Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM: The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS: The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS: Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS: An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.

The Mexican consensus on fecal incontinence.

Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence¼ and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.

Whole-genome sequence analysis of multidrug-resistant uropathogenic strains of Escherichia coli from Mexico.

Background : Escherichia coli is the main bacterium associated with urinary tract infections (UTIs), including cystitis and pyelonephritis. Uropathogenic E. coli (UPEC) harbors numerous genes that encode diverse virulence factors contributing to its pathogenicity. The treatment of UTIs has become complicated due to the natural selection of E. coli strains that are multiresistant to several groups of antibiotics regularly used in clinical settings such as hospitals. Genomic reports of the global composition and distribution of the antibiotic resistance and virulence genes of these pathogenic strains are lacking in the Mexican population. Purpose and methods : The aim of this study was to globally characterize the genomes of a group of UPEC strains by massive parallel sequencing to determine the prevalence and distribution of virulence and antibiotic resistance genes associated with different serotypes and phylogenetic groups. Results: The strains exhibited 138-197 virulence genes and 29 antibiotic resistance genes related to antibiotics that are commonly used in clinical practice.  Conclusions: These findings are relevant to the definition of new strategies for treating urinary tract infections in public hospitals and private practice. To further define the epidemiological distribution and composition of these virulence and antibiotic resistance genes, larger studies are needed.

Probiotic use in clinical practice: Results of a national survey of gastroenterologists and nutritionists. / Uso de probióticos en la práctica clínica: resultados de una encuesta nacional a gastroenterólogos y nutriólogos.

INTRODUCTION AND AIMS: Probiotics are effective in gastrointestinal disease management. In Mexico, there are no studies on the use and prescription of probiotics by healthcare professionals. Our aim was to evaluate probiotic use and prescription on the part of gastroenterologists and nutritionists. MATERIALS AND METHODS: An online survey questionnaire was sent to members of the Asociación Mexicana de Gastroenterología (n = 1042), the Asociación Mexicana de Nutriología (n = 220), and healthcare professionals registered at the Fourth International Symposium: Intestinal Microbiota (n = 1328). RESULTS: Response was 34% (997 questionnaires answered) and 570 (64%) of the respondents were women. Mean participant age was 36.2 years (range 18-83). Thirty-six percent of the participants were gastroenterologists, 46% were nutritionists, and 18% were chemists and microbiologists. Seventy-one percent of the respondents knew the Food and Agriculture Organization (FAO) definition of probiotics and recommended them «always¼ (64.9%), «rarely¼ (31.7%), and «never¼ (3.6%). Gastroenterologists indicated probiotics for the treatment of disease (56.5%) and nutritionists for health maintenance (39%). Ninety-seven percent of the gastroenterologists and 98% of the nutritionists evaluated probiotics as effective in gastrointestinal symptom management and considered them safe. The majority of the respondents did not know which probiotic strain was contained in the commercial probiotic product. CONCLUSIONS: The survey results showed that the participating gastroenterologists and nutritionists understood the concept of probiotics, recommended them frequently, and considered them safe. The gastroenterologists prescribed probiotics as therapeutic agents and the nutritionists to maintain health. There was a lack of knowledge about the microbial composition of the products containing probiotics available in Mexico.

The Mexican consensus on non-cardiac chest pain. / Consenso mexicano sobre dolor torácico no cardiaco.

INTRODUCTION: Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM: To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS: Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS: The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection. / Consenso sobre prevención, diagnóstico y tratamiento de la infección por Clostridium difficile.

In recent decades, Clostridium difficile infection (CDI) has become a worldwide health problem. Mexico is no exception, and therefore the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, endoscopists, internists, infectious disease specialists, and microbiologists) to carry out the "Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection", establishing useful recommendations (in relation to the adult population) for the medical community. Said recommendations are presented herein. Among them, it was recognized that CDI should be suspected in subjects with diarrhea that have a history of antibiotic and/or immunosuppressant use, but that it can also be a community-acquired infection. A 2-step diagnostic algorithm was proposed, in which a highly sensitive test, such as glutamate dehydrogenase (GDH), is first utilized, and if positive, confirmed by the detection of toxins through immunoassay or nucleic acid detection tests. Another recommendation was that CDI based on clinical evaluation be categorized as mild-moderate, severe, and complicated severe, given that such a classification enables better therapeutic decisions to be made. In mild-moderate CDI, oral vancomycin is the medication of choice, and metronidazole is recommended as an alternative treatment. In addition, fecal microbiota transplantation was recognized as an efficacious option in patients with recurrence or in the more severe cases of infection, and surgery should be reserved for patients with severe colitis (toxic megacolon), in whom all medical treatment has failed.

How much does the specialist know about cardiogastroenterology? / ¿Cuánto sabe el especialista sobre cardiogastroenterología?

INTRODUCTION AND AIMS: Cardiovascular disease is a growing public health problem. Forty percent of the general population will suffer from the disease by 2030, consequently requiring antithrombotic therapy. Cardiogastroenterology is a new area of knowledge that evaluates the gastrointestinal effects and complications of antithrombotic therapy. Our aim was to evaluate, through a validated questionnaire, the knowledge held by a group of specialists and residents in the areas of gastroenterology and internal medicine, about pharmacology and drug prescription, as well as gastrointestinal risks and complications, in relation to antithrombotic therapy. PATIENTS AND METHODS: A validated questionnaire composed of 30 items was applied to a group of specialists and residents in the areas of gastroenterology and internal medicine. The questions were on indications, pharmacology, evaluation of risks for gastrointestinal bleeding and thromboembolic events, and use of antithrombotic therapy during endoscopic procedures. Sufficient knowledge was defined as 18 or more (≥ 60%) correct answers. RESULTS: The questionnaire was answered by 194 physicians: 82 (42%) internal medicine residents and gastroenterology residents and 112 (58%) specialists. Only 40 (20.6%) of the participants had sufficient knowledge of cardiogastroenterology. Residents had a higher number of correct answers than specialists (53 vs. 36%, P<.0001). The gastroenterology residents had more correct answers than the internal medicine residents, gastroenterologists, and internists (70 vs. 53, 40, and 46%, respectively, P<.001). Only residents had sufficient knowledge regarding pharmacology and the use of antithrombotic therapy in endoscopy (P<.0001). All groups had insufficient knowledge in evaluating the risk for gastrointestinal bleeding and thrombosis. CONCLUSIONS: Knowledge of cardiogastroenterology was insufficient in the group of residents and specialists surveyed. There is a need for medical education programs on the appropriate use of antithrombotic therapy.

The effects of transient starvation persist through direct interactions between CaMKII and ether-a-go-go K+ channels in C. elegans males.

Prolonged nutrient limitation has been extensively studied due to its positive effects on life span. However, less is understood of how brief periods of starvation can have lasting consequences. In this study, we used genetics, biochemistry, pharmacology and behavioral analysis to show that after a limited period of starvation, the synthesis of egl-2-encoded ether-a-go-go (EAG) K+ channels and its C-terminal modifications by unc-43-encoded CaMKII have a perduring effect on C. elegans male sexual behavior. EGL-2 and UNC-43 interactions, induced after food deprivation, maintain reduced excitability in muscles involved in sex. In young adult males, spastic contractions occur in cholinergic-activated sex muscles that lack functional unc-103-encoded ERG-like K+ channels. Promoting EGL-2 and UNC-43 interactions in unc-103 mutant adult males by starving them for a few hours reduce spastic muscle contractions over multiple days. Although transient starvation during early adulthood has a hormetic effect of suppressing mutation-induced muscle contractions, the treatment reduces the ability of young wild-type (WT) males to compete with well-fed cohorts in siring progeny.

Regulation of distinct muscle behaviors controls the C. elegans male's copulatory spicules during mating.

We demonstrate through cell ablation, molecular genetic, and pharmacological approaches that during C. elegans male mating behavior, the male inserts his copulatory spicules into the hermaphrodite by regulating periodic and prolonged spicule muscle contractions. Distinct cholinergic neurons use different ACh receptors and calcium channels in the spicule muscles to mediate these contractile behaviors. The PCB and PCC sensory neurons facilitate periodic contraction through muscle-encoded UNC-68 ryanodine receptor calcium channels. The SPC motor neurons trigger prolonged contraction through EGL-19 L-type voltage-gated calcium channels. The male gonad then lengthens the duration of EGL-19-mediated prolonged muscle contraction. This regulation of muscle contraction provides a paradigm to explain how animals initiate, monitor, and maintain a behavioral motor program.

Translocation and specific cleavage of bacteriophage T7 DNA in vivo by EcoKI.

Infection of Escherichia coli containing the type I restriction enzyme EcoKI by bacteriophage T7 0.3 mutants leads to restriction during the late stages of genome entry and during DNA replication. Patterns of cleavage in vivo suggest that some cutting occurs near the midpoint of two recognition sites, consistent with the idea that EcoKI translocates DNA bidirectionally through itself and cuts when two enzyme molecules collide. Rapid ejection of a 0.3(+) T7 genome from a bacteriophage lambda particle results in degradation of the infecting DNA by EcoKI, showing that the normal T7 DNA translocation process delays restriction. A unique recognition site inserted at the genomic left end allows EcoKI to function as a molecular motor and to translocate the remaining 39 kilobases of T7 DNA into the cell.

Neisseria meningitidis serogroup C polysaccharide and serogroup B outer membrane vesicle conjugate as a bivalent meningococcus vaccine candidate.

Neisseria meningitidis serogroup C polysaccharide (PS C) was conjugated to serogroup B outer membrane vesicles (OMV) in order to test the possibility of obtaining a bivalent group B and C meningococcus vaccine. The conjugate and controls were injected intraperitoneally into groups of ten mice with boosters on days 14 and 28 after the primary immunization. The following groups were used as control: (i) PS C; (ii) PS C plus OMV; (iii) OMV; and (iv) saline. The serum collected on days 0, 14, 28 and 42 were tested by enzyme-linked immunosorbent assay (ELISA) for PS C and OMV, and by complement mediated bactericidal assay against serogroups B and C. ELISA for PS C as well as bactericidal titres against serogroup C meningococci of the conjugated vaccine increased eight-fold (ELISA) and 32 fold (bactericidal) after 42 days in comparison with the PS C control group. ELISA for OMV and bactericidal titre against serogroup B meningococci of the conjugate showed no significant difference in comparison with the OMV containing controls. Furthermore, Western Blot assay of the conjugate immune serum did not bind OMV class four protein which is related to the complement dependent antibody suppressor. The results indicate that the PS C-OMV conjugate could be a candidate for a bivalent vaccine toward serogroups B and C meningococci.

Lesiones por flexodistracción de la columna cervical tratadas con placas por vía posterior / Flexodistraction injuries of the cervical spine treated by back route plates

Se realizó un estudio descriptivo, longitudinal ambispectivo en 18 pacientes con lesiones por flexodistracción cervical estadios 2 a 4 de Allen y Frerguson tratados con placas posteriores para determinar la evolución de la estabilidad de la columna y el estado neurológico de los pacientes de acuerdo a los criterios de White y Panjabi y a la Escala Fundación Medular de la American Spinal Injury Association (ASIA). La media del seguimiento fue de 14 meses. En la valoración preoperatoria la puntuación inicial de ASIA fue entre mala y pobre en un 27 por ciento y todos los pacientes tuvieron más de 5 puntos de inestabilidad, en la valoración de control postratamiento la puntuación de ASIA fue excelente en el 77.8 por ciento y buena en el 11 por ciento de los casos; 1 casos (estadio 4) continuó con una puntuación mala < 25 puntos de ASIA (lesión medular completa), pero con columna estable, y otro cursó con inestabilidad cervical por puntuación aunque con una evolución clínica normal (ASIA 125 puntos) y columna fusionada. Se identificó una asociación significativa entre la valoración prequirúrgica con evolución clínia (RR = 13.50, IC 95 por ciento = 6.78, p = 0.00003) y en la valoración de ASIA pre y postratamiento (RR = 1.55, IC 95 por ciento = 1.4866 - 5.6041, p = 0.02)

Transcription-independent DNA translocation of bacteriophage T7 DNA into Escherichia coli.

Penetration of wild-type T7 DNA into the host cell occurs in two steps. The phage particle ejects a few hundred base pairs of the left end of the genome into the host. Translocation of the remainder of the DNA is then coupled to transcription. In a normal infection, transcription-coupled translocation of wild-type T7 DNA is initiated at the major A1, A2, and A3 promoters for Escherichia coli RNA polymerase. At 37 degrees C, various deletion mutants lacking these three promoters grow at the same efficiency as wild-type T7 because the minor B promoter is efficiently transferred from the phage head into the cell. As the temperature of the phage infection decreases, the latent periods of (A1, A2, A3)- phages increase relative to that of wild-type T7; nevertheless, (A1, A2, A3)- phages have normal plating efficiencies at reduced temperatures. Lengthening of the latent period at low temperatures is due to a delay in transferring the complete (A1, A2, A3)- genome into the host cell. The (A1, A2, A3)- phages eject the leading end of their genome into the host, but at low temperature, insufficient DNA is transferred into the cell to allow RNA polymerase immediate access the B promoter. However, by an inefficient transcription-independent process, the B promoter eventually translocates into the cell. Mutant derivatives of (A1, A2, A3)- phages that have growth profiles at low temperatures similar to that of wild-type T7 have been isolated. The mutations allow both (A1, A2, A3)- and (A1, A2, A3)+ phages to translocate their entire genomes into the cell by a transcription-independent mechanism. The mutations are located in gene 16, a gene that encodes a component of the internal virion core. We postulate that gp16 is directly involved with the process of DNA translocation from the virion into the cell.

Incomplete entry of bacteriophage T7 DNA into F plasmid-containing Escherichia coli.

The penetration of bacteriophage T7 DNA into F plasmid-containing Escherichia coli cells was determined by measuring Dam methylation of the entering genome. T7 strains that cannot productively infect F-containing cells fail to completely translocate their DNA into the cell before the infection aborts. The entry of the first 44% of the genome occurs normally in an F-containing cell, but the entry of the remainder is aberrant. Bypassing the normal mode of entry of the T7 genome by transfecting naked DNA into competent cells fails to suppress F exclusion of phage development. However, overexpression of various nontoxic T7 1.2 alleles from a high-copy-number plasmid or expression of T3 1.2 from a T7 genome allows phage growth in the presence of F.

Rate of translocation of bacteriophage T7 DNA across the membranes of Escherichia coli.

Translocation of bacteriophage T7 DNA from the capsid into the cell has been assayed by measuring the time after infection that each GATC site on the phage genome is methylated by cells containing high levels of DNA adenine methylase. Methylation at GATC sites on T7 DNA renders both the infecting genome and any newly synthesized molecules sensitive to the restriction enzyme DpnI. In a normal infection at 30 degrees C, translocation of the T7 genome into the cell takes between 9 and 12 min. In contrast, translocation of the entire phage lambda genome or of a T7 genome ejected from a lambda capsid can be detected within the first minute of infection. Entry of the leading end of the T7 genome occurs by a transcription-independent mechanism that brings both Escherichia coli and T7 promoters into the cell. Further translocation of the genome normally involves transcription by the RNA polymerases of both E. coli and T7; the rates of DNA translocation into the cell when catalyzed by each enzyme are comparable to the estimated rates of transcription of the respective enzymes. A GATC site located between the early E. coli promoters and the coding sequences of the first T7 protein made after infection is not methylated before the protein is synthesized, a result supporting the idea (B. A. Moffatt and F. W. Studier, J. Bacteriol. 170:2095-2105, 1988) that only certain proteins are permitted access to the entering T7 DNA. In the absence of transcription, the genomes of most T7 strains do not completely enter the cell. However, the entire genome of a mutant that lacks bp 3936 to 808 of T7 DNA enters the cell in a transcription-independent process at an average overall rate of 50 bp per s.

Self-derogation and defense style in college students.

The self-concept literature generally shows that different measures of self-acceptance and self-satisfaction are positively related to psychological adjustment and several measures of defensiveness. In order to understand clearly the relationship between self-concept and adjustment it is also important to consider characteristic defense styles. With this purpose in mind, Kaplan, and Pokorny's Self-derogation scale, three of the most commonly used measures of defensive styles, and a measures of trait-anxiety, were administered to 158 college students. Self-derogation correlated positively with repression-sensitization and trait-anxiety, and negatively with general defensiveness. A positive relationship between self-derogation and ego-control was also found. The results were interpreted as consistent with self theory.