Tercera Cumbre Nacional de Delegados y Vocales de la Asociación Mexicana para Estudio y Tratamiento del Dolor (AMETD) / Third National Summit of Delegates and Vocals of the Mexican Association for the Study and Treatment of Pain (AMETD)

Resumen: La Asociación Mexicana para el Estudio y Tratamiento del Dolor nació en la década de los ochenta. Desde su fundación ha intervenido activamente en la educación continua de la nación y ha colaborado en la elaboración de documentos gubernamentales sobre diversos tópicos. En esta ocasión, durante la tercera reunión de delegados y vocales, se ponen a consideración diversas recomendaciones generales en materia de educación y regulación de opioides.

Abstract: The Mexican Association for the Study and Treatment of Pain was born in the eighties. Since its foundation, it has actively participated in the continuing education of the Nation and has collaborated in the preparation of government documents on various subjects. On this occasion, during the third meeting of delegates and members, various general recommendations regarding education and regulation of opioids are put for consideration.

Actualización de las guías del tratamiento farmacológico de la artritis reumatoide del Colegio Mexicano de Reumatología 2018 / Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018

Los avances terapéuticos en la artritis reumatoide obligan a revisión periódica de las guías de tratamiento. Objetivo: Actualizar las guías del Colegio Mexicano de Reumatología del tratamiento farmacológico de la artritis reumatoide. Método: Participaron reumatólogos certificados de diferentes instituciones de salud y regiones del país. Se conformaron equipos de trabajo que revisaron las guías previas, elaboraron nuevas preguntas, revisaron la literatura y calificaron la evidencia, que fue presentada y discutida en sesión plenaria. Las conclusiones se comentaron con infectólogos, ginecobstetras y pacientes. Se emiten recomendaciones basadas en niveles de evidencia de acuerdo con la metodología GRADE. Resultados: Se presentan recomendaciones actualizadas para el empleo de los medicamentos disponibles en México hasta 2017 para el tratamiento de la artritis reumatoide. Se enfatiza la importancia del control adecuado y sostenido de la enfermedad y se describen aspectos relevantes de seguridad. Se incluyen conflictos bioéticos y se invita a la acción gubernamental para fortalecer el tratamiento adecuado de la enfermedad. Conclusiones: La actualización de las recomendaciones del Colegio Mexicano de Reumatología del tratamiento farmacológico de la artritis reumatoide integra la mejor información disponible para ser utilizada en el sistema de salud de México.(AU)

Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines.Objective: To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. Method: Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. Results: Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. Conclusions: The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.(AU)

Update of the Mexican College of Rheumatology Guidelines for the Pharmacological Treatment of Rheumatoid Arthritis, 2018. / Actualización de las guías del tratamiento farmacológico de la artritis reumatoide del Colegio Mexicano de Reumatología 2018.

Therapeutic advances in rheumatoid arthritis require periodic review of treatment guidelines. OBJECTIVE: To update the Mexican College of Rheumatology guidelines on the pharmacological treatment of rheumatoid arthritis. METHOD: Board certified rheumatologists from different health institutions and regions of the country participated. Work teams were formed that reviewed the previous guidelines, elaborated new questions, reviewed the literature, and scored the evidence that was presented and discussed in plenary session. The conclusions were presented to infectologists, gynaecologists and patients. Recommendations were based on levels of evidence according to GRADE methodology. RESULTS: Updated recommendations on the use of available medications for rheumatoid arthritis treatment in Mexico up to 2017 are presented. The importance of adequate and sustained control of the disease is emphasized and relevant safety aspects are described. Bioethical conflicts are included, and government action is invited to strengthen correct treatment of the disease. CONCLUSIONS: The updated recommendations of the Mexican College of Rheumatology on the pharmacological treatment of rheumatoid arthritis incorporate the best available information to be used in the Mexican health care system.

The GLIM criteria for adult malnutrition and its relation with adverse outcomes, a prospective observational study.

BACKGROUND & AIMS: Malnutrition is considered a risk factor for many complications and mortality among hospitalized patients. Until 2016 there was a wide variety of clinical definitions for malnutrition, until the GLIM criteria proposed a consensual definition. The main goal of this study is to assess the performance of the GLIM criteria at acute care admission to detect those patients with adverse clinical outcomes such as mortality and the need to be transferred to critical care areas (CCA). METHODS: This was a prospective observational study including every adult patient admitted to the regular ward of the Hospital San Ángel Inn Universidad. Every nutrition and demographic variable evaluated by the nutrition team at hospital admission was captured. The malnutrition definition according to the GLIM and separate criteria were tested for their performance to detect patients at high risk for adverse outcomes (mortality and the need to be transferred to CCA), using odd ratios (OR), their confidence interval of 95% (CI95%) and binary logistic regression accordingly. RESULTS: A total of 1015 patients were included in the final analysis, with a prevalence of 18.9% of malnutrition (according to the GLIM definition) at hospital admission. Malnutrition was associated with mortality (OR of 59.69,CI95% 7.76-459.28) and unplanned transfer to CCA (OR of 9.453, CI95%4.35-20.56). However, despite being sensitive, the GLIM definition of malnutrition, displayed low positive predictive value, and was therefore associated with many false positives. There was a trend for higher risks for adverse outcomes with higher severity of malnutrition. Muscle wasting, chronic and acute inflammation were independent predictors for mortality and for unplanned transfer to CCA. CONCLUSIONS: Malnutrition according to the GLIM criteria is strongly associated with mortality and transfer to CCA. Muscle wasting and inflammation (acute and chronic) were independently associated with these outcomes.

Escenario actual de los medicamentos biocomparables en México: posicionamiento del Colegio Mexicano de Reumatología, 2016 / Current state of biosimilars in Mexico: The position of the Mexican College of Rheumatology, 2016

El presente documento refleja el posicionamiento del Colegio Mexicano de Reumatología y de expertos sobre el uso de medicamentos biocomparables (conocidos como biosimilares en otros países) en enfermedades reumáticas. En resumen, este posicionamiento considera que si bien los biocomparables deben considerarse como intercambiables, no es ética la sustitución automática de medicamentos sin previo aviso en pacientes estables durante el seguimiento; que la aprobación de un biocomparable debe llevarse a cabo solo después de revisar exhaustivamente las pruebas preclínicas y clínicas señaladas por la ley mexicana; que debe modificarse la forma de enfatizar en su nomenclatura que se trata de un medicamento biotecnológico innovador o biocomparable de manera clara; que no es adecuado elegir como tratamiento un biocomparable basándose únicamente en aspectos económicos ni realizarse la extrapolación de indicaciones basándose únicamente en la aprobación obtenida por el innovador y en ausencia de datos de seguridad y eficacia para el biocomparable

The present document is a position statement of the Mexican College of Rheumatology on the use of biosimilars in rheumatic diseases. This position considers that biosimilars should be considered as interchangeable, that automatic substitution without previous notice in stable patients during follow-up is not ethical, that the approval of a biosimilar should only be given after exhaustive review of preclinical and clinical data marked by Mexican regulations, that it should be clearly stated in the nomenclature of biologic drugs which is the innovator and which is the biosimilar, that it is not correct to choose a biosimilar as treatment based only on economic reasons or extrapolate indications based only on the approval of the innovator and in the absence of safety and efficacy data for the biosimilar

Current state of biosimilars in Mexico: The position of the Mexican College of Rheumatology, 2016. / Escenario actual de los medicamentos biocomparables en México: posicionamiento del Colegio Mexicano de Reumatología, 2016.

The present document is a position statement of the Mexican College of Rheumatology on the use of biosimilars in rheumatic diseases. This position considers that biosimilars should be considered as interchangeable, that automatic substitution without previous notice in stable patients during follow-up is not ethical, that the approval of a biosimilar should only be given after exhaustive review of preclinical and clinical data marked by Mexican regulations, that it should be clearly stated in the nomenclature of biologic drugs which is the innovator and which is the biosimilar, that it is not correct to choose a biosimilar as treatment based only on economic reasons or extrapolate indications based only on the approval of the innovator and in the absence of safety and efficacy data for the biosimilar.

Repetitive Transcranial Magnetic Stimulation for Phantom Limb Pain in Land Mine Victims: A Double-Blinded, Randomized, Sham-Controlled Trial.

UNLABELLED: We evaluated the effects of repetitive transcranial magnetic stimulation (rTMS) in the treatment of phantom limb pain (PLP) in land mine victims. Fifty-four patients with PLP were enrolled in a randomized, double-blinded, placebo-controlled, parallel group single-center trial. The intervention consisted of real or sham rTMS of M1 contralateral to the amputated leg. rTMS was given in series of 20 trains of 6-second duration (54-second intertrain, intensity 90% of motor threshold) at a stimulation rate of 10 Hz (1,200 pulses), 20 minutes per day, during 10 days. For the control group, a sham coil was used. The administration of active rTMS induced a significantly greater reduction in pain intensity (visual analogue scale scores) 15 days after treatment compared with sham stimulation (-53.38 ± 53.12% vs -22.93 ± 57.16%; mean between-group difference = 30.44%, 95% confidence interval, .30-60.58; P = .03). This effect was not significant 30 days after treatment. In addition, 19 subjects (70.3%) attained a clinically significant pain reduction (>30%) in the active group compared with 11 in the sham group (40.7%) 15 days after treatment (P = .03). The administration of 10 Hz rTMS on the contralateral primary motor cortex for 2 weeks in traumatic amputees with PLP induced significant clinical improvement in pain. PERSPECTIVE: High-frequency rTMS on the contralateral primary motor cortex of traumatic amputees induced a clinically significant pain reduction up to 15 days after treatment without any major secondary effect. These results indicate that rTMS is a safe and effective therapy in patients with PLP caused by land mine explosions.

[Interscalene block for total shoulder arthroplasty: comparative study (ultrasound vs. neurostimulation)]. / Bloqueo interescalénico para artroplastia total de hombro: estudio comparativo ultrasonido vs neuroestimulación.

BACKGROUND: Modern anesthesiology has integrated the use of ultrasonography as a tool that has displaced neurostimulation as a technique for locating peripheral nerves. The aim of this study was to determine which procedure is more effective for guiding interscalene block for total shoulder arthroplasty. METHODS: We carried out a comparative, prospective non-randomized study comprised of the group guided by neurostimulation interscalene block and the group guided by ultrasound. All patients in both groups were scheduled for total shoulder arthroplasty. Latency, degree of sensory and motor block, success rate, postoperative pain intensity at 6, 12, and 24 h, patient satisfaction and complications were measured. RESULTS: We included 110 patients, 55 per group. Patients were placed in beach chair position and the deltopectoral approach was used. There were no differences in demographic characteristics. Results for neurostimulation vs. ultrasound group: latency 19.11 ± 2.27 vs. 17.24 ± 1.42 min, p= 0.23. Block sensitivity in both groups was grade 0 motor block grade 0 in 76.4% and grade 1 in 23.6% vs. grade 0 to 100%. There was 100% success rate for both groups. Postoperative pain at 6 h was 0.13 ± 0.54 vs. 0.11 ± 0.13 p= 0.90, at 12 h 1.67 ± 1.15 vs. 1.65 ± 0.59 p= 0.89 and at 24 h 3.15 ± 1.66 vs. 2.99 ± 1.15 p= 0.78. Satisfaction 54.5% very satisfied and 45.5% satisfied 96.36% vs 3.6% very satisfied and satisfied. Complications 18.18% vs. 3.6% p= 0.023. CONCLUSION: Ultrasound-guided interscalene nerve block is the technique of choice in elective total shoulder arthroplasty.

ANTECEDENTES: la anestesiología moderna ha integrado a la ultrasonografía como una herramienta que ha desplazado a la neuroestimulación como técnica de localización de nervios periféricos: ¿cuál es más efectiva para guiar el bloqueo interescalénico en artroplastia total de hombro? OBJETIVO: comparar dos técnicas de localización del plexo braquial bloqueo interescalénico como técnica anestésica en artroplastia total de hombro. MATERIAL Y MÉTODOS: estudio comparativo, prospectivo, sin asignación al azar. Se incluyeron todos los pacientes programados para artroplastia total de hombro; se formaron 2 grupos: grupo neuroestimulación donde el bloqueo interescalénico fue guiado por neuroestimulación, grupo ultrasonido que fue guiado por ultrasonido. Se midió el tiempo de latencia, grado de bloqueo sensitivo y motor, tasa de éxito, intensidad del dolor postoperatorio a las 6, 12 y 24 horas, satisfacción, y complicaciones. RESULTADOS: se incluyeron 110 pacientes, 55 por grupo, posición de silla de playa y abordaje deltopectoral. No hubo diferencias en las características demográficas, neuroestimulación vs ultrasonografía: latencia 19.11 ± 2.27 vs 17.24 ± 1.42 minutos p= 0.23. Bloqueo sensitivo en ambos grupos grado 0, bloqueo motor grado 0 en 76.4% y grado 1 en 23.6%, vs grado 0 en 100%. Tasa de éxito 100% en ambos grupos, dolor postoperatorio 6 horas 0.13 ± 0.54 vs 0.11 ± 0.13 p= 0.90; 12 horas de 1.67 ± 1.15 vs 1.65 ± 0.59 p= 0.89, 24 horas 3.15± 1.66 vs 2.99 ± 1.15 p= 0.78. Satisfacción: 54.5% muy satisfecho, y 45.5% satisfecho vs 96.36% muy satisfecho y 3.6% satisfecho. Complicaciones 18.18% vs 3.6% p= 0.023. CONCLUSIÓN: el ultrasonido es la técnica de localización del plexo braquial de elección en artroplastia total de hombro.

Fundamentos y aplicaciones clínicas de la estimulación magnética transcraneal en neuropsiquiatría / Fundamentals and Clinical Applications of Transcranial Magnetic Stimulation in Neuropsychiatry

La estimulación magnética transcraneal (EMT) es una herramienta no invasiva de estimulación cerebral que se basa en la capacidad de un campo magnético generado para penetrar el cráneo y las meninges y originar una corriente eléctrica secundaria en el tejido cerebral que produce despolarización neuronal. Esta técnica se puede aplicar en un solo estímulo, en pares de estímulos separados por intervalos o en trenes de estímulos repetidos a varias frecuencias. Si bien el mecanismo de acción exacto se desconoce, la EMT repetitiva puede modular la excitabilidad de la corteza cerebral, por lo cual se ha vislumbrado como una posible herramienta diagnóstica y terapéutica en el área de neuropsiquiatría. El objetivo de este artículo es revisar el conocimiento actual de la EMT en cuanto a principios básicos, mecanismos fisiopatológicos y utilidad en la práctica clínica de la neuropsiquiatría.

Transcranial Magnetic Stimulation (TMS) is a non-invasive method for stimulation of brain that is based on the ability of a generated magnetic field to penetrate skull and brain meninges, inducing an electric current in the brain tissues that produces neuronal depolarization. TMS can be applied as single pulse of stimulation, pairs of stimuli separated by variable intervals to the same or different brain areas, or as trains of repetitive stimuli at various frequencies. Its mechanism of action is currently unknown. Repetitive TMS can modify the excitability of the cerebral cortex, and has been postulated as a diagnostic and therapeutic tool in the area of neuropsychiatry. The aim of this article is to review the knowledge of the TMS as regards its basic principles, pathophysiological mechanism, and its usefulness in clinical practice.

[Fundamentals and Clinical Applications of Transcranial Magnetic Stimulation in Neuropsychiatry]. / Fundamentos y aplicaciones clínicas de la estimulación magnética transcraneal en neuropsiquiatría.

Transcranial Magnetic Stimulation (TMS) is a non-invasive method for stimulation of brain that is based on the ability of a generated magnetic field to penetrate skull and brain meninges, inducing an electric current in the brain tissues that produces neuronal depolarization. TMS can be applied as single pulse of stimulation, pairs of stimuli separated by variable intervals to the same or different brain areas, or as trains of repetitive stimuli at various frequencies. Its mechanism of action is currently unknown. Repetitive TMS can modify the excitability of the cerebral cortex, and has been postulated as a diagnostic and therapeutic tool in the area of neuropsychiatry. The aim of this article is to review the knowledge of the TMS as regards its basic principles, pathophysiological mechanism, and its usefulness in clinical practice.

Consumo de psicotrópicos sin prescripción médica en farmacodependientes en proceso de rehabilitación / Consumption of psychotropics without medical prescription drug abusers in rehabilitation process

Objetivo. Caracterizar el consumo de psicotrópicos sin prescripción médica en farmacodependientes atendidos por una fundación dedicada a la rehabilitación, en el departamento del Quindío, Colombia, entre los años 2006 y 2009.Métodos. Se utilizó como instrumento para recolectar la información el formulario del Sistema de Vigilancia Epidemiológica para Uso Indebido de Sustancias Psicoactivas –VESPA–, aplicados a los usuarios al momento de ingresar a la institución.Resultados. En total, 175 personas manifestaron haber consumido psicotrópicos sin prescripción médica; de ellas, 92% dijo haber consumido Rivotril y 15% consumieron Rohypnol. Actualmente, 62 consume psicotrópicos y, de ellos, 21% los ingieren, por lo menos, una vez al día. La edad promedio de inicio de consumo de sustancias psicoactivas fue 12,61 años, en su mayoría, tabaco (43%); la de psicotrópicos fue 16,9 años.Conclusiones. Estas cifras sugieren, por un lado, la necesidad de más programas de prevención de consumo de sustancias psicoactivas y, por el otro, de que las autoridadescompetentes adopten más medidas de control sobre la circulación y el expendio de psicotrópicos...

Objective: characterize the consumption of psychotropicdrugs without a medical prescriptionin drug addict treated by a foundation dedicated to the rehabilitation in the department of Quindío, Colombia, between the years 2006 to 2009.Methods: The instruments for data collection employed were the Epidemiological SurveillanceSystem for Inadequate Use of Psychoactive Substances’ (VESPA),applied to users when entering the institution.Results: 175 people claim to have used psychotropic drugs without a medical prescription; of these, 92% said they had consumed Rivotril and 15% consumed Rohypnol. Actually consume 62% psychotropic drug, of which 21% ingested at least once a day. The average age of onset was 12.61 years, in the majority with tobacco (43%)of psychotropic to 16.9.Conclusions: These figures suggest first, the need to make major prevention programs of psychoactive substance use, another importantthing the competent authorities should carry out a more efficient ways of control about the traffic and selling of psychotropic substances...

Complicaciones neurológicas de la endocarditis infecciosa: controversias / Neurological complications of infective endocarditis: controversies

En la endocarditis infecciosa aguda se describen complicaciones neurológicas entre 20% y 40% de los casos, lo cual representa un importante factor que predice morbimortalidad, secuelas y discapacidad. Esta entidad se caracteriza por un amplio espectro clínico debido a su compleja fisiopatología, que involucra entre otros, fenómenos inflamatorios, inmunes, infecciosos y embólicos. A pesar de la notable frecuencia de las complicaciones neurológicas en la endocarditis infecciosa, dadas especialmente por enfermedad cerebrovascular y neuroinfecciones, aun existen controversias acerca de algunos aspectos diagnósticos y terapéuticos, en parte por la poca evidencia disponible, las cuales se discuten a continuación, a partir de una serie de casos atendidos en la Fundación Cardiovascular de Colombia.

Neurological complications of acute infective endocarditis are described in 20%-40% of cases, representing an important predictive factor of morbidity, mortality, sequels and disability. Acute endocarditis is characterized by a wide clinical spectrum due to its complex physiopathology that involves inflammatory, immune, infectious and embolic phenomena. Despite the remarkable frequency of neurological complications in the infective endocarditis especially by cerebrovascular disease and neuroinfections, there are still some controversies about some diagnostic and therapeutic aspects, partly because of the little evidence available. This paper describes a number of cases seen in the Fundación Cardiovascular de Colombia and discusses some aspects related with the diagnosis and treatment of the neurological complications of acute endocarditis.

Coexistence of √3 ×√3 and quasi-linear phases of sulfur adsorbed (Θ = 1/3) on a gold (111) substrate.

We analyze with the aid of density functional theory and molecular dynamics simulations the adsorption of sulfur (S) on a Au(111) surface at different temperatures with a variety of geometries. We have found a new superficial phase in which sulfur atoms form a quasi-linear chain with energies very close to the expected . The results suggest the coexistence of both configurations at T < 300 K. At high temperatures (T > 300 K) it was shown that the sulfur atoms have high mobility which allows their migration among different adsorption sites. At low temperatures, the mobility decreases and a thermal activation barrier of 25-30 meV can be estimated.

Hemicraniectomía en pacientes con ataque cerebro vascular isquémico extenso: aspectos relevantes a propósito de una serie de casos / Decompressive hemicranectomy in patients with extensive ischemic stroke discussion issues about a series of case

IntroduccIón: cerca del 10% de los pacientes con ataque cerebro vascular isquémico agudo (ACV), presentan una oclusión completa de la arteria cerebral media (ACM) generando una mortalidad que puede alcanzar el 80%. La hemicraniectomía descompresiva (HD) puede reducir dramáticamente la mortalidad; sin embargo se encuentra en discusión su papel frente a la discapacidad asociada en estos pacientes.objetIvo: describir en una cohorte histórica, las consideraciones para la realización de la Hemicraniectomía descompresiva (HD), evaluar los desenlaces en términos de la mortalidad y la funcionalidad evaluada por el Rankin-m y el Barthel al egreso hospitalario.Métodos: análisis descriptivo de pacientes atendidos en el Instituto del Corazón de la Fundación Cardiovascular de Colombia en los últimos 2 años con diagnóstico de ACV extenso, dividiéndolos en dos grupos, un grupo con HD y otro con manejo convencional.resultados: se recolectaron 18 pacientes con ACV extenso, a 7 (38,8%) se les realizó HD y a 11 (61,1%) se les dio manejo médico convencional. La etiología del ACV más frecuente en ambos grupos fue la cardioembólica (61%), no hubo diferencias en cuanto a la severidad del ACV medida por escala NIHSS. Todas las HD se realizaron en las primeras 48 horas. La mortalidad en el grupo con HD fue de 14,2% mientras en el grupo con manejo médico convencional fue 54,5%. En cuanto a la funcionalidad al egreso hospitalario se observó una menor discapacidad en el grupo de HD comparado con el grupo sin HD (Rankin-m p=0,08 y Barthel p=0,03).conclusIón: la hemicraniectomía es una alternativa para pacientes con ACV extenso de la ACM, cuyo objetivo principal es disminuir la mortalidad y evitar el daño del hemisferio contralateral.