Position statement of the Latin American Dysphagia Society for the management of oropharyngeal and esophageal dysphagia during the COVID-19 pandemic.

INTRODUCTION: The SARS-CoV-2 virus that causes the COVID-19 disease is transmitted through the inhalation of droplets or aerosols and inoculation via the oronasal or ocular routes, transforming the management of swallowing disorders into a challenge for healthcare teams, given their proximity to the aerodigestive tract and the high probability of aerosol generation during patient evaluation and treatment. AIM: To provide essential guidance for Latin American multidisciplinary teams, regarding the evaluation and treatment of oropharyngeal and esophageal dysphagia, at the different levels of healthcare. The position statement was formulated for the purpose of maintaining medical service continuity, in the context of a pandemic, and minimizing the propagation and infection risks of the virus. METHODS: Thirteen experts in swallowing disorders were summoned by the Latin American Dysphagia Society to formulate a series of clinical suggestions, based on available evidence and clinical experience, for the management of dysphagia, taking the characteristics of Latin American healthcare systems into account. RESULTS: The position statement of the Latin American Dysphagia Society provides a series of clinical suggestions directed at the multidisciplinary teams that manage patients with oropharyngeal and esophageal dysphagia. It presents guidelines for evaluation and treatment in different contexts, from hospitalization to home care. CONCLUSIONS: The present statement should be analyzed by each team or healthcare professional, to reduce the risk for COVID-19 infection and achieve the best therapeutic results, while at the same time, being mindful of the reality of each Latin American country.

[Position statement of the Latin American Dysphagia Society for the management of oropharyngeal and esophageal dysphagia during the COVID-19 pandemic]. / Posicionamiento de la Sociedad Latinoamericana de Disfagia para el manejo de la disfagia orofaríngea y esofágica durante la pandemia COVID-19.

INTRODUCTION: The SARS-CoV-2 virus that causes the COVID-19 disease is transmitted through the inhalation of droplets or aerosols and inoculation via the oronasal or ocular routes, transforming the management of swallowing disorders into a challenge for healthcare teams, given their proximity to the aerodigestive tract and the high probability of aerosol generation during patient evaluation and treatment. AIM: To provide essential guidance for Latin American multidisciplinary teams, regarding the evaluation and treatment of oropharyngeal and esophageal dysphagia, at the different levels of healthcare. The position statement was formulated for the purpose of maintaining medical service continuity, in the context of a pandemic, and minimizing the propagation and infection risks of the virus. METHODS: Thirteen experts in swallowing disorders were summoned by the Latin American Dysphagia Society to formulate a series of clinical suggestions, based on available evidence and clinical experience, for the management of dysphagia, taking the characteristics of Latin American healthcare systems into account. RESULTS: The position statement of the Latin American Dysphagia Society provides a series of clinical suggestions directed at the multidisciplinary teams that manage patients with oropharyngeal and esophageal dysphagia. It presents guidelines for evaluation and treatment in different contexts, from hospitalization to home care. CONCLUSIONS: The present statement should be analyzed by each team or healthcare professional, to reduce the risk for COVID-19 infection and achieve the best therapeutic results, while at the same time, being mindful of the reality of each Latin American country.

High-level disinfection of re-usable neonatal resuscitation equipment through boiling and steaming.

Infection and asphyxia are two major causes of neonatal death globally. Where single-use resuscitation devices or sterilization of re-usable devices are unavailable, there is a need for effective, low-cost methods of high-level disinfection. Laboratory validation examined the efficacy of boiling and enclosed steaming (without pressure) as methods for attaining high-level disinfection of re-usable neonatal resuscitation equipment. The microbial load extracted and measured for each test article met internationally accepted standards for high-level disinfection. Boiling and steaming are low-cost, effective methods for reprocessing re-usable neonatal resuscitation devices in low- and middle-income countries.

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.

Mexican consensus on dyspepsia / Consenso mexicano sobre la dispepsiaMexican consensus on dyspepsia

Desde la publicación de las guías de dispepsia 2007 de la Asociación Mexicana de Gastroenterología ha habido avances significativos en el conocimiento de esta enfermedad. Se realizó una revisión sistemática de la literatura en PubMed (01/2007 a 06/2016) con el fin de revisar y actualizar las guías 2007 y proporcionar nuevas recomendaciones basadas en evidencia. Se incluyeron todas las publicaciones en español e inglés, de alta calidad. Se redactaron enunciados que fueron votados utilizando el método Delphi. Se estableció la calidad de la evidencia y la fuerza de las recomendaciones según el sistema GRADE para cada enunciado. Treinta y un enunciados fueron redactados, votados y calificados. Se informan nuevos datos sobre definición, clasificación, epidemiología y fisiopatología. La endoscopia debe realizarse en dispepsia no investigada cuando hay datos de alarma o falla al tratamiento. Las biopsias gástricas y duodenales permiten confirmar infección por Helicobacter pylori y excluir enfermedad celiaca, respectivamente. Establecer una fuerte relación médico-paciente, cambios en la dieta y en el estilo de vida son útiles como medidas iniciales. Los bloqueadores H2, inhibidores de la bomba de protones, procinéticos y fármacos antidepresivos son efectivos. La erradicación de H. pylori puede ser eficaz en algunos pacientes. Con excepción de Iberogast y rikkunshito, las terapias complementarias y alternativas carecen de beneficio. No existe evidencia con respecto a la utilidad de prebióticos, probióticos o terapias psicológicas. Los nuevos enunciados proporcionan directrices basadas en la evidencia actualizada. Se presenta la discusión, el grado y la fuerza de la recomendación de cada uno de ellos.

Abstract Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H. pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement. © 2017 Asociacion Mexicana de Gastroenterologiia.

Mexican consensus on dyspepsia. / Consenso mexicano sobre la dispepsia.

Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.

The Mexican consensus on irritable bowel syndrome. / Consenso mexicano sobre el síndrome de intestino irritable.

BACKGROUND: Since the publication in 2009 of the Guidelines on the Diagnosis and Treatment of Irritable Bowel Syndrome of the Asociación Mexicana de Gastroenterología (2009 Guidelines), there have been significant advances in our knowledge of the epidemiology, pathophysiology, diagnosis, and treatment of this disease. AIMS: To present a consensus review of the most current knowledge of IBS, updating the 2009 Guidelines by incorporating new internationally published scientific evidence, with a special interest in Mexican studies. METHODS: The PubMed literature from January 2009 to March 2015 was reviewed and complemented through a manual search. Articles in English and Spanish were included and preference was given to consensuses, guidelines, systematic reviews, and meta-analyses. Statements referring to the different aspects of the disease were formulated and voted upon by 24 gastroenterologists employing the Delphi method. Once a consensus on each statement was reached, the quality of evidence and strength of recommendation were determined through the GRADE system. RESULTS: Forty-eight statements were formulated, updating the information on IBS and adding the complementary data that did not appear in the 2009 Guidelines regarding the importance of exercise and diet, diagnostic strategies, and current therapy alternatives that were analyzed with more stringent scientific vigor or that emerged within the last 5 years. CONCLUSIONS: We present herein a consensus review of the most relevant advances in the study of IBS, updating and complementing the 2009 Guidelines. Several studies conducted in Mexico were included.

Optimizing CIGB-300 intralesional delivery in locally advanced cervical cancer.

BACKGROUND: We conducted a phase 1 trial in patients with locally advanced cervical cancer by injecting 0.5 ml of the CK2-antagonist CIGB-300 in two different sites on tumours to assess tumour uptake, safety, pharmacodynamic activity and identify the recommended dose. METHODS: Fourteen patients were treated with intralesional injections containing 35 or 70 mg of CIGB-300 in three alternate cycles of three consecutive days each before standard chemoradiotherapy. Tumour uptake was determined using (99)Tc-radiolabelled peptide. In situ B23/nucleophosmin was determined by immunohistochemistry. RESULTS: Maximum tumour uptake for CIGB-300 70-mg dose was significantly higher than the one observed for 35 mg: 16.1 ± 8.9 vs 31.3 ± 12.9 mg (P = 0.01). Both, AUC24h and biological half-life were also significantly higher using 70 mg of CIGB-300 (P < 0.001). Unincorporated CIGB-300 diffused rapidly to blood and was mainly distributed towards kidneys, and marginally in liver, lungs, heart and spleen. There was no DLT and moderate allergic-like reactions were the most common systemic side effect with strong correlation between unincorporated CIGB-300 and histamine levels in blood. CIGB-300, 70 mg, downregulated B23/nucleophosmin (P = 0.03) in tumour specimens. CONCLUSION: Intralesional injections of 70 mg CIGB-300 in two sites (0.5 ml per injection) and this treatment plan are recommended to be evaluated in phase 2 studies.

Individualizing early use of sirolimus in renal transplantation.

One of the main goals in the current care of kidney transplant recipients is to extend long-term graft survival. Efficacious immunosuppressive agents devoid of nephrotoxicity are needed. In human clinical transplantation, sirolimus combined with other immunosuppressive drugs has proven to be a powerful immunosuppressant capable of preventing acute graft rejection, as well as of improving renal function, renal histology, and graft survival when compared with immunosuppressive regimens that include calcineurin inhibitors. The valuable experience gained through many clinical studies allows clinicians to plan sirolimus use. We present a review of the clinical experience and literature review on the use of sirolimus in the first 12 months posttransplantation.

Cáncer cervical uterino en el Área Sanitaria III de Asturias: eficacia del cribado oportunista / Cervical cancer in Health Area III of Asturias (Spain). Efficacy of opportunistic screening

Objetivo: Investigar los carcinomas cervicales, en el período 1996-2005, en nuestra área sanitaria de Asturias. Estudiar la edad media de las pacientes con adenocarcinoma, carcinoma escamoso y la influencia del cribado citológico en el diagnóstico. Establecer el promedio de citologías negativas en mujeres sin infección por virus del papiloma humano. Material y métodos: Se obtuvieron los cánceres cervicales, el diagnóstico de la citología previa y el tiempo transcurrido desde la citología precedente. Para el análisis estadístico se aplicó la prueba de Mann-Whitney. Se estableció el promedio de citologías negativas en mujeres sanas durante ese período. Resultados: Se encontraron 67 cánceres invasivos cervicales, 49 escamosos y 18 adenocarcinomas. En el 40% de las pacientes nunca se realizó una citología. La edad media era de 59 años para los escamosos y de 49 años para los adenocarcinomas. El promedio de citologías negativas en mujeres sanas fue de 3,59. Conclusiones: El cribado oportunista, el más común en España, es inaccesible e ineficaz para muchas mujeres con carcinoma cervical, y consume recursos sanitarios en realizar citologías
innecesarias a mujeres sanas (AU)

Objective: To investigate the number of invasive cervical carcinomas detected in our hospital over a 10-year period (1996-2005), to study the mean age at diagnosis of squamous cell carcinomas, adenocarcinomas, and the relation of cervical screening in its diagnosis. Establish the mean number of negative smears in women without cervical human papilloma virus (HPV) infection. Material and methods: Data on all diagnoses of cervical cancer, the presence of smear tests prior to biopsy, and the interval between the two procedures were gathered. The Mann-Whitney test was applied. The mean number of negative cytologies without evidence of HPV infection during the period studied was established. Results: Between 1996 and 2005, 67 cervical carcinomas (49 squamous cell carcinomas and 18 adenocarcinomas) were diagnosed. In 40% cytology had never been performed. The mean age at diagnosis was 59 years for squamous cell carcinoma and was 49 years for adenocarcinoma. The mean number of negative cytologies per healthy woman was 3.59. Conclusions: Opportunistic screening for cervical cancer, the most common form of screening in Spain, is not accessible to many women with cervical carcinoma and wastes substantial healthcare resources on performing unneccessary cytologies in healthy women (AU)

Diagnóstico citológico de ASCUS. Identificación del riesgo para displasia cervical mediante test del virus del papiloma humano / Cytological diagnosis of ASCUS: Identification of the risk of cervical dysplasia with the human papiloma virus test

Objetivo. Identificar a mujeres con neoplasia cervical entre pacientes diagnosticadas de ASCUS, mediante colposcopia; se compara el estudio de PCR para el VPH con la repetición de una citología cervicovaginal. El fin es determinar si la PCR para VPH es útil en la evaluación de pacientes diagnosticadas de ASCUS y si puede ser un método alternativo a la repetición de la citología cervical. Material y métodos. Se estudia a 180 mujeres diagnosticadas de ASCUS, y se realiza una colposcopia, una nueva citología, PCR para VPH y estudio histológico de las biopsias cervicales. Las pacientes con resultados negativos se controlaron de nuevo a los 6 meses. Resultados. La PCR fue positiva en el 34% de las pacientes y negativa en el 66%. No se encontró lesión cervical en el 69%, había condiloma o CIN I en el 21% y CIN II o CIN III en el 10%. Cuando aplicamos el teorema de Bayes, para la PCR, la sensibilidad fue del 60%, la especificidad del 80%, el VPP del 61% y el VPN del 79%; para la citología, la sensibilidad fue del 64%, la especificidad del 88%, el VPP del 71% y el VPN del 84%, incluidas como positivas las citologías repetidamente diagnosticadas de ASCUS. Conclusiones. En nuestro estudio, tanto la citología repetida posterior como la investigación de PCR para VPH tienen valores de sensibilidad, especificidad, VPP y VPN parecidos, y sus intervalos de confianza son similares. Destaca el valor predictivo negativo del 94% para la PCR, y es el método más apropiado para identificar a las mujeres que no enfermarán (AU)

Objective. To identify women with cervical neoplasia amongst those patients diagnosed as having ASCUS after colposcopy and comparing the PCR study for human papilloma virus (HPV) with a repeat cervico- vaginal histology. Also, to determine if PCR for HPV is useful in patients diagnosed as ASCUS, and if it may be an alternative to repeat cervical cytology. Material and methods. A study was made of 180 women, after colposcopy, repeat cytology, PCR for HPV, and a histological study of the cervical biopsies. Results. PCR was positive in 34% of the patients and negative in the other 66%. No cervical lesion was found in 69%, there was condilloma or CIN I in 21% and CIN II or CIN III in 10%. Applying Bayes theorem, sensibility for PCR was 60%, specificity was 80%, VPP 61% and VPN 79%; for cytology, the sensibility was 64%, specificity 88%, VPP 71% and VPN 84%, including as positive those smear test repeatedly diagnosed as ASCUS. Conclusions. In our study, repeat cytology and PCR testing for HPV had similar sensibility, specificity, VPP and VPN values, the confidence intervals were also similar. We highlight the 94% negative predictive value for PCR, this being the most appropriate method to identify those women who are not going to develop disease (AU)

Impact of C2 measurement on cyclosporine Neoral dosing in a Latin-American transplant program: the Guatemalan experience.

Optimal dosing of cyclosporine is difficult in transplant recipients. The introduction of the microemulsion Neoral in 1997 into our program and the measurement of C2 levels since 2000 in our center has allowed for more accurate individual dose finding. In our series, 141 transplant recipients (92 de novo, 49 maintenance) were followed for a 3-year period with C2 monitoring and serum creatinine levels as well as creatinine clearance studies. Biopsy proven acute rejection episodes appeared in three patients. The target levels of C2 during the first week were of vital importance to prevent acute rejection. Targets for the later periods of our study were somewhat lower than those recommended in North American or European studies. Even so, the incidence of acute rejection was low (3.2% for the de novo group). We feel that special populations like ours (mostly Mayan) deserve more attention regarding the finding of the optimal dose for immunosuppressive therapy after kidney transplantation.

Assessment of adherence to a low-fat diet for breast cancer prevention.

BACKGROUND: The relationships between self-reported adherence to a low-fat diet in healthy women between the ages of 44 and 69 and a number of correlates of this self-reported behavior were examined in an attempt to improve monitoring of adherence to nutritional intervention trials for breast cancer prevention. METHODS: Dietary fat intake in 87 women who completed 6 months of nutritional intervention was reduced from 38.2 +/- 5.9% to 21.7 +/- 7.8% of total energy intake (P less than 0.005). Reported total calorie intake was reduced by approximately 20%. RESULTS: Body weight decreased by 2.7% from 68.1 +/- 11.2 kg to 66.3 +/- 11.9 kg (P less than 0.05). Fasting total plasma cholesterol levels decreased from 205 +/- 31 mg/dl to 184 +/- 29 mg/dl (P less than 0.05). Fasting plasma triglyceride levels did not change significantly (97 +/- 44 mg/dl vs 101 +/- 55 mg/dl). Relative percentage changes in body weight correlated with percentage changes in dietary fat intake (r = 0.23, P less than 0.05). CONCLUSION: Self-reported changes in dietary behavior correlated significantly with objective changes in body weight and fasting cholesterol in these healthy women encouraged to consume a low-fat diet for prevention of breast cancer.

[Acute-phase reaction after inflammatory aggression. Experimental study]. / Reacción de fase aguda tras agresión inflamatoria. Estudio experimental.

It is well known that inflammatory aggression makes important changes in plasma proteins levels. Among all of these proteins, C3 fragment of the complement system and haptoglobin, Acute Phase Reactants Proteins, are considered important mediators of the inflammatory response although their specific behaviour is not completely understood. In this work we have studied the modification of both proteins after an inflammatory aggression, which was experimentally induced in rats, trying to connect their behaviour with the lesion stages. Our data show that the plasmatic level of both proteins is increased during the inflammatory aggression, although haptoglobin level gives a more accurate approach to the local phenomenons which occur in the inflammatory focus. This fact suggests that each acute phase reactant has a certain specificity depending on the kind of aggression suffered by a patient.

[Acute phase reaction after inflammatory injury. Experimental study]. / Reacción de fase aguda tras agresión inflamatoria. Estudio experimental.

It is well known that inflammatory aggression makes important changes in plasma proteins levels. Among all of these proteins, C3 fragment of the complement system and haptoglobin, Acute Phase Reactants Proteins, are considered important mediators of the inflammatory response although their specific behaviour is not completely understood. In this work we have studied the modification of both proteins after an inflammatory aggression, which was experimentally induced in rats, trying to connect their behaviour with the lesion stages. Our data show that the plasmatic level of both proteins is increased during the inflammatory aggression, although haptoglobin level gives a more accurate approach to the local phenomenons which occur in the inflammatory focus. This fact suggests that each acute phase reactant has a certain specificity depending on the kind of aggression suffered by a patient.