopic resection for the treatment of gastric superficial neoplastic lesions is an established first-line treatment in Eastern countries, its role has yet to be considered in Western guidelines, mostly due to a lack of long-term studies. The aim of this study was to describe long-term outcomes for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in the treatment of gastric neoplasias in Portugal. Patients and methods: This was a single-center, retrospective, cohort study between March 2003 and April 2013. A total of 162 consecutive patients with 195 gastric superficial neoplasias underwent EMR (n = 54) or ESD (n = 141) and were followed up for a median of 3.2 years. Results: Resection was feasible in 97 %, with en bloc and R0 resection rates of 85 % (94 % ESD vs. 61 % EMR; P = 0.001) and 81 % (91 % ESD vs. 54 % EMR; P < 0.001), respectively. The recurrence rate was 7 %, and recurrence was associated with Rx/R1 resection irrespective of resection technique (OR 5.8; 95 % confidence interval 3.9 - 8.8). The long-term curative resection rate was 86 % after one procedure and 91 % after two procedures. Adverse events were observed in 13 % of cases: 8 % bleeding and 2 % of perforations (EMR = ESD). Surgery was performed in 7 %: 6 % after noncurative endoscopic resection and 1 % due to complications. Metachronous lesion detection rate was 1 % - 1.5 % per patient year. Cancer-specific survival rate was 100 % at follow-up. Conclusions: For the first time in a Western country, results are reported to be similar to those in Eastern countries. Endoscopic resection, particularly ESD, is a highly effective treatment for gastric superficial lesions, without compromising cancer survival. Endoscopic resection should also be considered as first-line treatment for gastric neoplasias in Western countries.
    Endoscopy 07/2014; · 5.20 Impact Factor
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    ABSTRACT: Targeting biopsies on the basis of visual recognition of mucosal changes in the stomach instead of the currently accepted random biopsy sampling may be attractive.
    European journal of gastroenterology & hepatology. 07/2014; 26(7):704-709.
  • Luís Lopes, Mário Dinis-Ribeiro, Carla Rolanda
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    ABSTRACT: The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). Single-center, prospective cohort study. University-affiliated hospital. A total of 350 patients with a naïve papilla. Standard biliary cannulation followed by needle-knife fistulotomy (NKF). Biliary cannulation rate, NKF success, adverse events, and ERCP duration. The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P < .001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P < .0001). Single-center study design, referral center. If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.
    Gastrointestinal endoscopy 05/2014; · 4.90 Impact Factor
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    ABSTRACT: Background and study aims: Clinical guidelines are a common feature in modern endoscopy practice and they are being produced faster than ever. However, their methodological quality is rarely assessed. This study evaluated the methodological quality of current clinical guidelines in the field of gastroenterology, with an emphasis on endoscopy. Materials and methods: Practice guidelines published by the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology (BSG), National Institute for Health and Care Excellence (NICE), and the Scottish Intercollegiate Guidelines Network (SIGN) were searched between September and October 2012 and evaluated using the AGREE II (Appraisal of Guidelines for Research and Evaluation) instrument (23 items, scores 1 – 7 for each item; higher scores mean better quality). Results: A total of 100 guidelines were assessed. The mean number of items scoring 6 or 7 per guideline was 9.2 (out of 23 items). Overall, 99 % of guidelines failed to include the target population in the development process, and 96 % did not report facilitators and barriers to guideline application. In addition, 86 % did not include advice or tools, and 94 % did not present monitoring or auditing criteria. Conclusion: The global methodological quality of clinical guidelines in the field of gastroenterology is poor, particularly regarding involvement of the target population in the development of guidelines and in the provision of clear suggestions to practitioners.
    Endoscopy 04/2014; · 5.20 Impact Factor
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    ABSTRACT: The pro-carcinogenic effects of prostaglandin E2 (PGE2) in colonic mucosa are not only regulated by the rates between Cyclooxygenase-2 (COX-2) biosynthesis and 15-Hydroxyprostaglandin Dehydrogenase (15-PGDH)-dependent degradation but also the steady-state levels of PGE2 in extracellular microenvironment, maintained by key specific prostaglandin transporters, the Multidrug Resistance Protein (MRP4) (efflux carrier) and Prostaglandin Transporter (PGT) (influx carrier). To understand the contribution of genetic variability in genes coding for COX-2/15-PGDH/MRP4/PGT proteins in CRC development, we conducted a hospital-based case-control study involving 246 CRC patients and 480 cancer-free controls. A total of 51 tagSNPs were characterized using the Sequenom platform through multiplexed amplification followed by mass-spectrometric product separation or allelic discrimination using real-time PCR. Seven tagSNPs were implicated in CRC development: the rs689466 in COX-2 gene, the rs1346271 and rs1426945 in 15-PGDH, the rs6439448 and rs7616492 in PGT and rs1751051 and rs1751031 in MRP4 coding genes. Upon a stratified analysis a measurable gene-environment interaction was noticed between rs689466 and smoking habits, with individuals ever-smokers carriers of rs689466 GG homozygous genotype having a nearly 6-fold increased susceptibility for CRC onset (95%CI: 1.49-22.42, P = 0.011). Furthermore, the multifactor dimensionality reduction (MDR) analysis identified an overall four-factor best gene-gene interactive model, including the rs1426945, rs6439448, rs1751051 and rs1751031 polymorphisms. This model had the highest cross-validation consistency (10/10, P<0.0001) and an accuracy of 0.6957 and was further associated with a 5-fold increased risk for CRC development (95%CI: 3.89-7.02, P<0.0001). In conclusion, specific low penetrance genes in the pro-carcinogenic PGE2 pathway appear to modulate the genetic susceptibility for CRC development. A clearer understanding on CRC etiology through the identification of biomarkers of colorectal carcinogenesis might allow a better definition of risk models that are more likely to benefit from targeted preventive strategies to reduce CRC burden.
    PLoS ONE 04/2014; 9(4):e92000. · 3.53 Impact Factor
  • Luís Lopes, Mário Dinis-Ribeiro, Carla Rolanda
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    ABSTRACT: Abstract Objective. Although precut is considered an useful alternative when standard methods of biliary access have failed, there is some controversy about it's safety. The study aim was to evaluate the effectiveness of needle-knife fistulotomy (NKF) after a difficult biliary cannulation and whether common bile duct (CBD) diameter influenced complications. Material and methods. Between November 2006 and December 2010, a total of 1087 consecutive patients with naive papilla were submitted to endoscopic retrograde cholangiopancreatography (ERCP) for biliary access, in an affiliated university hospital. If the biliary cannulation was unsuccessful after 12-15 min, a NKF was performed. The main outcomes were biliary cannulation rate, NKF success and post-ERCP complications. Results. Biliary cannulation by standard methods was successful in 883 patients (81%). In the remaining 204 patients, NKF was performed and allowed CBD access in 166 (81%), leading to a 96% cannulation rate. A second ERCP was performed in 25 patients, with an NKF success of 90% and an overall biliary cannulation rate of 98%. The post-ERCP complication rate was 7.9% (n = 16) with a 6.4% pancreatitis rate and no deaths. The complication for patients with a CBD ≤ to 4 mm was 13.9% compared with 4.5% in the remaining patients (OR = 3.39, p = 0.024). Conclusions. NKF is a safe and highly useful method of accessing the CBD in the setting of a difficult biliary cannulation. Despite its safety profile, extra caution is needed when applying NKF to patients with thin bile ducts.
    Scandinavian Journal of Gastroenterology 03/2014; · 2.33 Impact Factor
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    ABSTRACT: Guidelines for diagnostic and treatment of gastric adenocarcinoma ( Portuguese Digestive Cancer Research Group) O Grupo de Investigação de Cancro Digestivo (GICD), com o objetivo de sistematizar e harmonizar o conhecimento e atuação dos seus membros no que concerne à patologia oncológica digestiva, decidiu realizar recomendações recorrendo a especialistas nas áreas abordadas e a um painel de peritos
    Revista Portuguesa de Cirurgia. 03/2014; II serie(nº 28):45.
  • Luís Marques-Silva, Miguel Areia, Luís Elvas, Mário Dinis-Ribeiro
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    ABSTRACT: Several reports of estimates for precancerous conditions for gastric adenocarcinoma can be found in the current literature. Our aim was to systematically review and estimate the prevalence of gastric precancerous conditions. Four databases (PubMed, Scopus, Web of Knowledge and EBSCO Academic Search Complete) were searched for original manuscripts addressing the presence of chronic atrophic gastritis (CAG) or intestinal metaplasia (IM). Subgroup analysis was carried out on methods of diagnosis, type of population, incidence of gastric cancer, sex, Helicobacter pylori status, age and extent of conditions. Overall, 107 studies were included. The worldwide prevalence of CAG in the general population was 33% (95% confidence interval: 26-41%) when considering biopsies (n=20 912) and 24% (19-29%) if serology (n=51 886) was used, whereas IM was found in 25% (19-30%) (n=30 960). Estimates for CAG were higher in countries with a high incidence of gastric cancer (42 vs. 23%), men (32 vs. 28%), H. pylori positive (46 vs. 17%) and if aged 40 years or older (48 vs. 22%). The prevalence of extensive conditions was 16% (12-20%) for CAG and 13% (9.0-17%) for IM. When comparing countries with high versus low to moderate incidence of gastric cancer, significant differences were achieved for CAG: 27% (12-36%) versus 7.3% (5.6-9.0%). Worldwide, one-third and one-fourth of individuals may harbour CAG and IM, respectively. In countries with a high incidence of gastric cancer, the prevalence of extensive conditions may increase up to 27% and these patients represent a high-risk population to whom endoscopic surveillance should be offered according to recent guidelines.
    European journal of gastroenterology & hepatology 02/2014; · 1.66 Impact Factor
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    ABSTRACT: We aimed to systematically review the available systems used to classify diabetic foot ulcers (DFU) in order to synthetize their methodological qualitative issues and accuracy to predict lower extremity amputation (LEA), as this may represent a critical point in these patients' care. Two investigators searched, in EBSCO, ISI, PubMed and SCOPUS databases, and independently selected studies published until May 2013 and reporting prognostic accuracy and/or reliability of specific systems for patients with DFU in order to predict LEA. We included 25 studies reporting a prevalence of LEA between 6 to 78%. Eight different DFU descriptions and 7 prognostic stratification classification systems were addressed with a variable (1-9) number of factors included, being the presence of peripheral arterial disease (n = 12) or infection at the ulcer site (n = 10) or its (ulcer) depth (n = 10) the most frequently included. The Meggit-Wagner, S(AD)SAD and Texas University Classification systems were the most extensively validated, whereas 10 classifications were derived or validated only once. Reliability was reported in a single study and accuracy measures reported in 5 studies with another 8 allowing their calculation. Meta-analysis was only possible for the composing variables` accuracy. Pooled accuracy ranged from 0.65 (for gangrene) to 0.74 (for infection). There are numerous classification systems for DFU outcome prediction but only few studies evaluated their reliability or external validity. Also only rarely studies validated several systems' simultaneously and reported accuracy measures. Further studies assessing reliability and accuracy of the available systems and their composing variables are needed. This article is protected by copyright. All rights reserved.
    Diabetes/Metabolism Research and Reviews 02/2014; · 3.59 Impact Factor
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    ABSTRACT: The incidence of Inflammatory Bowel Disease (IBD) is increasing worldwide and the underlying molecular mechanisms are far from being fully elucidated. Herein, we evaluated the role of N-glycosylation dysregulation in T cells as a key mechanism in the Ulcerative Colitis (UC) pathogenesis.The evaluation of the branched N-glycosylation levels and profile of intestinal T Cell Receptor (TCR) were assessed in colonic biopsies from UC patients and healthy controls. Expression alterations of glycosyltransferase gene MGAT5 were also evaluated. We demonstrated that UC patients exhibit a dysregulation of TCR branched N-glycosylation on lamina propria T lymphocytes. Patients with severe UC showed the most pronounced defect on N-glycan branching in T cells. Moreover, UC patients showed a significant reduction of MGAT5 gene transcription in T lymphocytes. In this study we disclose for the first time that a deficiency in branched N-glycosylation on TCR due to a reduced MGAT5 gene expression is a new molecular mechanism underlying UC pathogenesis, being a potential novel biomarker with promising clinical and therapeutic applications.
    Human Molecular Genetics 12/2013; · 6.68 Impact Factor
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    ABSTRACT: A simplified narrow-band imaging (NBI) endoscopy classification of gastric precancerous and cancerous lesions was derived and validated in a multicenter study. This classification comes with the need for dissemination through adequate training. To address the learning curve of this classification by endoscopists with differing expertise and to assess the feasibility of a YouTube-based learning program to disseminate it. Prospective study. Five centers. Six gastroenterologists (3 trainees, 3 fully trained endoscopists [FTs]). Twenty tests provided through a Web-based program containing 10 randomly ordered NBI videos of gastric mucosa were taken. Feedback was sent 7 days after every test submission. Measures of accuracy of the NBI classification throughout the time. From the first to the last 50 videos, a learning curve was observed with a 10% increase in global accuracy, for both trainees (from 64% to 74%) and FTs (from 56% to 65%). After 200 videos, sensitivity and specificity of 80% and higher for intestinal metaplasia were observed in half the participants and a specificity for dysplasia greater than 95%, along with a relevant likelihood ratio for a positive result of 7 to 28 and likelihood ratio for a negative result of 0.21 to 0.82, were achieved by all of the participants. No constant learning curve was observed for the identification of Helicobacter pylori gastritis and sensitivity to dysplasia. The trainees had better results in all of the parameters, except specificity for dysplasia, compared with the FTs. Globally, participants agreed that the program's structure was adequate, except on the feedback, which should have consisted of a more detailed explanation of each answer. No formal sample size estimate. A Web-based learning program could be used to teach and disseminate classifications in the endoscopy field. In this study, an NBI classification for gastric mucosal features seems to be easily learned for the identification of gastric preneoplastic lesions.
    Gastrointestinal endoscopy 11/2013; · 4.90 Impact Factor
  • Carla Rolanda, Ana C Caetano, Mário Dinis-Ribeiro
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    ABSTRACT: Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.
    Best practice & research. Clinical gastroenterology 10/2013; 27(5):783-98. · 2.48 Impact Factor
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    ABSTRACT: Abstract Aim. The aim of the article is to systematically review the current evidence on the diagnostic use of narrow band imaging (NBI), flexible spectral imaging color enhancement (FICE) and endoscopic image enhancement technology i-scan endoscopies for gastric precancerous and cancerous lesions. Materials and methods. Original manuscripts were searched in PubMed until October 2012. Pertinent data were collected and pooled diagnostic accuracy measures were estimated when possible. Results. In total, 38 studies were evaluated. Thirty-one studies were included for NBI and 7 studies for FICE assessment in this systematic review. No article was found meeting inclusion criteria for i-scan endoscopy. The most defined and evaluated outcomes were cancer-related (n = 26). Quality Assessment of Diagnostic Accuracy Studies score varied from 9 to 12 (out of 14). Only few studies assessed the interobserver reliability. On a patient level analysis, NBI's pooled sensitivity, specificity and diagnostic odds ratio were 0.67 (95% CI: 0.61-0.73), 0.81 (95% CI: 0.76-0.85) and 22.71 (95% CI: 12.53-41.1), respectively for diagnosing normal mucosa; 0.86 (95% CI: 0.82-0.90), 0.77 (95% CI: 0.73-0.80) and 17.01 (95% CI: 1.4-207.2) for intestinal metaplasia and 0.90 (95% CI: 0.84-0.94), 0.83 (95% CI: 0.80-0.86) and 47.61 (95% CI: 4.61-491.34) for dysplasia. Owing to the insufficient data and different definitions, we could not aggregate the results for FICE. Conclusion. Gastric pattern descriptions have been proposed for NBI and FICE studies by gathering all descriptions in one single description. The classification systems varied between studies, a single description of gastric mucosal features with HR - scopes or at least per technology - will have to be agreed on.
    Scandinavian Journal of Gastroenterology 10/2013; 48(10):1108-17. · 2.33 Impact Factor
  • Mário Dinis-Ribeiro, Pedro Amaro
    Best practice & research. Clinical gastroenterology 10/2013; 27(5):631-2. · 2.48 Impact Factor
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    ABSTRACT: The following recommendations for post-polypectomy endoscopic surveillance should be applied only after a high quality baseline colonoscopy with complete removal of all detected neoplastic lesions.1 In the low risk group (patients with 1 - 2 tubular adenomas < 10 mm with low grade dysplasia), the ESGE recommends participation in existing national screening programmes 10 years after the index colonoscopy. If no screening programme is available, repetition of colonoscopy 10 years after the index colonoscopy is recommended (strong recommendation, moderate quality evidence). 2 In the high risk group (patients with adenomas with villous histology or high grade dysplasia or ≥10 mm in size, or ≥ 3 adenomas), the ESGE recommends surveillance colonoscopy 3 years after the index colonoscopy (strong recommendation, moderate quality evidence). Patients with 10 or more adenomas should be referred for genetic counselling (strong recommendation, moderate quality evidence). 3 In the high risk group, if no high risk adenomas are detected at the first surveillance examination, the ESGE suggests a 5-year interval before a second surveillance colonoscopy (weak recommendation, low quality evidence). If high risk adenomas are detected at first or subsequent surveillance examinations, a 3-year repetition of surveillance colonoscopy is recommended (strong recommendation, low quality evidence).4 The ESGE recommends that patients with serrated polyps < 10 mm in size with no dysplasia should be classified as low risk (weak recommendation, low quality evidence). The ESGE suggests that patients with large serrated polyps (≥ 10 mm) or those with dysplasia should be classified as high risk (weak recommendation, low quality evidence).5 The ESGE recommends that the endoscopist is responsible for providing a written recommendation for the post-polypectomy surveillance schedule (strong recommendation, low quality evidence).
    Endoscopy 10/2013; 45(10):842-51. · 5.20 Impact Factor
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    ABSTRACT: Gastric cancer has a high incidence and mortality, so there is a pressing need to understand the underlying molecular mechanisms in order to discover novel biomarkers. Glycosylation alterations are frequent during gastric carcinogenesis and cancer progression. This review describes the role of glycans from the initial steps of the carcinogenesis process, in which Helicobacter pylori adheres to host mucosa glycans and modulates the glycophenotype, as well as how glycans interfere with epithelial cell adhesion by modulating epithelial cadherin functionality in gastric cancer progression. Other mechanisms regulating gastric cancer malignant behavior are discussed, such as increased sialylation interfering with key signaling pathways and integrin glycosylation leading to an invasive phenotype. Applications of these glycosylation alterations in the clinical management of gastric cancer patients are discussed.
    Trends in Molecular Medicine 08/2013; · 10.11 Impact Factor

Publication Stats

1k Citations
413.46 Total Impact Points


  • 2012–2014
    • Centre for Research in Health Technologies and Information Systems (CINTESIS)
      Oporto, Porto, Portugal
  • 2010–2014
    • University of Porto
      • • Center for Research in Health Technologies and Information Systems
      • • Faculdade de Medicina
      Oporto, Porto, Portugal
  • 2002–2014
    • Instituto Português de Oncologia
      • • Department of Pathology
      • • Molecular Oncology Group
      Oporto, Porto, Portugal
  • 2011–2012
    • Centro Hospitalar de Vila Nova de Gaia/Espinho
      Portus Cale, Porto, Portugal
  • 2006–2010
    • Porto Military Hospital
      Oporto, Porto, Portugal
  • 2004
    • Showa University
      Shinagawa, Tōkyō, Japan