RESUMEN
Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.
Asunto(s)
Fundoplicación , Reflujo Gastroesofágico/cirugía , Complicaciones Posoperatorias , Fundoplicación/métodos , Humanos , Laparoscopía , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/terapia , Recurrencia , Resultado del TratamientoAsunto(s)
Mediastinitis/tratamiento farmacológico , Sepsis/tratamiento farmacológico , Anciano , Femenino , Fluidoterapia , Hematínicos/uso terapéutico , Humanos , Hidroxocobalamina/uso terapéutico , Mediastinitis/cirugía , Azul de Metileno/uso terapéutico , Resucitación , Vasoplejía/tratamiento farmacológicoRESUMEN
INTRODUCTION AND AIMS: Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of agreement among Latin American specialists, with respect to the management of GERD. MATERIALS AND METHODS: A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic. RESULTS: The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics. CONCLUSIONS: In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, is different in each country.
Asunto(s)
Reflujo Gastroesofágico , Humanos , Estudios Transversales , Reproducibilidad de los Resultados , Reflujo Gastroesofágico/terapia , Reflujo Gastroesofágico/tratamiento farmacológico , Inhibidores de la Bomba de Protones/uso terapéutico , Endoscopía GastrointestinalRESUMEN
INTRODUCTION AND AIMS: Due to its different clinical manifestations, gastroesophageal reflux disease (GERD) requires diverse diagnostic and therapeutic interventions. The aim of the study was to evaluate the degree of concordance among Latin American specialists, with respect to the management of GERD. MATERIALS AND METHODS: A cross-sectional study was conducted through a survey with 42 statements (22 related to diagnosis and 20 to treatment) applied to 56 specialists from Latin America. There were 4 possible statement responses: in complete agreement, in partial agreement, in partial disagreement, and in complete disagreement. Reproducibility, level of agreement, and concordance were measured through the Kappa statistic. RESULTS: The response rate was 81% (47/56). General concordance was low, given that there was complete concordance in only 12 statements (28.6%). There was partial concordance in 22 statements (52.4%) and no concordance in 8 (19%). The following themes had the most disagreement: the performance of endoscopy before beginning treatment, the use of proton pump inhibitors (PPIs) in patients with extraesophageal symptoms and with no typical symptoms, and the combined use of PPIs and prokinetics. CONCLUSIONS: In the present study, we found that there was agreement among the Latin American specialists for the diagnosis and management of GERD in less than one-third of the recommendations considered standard. The low concordance could be related to the fact that the availability of diagnostic tools and medications, as well as the prevalence of GERD phenotypes, are different in each country.
RESUMEN
Integrin heterodimers mediate a variety of adhesive interactions, including neuronal attachment to and process outgrowth on laminin. We report here the cloning and primary sequence of an M-200 kD integrin alpha subunit that associates with the integrin beta 1 subunit to form a receptor for both laminin and collagen. Similarities in ligand-binding specificity, relative molecular mass and NH2-terminal sequence make this a strong candidate for the rat homologue of the alpha subunit of the human integrin VLA-1. The full-length rat alpha 1 cDNAs encode a protein containing a purative signal sequence and a mature polypeptide of 1,152 amino acids, with extracellular, transmembrane and cytoplasmic domains. Several structural features are conserved with other integrin alpha chains, including (a) a sequence motif repeated seven times in the NH2-terminal half; (b) potential Ca2+/Mg2+ binding sites in repeats 5, 6, and 7, and (c) alignment of at least 14 of 23 cysteine residues. This rat alpha 1 sequence also contains a 206-amino acid I domain, inserted between repeats 2 and 3, that is homologous to I domains found in the same position in the alpha subunits of several integrins (VLA-2, Mac-1, LFA-1, p150). The rat alpha 1 and human VLA-2 apha subunits share greater than 50% sequence identity in the seven repeats and I domain, suggesting that these sequence identities may underlie some of their similar ligand-binding specificities. However, the rat integrin alpha 1 subunit has several unique features, including a 38-residue insert between two Ca2+/Mg2+ binding domains, and a divergent 15-residue cytoplasmic sequence, that may potentially account for unique functions of this integrin.
Asunto(s)
Integrinas/genética , Laminina/metabolismo , Neoplasias de las Glándulas Suprarrenales , Secuencia de Aminoácidos , Animales , Secuencia de Bases , Sitios de Unión , Línea Celular , Clonación Molecular/métodos , Colágeno/metabolismo , ADN de Neoplasias/genética , Biblioteca de Genes , Humanos , Integrinas/metabolismo , Sustancias Macromoleculares , Datos de Secuencia Molecular , Peso Molecular , Sondas de Oligonucleótidos , Feocromocitoma , Ratas , Homología de Secuencia de Ácido NucleicoRESUMEN
Proton pump inhibitors are the reference standards for the treatment of acid-related diseases. Acid suppression in gastroesophageal reflux disease is associated with a high rate of mucosal cicatrization, but symptom response differs among endoscopic phenotypes. Extraesophageal manifestations have a good clinical response in patients that present with abnormal acid exposure (diagnostic test) in the esophagus. Proton pump inhibitors have shown their effectiveness for reducing symptom intensity in nighttime reflux and sleep disorders, improving quality of life and work productivity. That can sometimes be achieved through dose modifications by splitting or increasing the dose, or through galenic formulation. Proton pump inhibitors are not exempt from controversial aspects related to associated adverse events. Technological development is directed at improving proton pump inhibitor performance through increasing the half-life, maximum concentration, and area under the curve of the plasma concentrations through galenic formulation, as well as creating safer and more tolerable drugs. The present review is focused on the mechanisms of action, pharmacokinetic properties, and technological advances for increasing the pharmacologic performance of a proton pump inhibitor.
Asunto(s)
Ácido Gástrico/química , Inhibidores de la Bomba de Protones/farmacología , Animales , Monitorización del pH Esofágico , Reflujo Gastroesofágico , Humanos , Inhibidores de la Bomba de Protones/química , Inhibidores de la Bomba de Protones/farmacocinética , Inhibidores de la Bomba de Protones/uso terapéuticoRESUMEN
In the event of a major accidental release of radionuclides at a nuclear power plant, large populated areas could become seriously contaminated. Local officials would be responsible for establishing radiation recovery criteria that would permit the evacuated population to return safely to their jobs and homes. The range of acceptable criteria could imply variations in property losses in the billions of dollars. Given the likely public concern over the health consequences and the enormity of the potential property losses, a cost/risk analysis can provide important input to establishing the recovery criteria. This paper describes procedures for conducting a cost/risk analysis of a site radiologically contaminated by a nuclear power plant accident. The procedures are illustrated by analyzing a hypothetically contaminated site, using software developed for determining the property and health effects of major reactor accidents.
Asunto(s)
Accidentes/economía , Planificación en Desastres/economía , Reactores Nucleares , Costos y Análisis de Costo , Humanos , Riesgo , Estados UnidosRESUMEN
Six numerical examples of optimization of radiation protection are provided in the appendices of International Commission on Radiological Protection (ICRP) Publication No. 37 (1983). In each case, the calculations were based on well-defined parameters and assumptions. In this paper, we examined three different numerical examples that were based on empirical data and less-certain assumptions. In the first example, the optimum sampling frequency for a typical 3H bioassay program was found to be once every 2 mo. However, this result depended on assumed values for several variables that were difficult to evaluate. The second example showed that the optimum frequency for recalibrating a group of "cutie pie" (CP) ionization chamber survey instruments was once every 85 d. This result depended largely on the assumption that an improperly operating CP instrument could lead to a serious overexposure. In the third example, one continuous air monitor (CAM) was determined to be the optimum number in a workplace at a Department of Energy (DOE) Pu facility. The optimum location of the CAM was determined from past glove-box release studies. These examples demonstrated that cost-benefit analysis of individual elements of radiation protection programs can be useful even if limited data are available.
Asunto(s)
Protección Radiológica/métodos , Contaminación Radiactiva del Aire/análisis , Bioensayo , Análisis Costo-Beneficio , Agencias Gubernamentales , Humanos , Enfermedades Profesionales/prevención & control , Monitoreo de Radiación/métodosRESUMEN
During 17 months, 73 HIV-positive patients with diarrhea lasting at least for 14 days, were studied prospectively. The patients had stool specimen examinations negative for enteric pathogens, or positive for one of them, but with no response to specific treatment. All patients were subcomitted to digestive endoscopy and biopsies were taken for microbiological and histological studies. The etiology of the diarrhea could be established in 48 patients (66%). In 45, the cause was an enteric infection. There was association of 2 pathogens in 11 patients, and of 3 in 1 patient. The agents found were: Cryptosporidium (24%), MAI (16%), Giardia lambila (12%), isospora belli (5%), Shigella (5%), Salmonella (5%); Entamoeba histolytica (3%), HSV (3%), tuberculosis (2%), adherent bacteria (2%) and spirochetes (2%). In 3 patients the etiology was not infection, their diagnoses were coeliac disease, lymphoma and idiophatic colonic ulcers, respectively. In 51% of the cases only the examination of endoscopic biopsy specimens could identify the cause of the diarrhea. These results justify the use of these methods to improve diagnosis and therapeutic attempts in these patients.
Asunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/diagnóstico , Diarrea/diagnóstico , Enteropatía por VIH/diagnóstico , Adulto , Anciano , Biopsia , Diarrea/complicaciones , Diarrea/terapia , Endoscopía Gastrointestinal , Femenino , Enteropatía por VIH/complicaciones , Humanos , Intestinos/patología , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Durante 17 meses se esdudiaron prospectivamente 73 pts HIV + con diarrea más de 14 dias de evolución, sin diagnóstico etiológico por el examen de la mf, o bien con coprocultivos positivos, pero sin respuesta al tratamiento específico. A todos se les realizó endoscopía digestiva con tomas de biopsias intestinales para estudio microbiológico (directo y cultivo) e histopatológico. El diagnóstico causal de diarrea pudo realizarse en 48 prs (66 por ciento). En 45, la cuasa fue infecciosa. Hubo asociación de 2 gérmenes en 11 pts y de 3 gérmenes en 1. Los patógenos hallados fueron: Cryptosporidium (24 por ciento), CMV (21 por ciento), MAI (16 por ciento), Giardias (12 por ciento), Isospora belli (5 por ciento), Shigella (5 por ciento), Salmonella (5 por ciento) , Entamoeba histolítica (3 por ciento), HSV (3 por ciento, TBC (2 por ciento), bacteria adherente (2 por ciento) y espiroqueta (2 por ciento). En 3 pts la causa de la diarrea no fue infecciosa, en ellos se diagnosticó respectivamente enfermedad celíaca, linfoma y úlceras inespecíficas de colon. En el 51 por ciento de los casos sólo la endoscopía con biopsia intestinal permitó identificar el agente causal, resultando que justifica el uso de este método como diagnóstico en esta patología.