Mucositis Oral: Actualización en el Diagnóstico, Prevención y Tratamiento

RESUMEN: La mucositis oral (MO) es la reacción secundaria aguda más frecuente en la cavidad oral y tracto gastrointestinal en pacientes oncológicos sometidos a quimioterapia o radioterapia de cabeza y cuello que incide negativamente en la calidad de vida del paciente. Su tratamiento requiere de un manejo multidisciplinario con el objetivo de minimizar la incidencia y severidad de esta patología. El desconocimiento parcial respecto de su etiopatogenia imposibilita la realización de protocolos para el manejo de esta complicación. Si bien existe evidencia científica respecto a las alternativas de prevención y tratamiento, éstas dependen de la evaluación individual que haga el clínico con cada paciente. A continuación, se presenta una revisión bibliográfica actualizada de la literatura científica publicada y se discuten aquellos aspectos más relevantes en torno a la prevención y tratamiento de la mucositis oral.

ABSTRACT: Oral mucositis (OM) is the most common acute secondary reaction in the oral cavity and gastrointestinal tract in cancer patients undergoing chemotherapy or radiotherapy to the head and neck, which adversely affects the patient's quality of life even at the risk of death. This requires multidisciplinary knowledge and management in order to minimize the incidence and severity of this pathology. The partial lack of knowledge regarding its etiopathogenesis makes it impossible to establish standardized guidelines for the management of this complication. Although there is scientific evidence regarding prevention and treatment alternatives, these depend on the individual evaluation of each patient and the clinical scenario in which they are presented. An updated review of the published scientific literature is presented below and those aspects most relevant to the prevention and treatment of oral mucositis are discussed.

Psicoterapia de pareja ante el descubrimiento del involucramiento del varón en actividades sexuales por Internet / Couple Psychotherapy in front of the discovery of male involvement in sexual activities on the Internet

Resumen El desarrollo tecnológico de Internet ha facilitado la conectividad entre personas con motivaciones muy diversas. Una de ellas, es acceder a contenidos sexuales y conectarse con otros que comparten este interés. El uso de internet con fines sexuales incluye una amplia gama de comportamientos, algunos de los cuales pueden generar una crisis en una relación de pareja estable y comprometida, al ser significados como una infidelidad. Las características propias del medio y de los usuarios de internet con fines sexuales, desafía a los terapeutas a adquirir nuevas herramientas psicoterapéuticas para ayudar a las parejas en conflicto. El artículo tiene por objetivo a) dar a conocer los principales conceptos vinculados al uso de internet con fines sexuales (b) describir las características del cyber affair y comportamientos significados como infidelidad (c) establecer lineamientos psicoterapéuticos para el tratamiento de este tipo de casos.

Abstract The technological development of the Internet has facilitated the connectivity between people with very diverse motivations. One is accessing sexual content and connecting with others who share this interest. The use of the Internet for sexual purposes includes a wide range of behaviors, some of which can generate a crisis in a stable and committed couple relationship, being signified as an infidelity. The characteristics of the media and Internet users for sexual purposes, challenges therapists to acquire new psychotherapeutic tools to help couples in conflict. The article aims to a) to disclose the main concepts related to the use of the Internet for sexual purposes (b) to describe the characteristics of the cyber affair and behaviors signified as infidelity (c) to establish psychotherapeutic guidelines for the treatment of this type of cases.

Rapid screening fluorescence method applied to detection and quantitation of paralytic shellfish toxins in invertebrate marine vectors.

A rapid screening method is described for the determination of paralytic shellfish toxins (PST), in fresh marine vectors (bivalves and gastropods), at levels ranging from 0.05 to 5.0 mg STX-eq kg-1. PST are extracted from marine vector homogenates with acetic acid according to the Pre-COX-LC-FLD method. At the same time, the obtained extract is oxidised simultaneously in hydrogen peroxide and periodate oxidate to determine PST, non-N-hydroxylated and N-hydroxylated toxins, respectively. Then, they are analysed using a microplate fluorometer (Ex: 335 nm/Em: 405 nm). All the samples were compared with the liquid chromatography post-column oxidation method. Recoveries of PST added to fresh and processed marine vectors averaged 93.9% with a coefficient of variation of 6.1%. Both methods showed a good linear regression (r2 = 0.97). The method shows good intra- and inter-day precisions with a relative coefficient of variation of ≈ 3.8% and 5.7%, respectively. The limit of quantification of the rapid screening fluorescence method was ≈ 0.082 mg STX-eq kg-1, with ≤5% false positives. The established rapid screening fluorescence methods offer highly effective and verifiable pre-analyses of PST contamination in marine vectors and can be used for routine screening of the PST in seafood before formal identification by confirmatory methods (Pre-COX LC-FLD method, Lawrence method).

Determination of the toxic variability of lipophilic biotoxins in marine bivalve and gastropod tissues treated with an industrial canning process.

Contamination of shellfish with lipophilic marine biotoxins (LMB), pectenotoxins (PTXs), yessotoxins (YTXs) and okadaic acid (OA) toxin groups in southern Chile is a constant challenge for the development of miticulture considering the high incidence of toxic episodes that tend to occur. This research is focused on using methodologies for assessing the decrease in toxins of natural resources in Chile with high value, without altering the organoleptic properties of the shellfish. The species were processed through steaming (1 min at 121°C) and subsequent canning (5 min at 121°C). Changes in the profiles of toxins and total toxicity levels of LMB in endemic bivalves and gastropods were determined using liquid chromatography-tandem mass spectrometry (LC-MS/MS). The total reduction of toxicity (≈ 15%) was not related to the destruction of the toxin, but rather to the loss of LMB on removing the shells and packing media of canned products (***p < 0.001). Industrial processing of shellfish reduces LMB contents by up to 15% of the total initial contents, concomitant only with the interconversion of PTX-group toxins into PTX-2sa. In soft bottom-dwelling species with toxicities beyond the standard for safe human consumption (≥ 160 µg OA-eq kg-1), toxicity can be reduced to safe levels through industrial preparation procedures.

Saxitoxins and okadaic acid group: accumulation and distribution in invertebrate marine vectors from Southern Chile.

Harmful algae blooms (HABs) are the main source of marine toxins in the aquatic environment surrounding the austral fjords in Chile. Huichas Island (Aysén) has an history of HABs spanning more than 30 years, but there is limited investigation of the bioaccumulation of marine toxins in the bivalves and gastropods from the Region of Aysén. In this study, bivalves (Mytilus chilenses, Choromytilus chorus, Aulacomya ater, Gari solida, Tagelus dombeii and Venus antiqua) and carnivorous gastropods (Argobuccinum ranelliformes and Concholepas concholepas) were collected from 28 sites. Researchers analysed the accumulation of STX-group toxins using a LC with a derivatisation post column (LC-PCOX), while lipophilic toxins (OA-group, azapiracids, pectenotoxins and yessotoxins) were analysed using LC-MS/MS with electrospray ionisation (+/-) in visceral (hepatopancreas) and non-visceral tissues (mantle, adductor muscle, gills and foot). Levels of STX-group and OA-group toxins varied among individuals from the same site. Among all tissue samples, the highest concentrations of STX-group toxins were noted in the hepatopancreas in V. antiqua (95 ± 0.1 µg STX-eq 100 g(-1)), T. dombeii (148 ± 1.4 µg STX-eq 100 g(-1)) and G. solida (3232 ± 5.2 µg STX-eq 100 g(-1); p < 0.05); in the adductor muscle in M. chilensis (2495 ± 6.4 µg STX-eq 100 g(-1); p < 0.05) and in the foot in C. concholepas (81 ± 0.7 µg STX-eq 100 g(-1)) and T. dombeii (114 ± 1.2 µg STX-eq 100 g(-1)). The highest variability of toxins was detected in G. solida, where high levels of carbamate derivatives were identified (GTXs, neoSTX and STX). In addition to the detected hydrophilic toxins, OA-group toxins were detected (OA and DTX-1) with an average ratio of ≈1:1. The highest levels of OA-group toxins were in the foot of C. concholepas, with levels of 400.3 ± 3.6 µg OA eq kg(-1) (p < 0.05) and with a toxic profile composed of 90% OA. A wide range of OA-group toxins was detected in M. chilensis with a toxicity < 80 µg OA eq kg(-1), but with 74% of those toxins detected in the adductor muscle. In all evaluated species, there was no detection of lipophilic toxins associated with biotransformation in molluscs and carnivorous gastropods. In addition, the STX-group and OA-group toxin concentrations in shellfish was not associated with the presence of HAB. The ranking of toxin concentration in the tissues of most species was: digestive glands > mantle > adductor muscle for the STX-group toxins and foot > digestive gland for the OA-group toxins. These results gave a better understanding of the variability and compartmentalisation of STX-group and OA-group toxins in different bivalve and gastropod species from the south of Chile, and the analyses determined that tissues could play an important role in the biotransformation of STX-group toxins and the retention of OA-group toxins.

Determination of the variability of both hydrophilic and lipophilic toxins in endemic wild bivalves and carnivorous gastropods from the southern part of Chile.

The aim of this study was to analyse and determine the composition of paralytic shellfish poisoning (PSP) toxins and lipophilic toxins in the Region of Aysén, Chile, in wild endemic mussels (Mytilus chilensis, Venus antiqua, Aulacomya ater, Choromytilus chorus, Tagelus dombeii and Gari solida) and in two endemic carnivorous molluscs species (Concholepas concholepas and Argobuccinum ranelliforme). PSP-toxin contents were determined by using HPLC with fluorescence detection, while lipophilic toxins were determined by using LC-MS/MS. Mean concentrations for the total of PSP toxins were in the range 55-2505 µg saxitoxin-equivalent/100 g. The two most contaminated samples for PSP toxicity were bivalve Gari solida and carnivorous Argobuccinum ranelliforme with 2505 ± 101 and 1850 ± 137 µg saxitoxin-equivalent/100 g, respectively (p < 0.05). The lipophilic toxins identified were okadaic acid, dinophysistoxin-1 (DTX-1), azaspiracid-1 (AZA-1), pectenotoxin-2 (PTX-2) and yessotoxins (YTX). All analysed molluscs contained lipophilic toxins at levels ranging from 56 ± 4.8 to 156.1 ± 8.2 µg of okadaic acid-equivalent/kg shellfish together with YTX at levels ranging from 1.0 ± 0.1 to 18 ± 0.9 µg of YTX-equivalent/kg shellfish and AZA at levels ranging from 3.6 ± 0.2 to 31 ± 2.1 µg of AZA-equivalent/kg shellfish. Furthermore, different bivalves and gastropods differ in their capacity of retention of lipophilic toxins, as shown by the determination of their respective lipophilic toxins levels. In all the evaluated species, the presence of lipophilic toxins associated with biotransformation in molluscs and carnivorous gastropods was not identified, in contrast to the identification of PSP toxins, where the profiles identified in the different species are directly related to biotransformation processes. Thus, this study provides evidence that the concentration of toxins in the food intake of the evaluated species (Bivalvia and Gastropoda class) determines the degree of bioaccumulation and biotransformation they will thereafter exhibit.

Lipophilic toxin profiles detected in farmed and benthic mussels populations from the most relevant production zones in Southern Chile.

Lipophilic toxins associated with diarrhoeic toxins were found in Mytilus chilensis (Blue mussels) and Aulacomya ater (Ribbed mussels). These shellfish samples were collected from Chiloe Island, Southern Chile. The samples were tested by liquid chromatography-tandem mass spectrometry (LC-MS/MS). After the analysis, four toxins were found: DTX-1, DTX-3, YTX and PTX. All toxins were identified by comparing their HPLC retention times with those of analytical standards and confirmed by LC-MS/MS. Dinophysistoxin-1 (DTX-1) and dinophysistoxin-3 (DTX-3) toxins were the major components within the mussel extracts. Nevertheless, the percentages of these toxins differed depending on the area they were collected from and/or the sampling date. The levels detected in Butacheuques Island for okadaic acid (OA) was 267 ± 3.5 µg OA eq kg(-1) (p < 0.05) and for DTX-3 was 183.4 ± 7.5 µg kg(-1) in ribbed mussels. Pectenotoxin (PTX) and yessotoxin (YTX) were the toxins detected in minor proportions in the toxic profile of the bivalves. The maximum concentration of YTX detected in ribbed mussels was 85.2 ± 2.8 µg kg(-1) in Mechuque Island, whereas the PTX-2 level in ribbed mussels was 82.0 ± 2.4 µg kg(-1) in Cailin Island. Analogues of YTX and PTX-2 were not detected in any of the analysed mussels, which did not support the supposed presence of isomers of toxins as a result of the enzymatic metabolism of bivalves. This study found evidence proving co-occurrence of lipophilic toxins - like PTX and YTX - with diarrhoeic toxin in samples collected in Southern Chile, which is, to date, the more complex mix of lipophilic toxins ever found in mussels samples from Southern Chile.

First evidence of Okadaic acid acyl-derivative and Dinophysistoxin-3 in mussel samples collected in Chiloe Island, Southern Chile.

This paper shows the detection of Diarrhetic Shellfish Poison (DSP) phycotoxins, using HPLC-FLD with pre-column derivatization procedure and HPLC-MS methods, in the analysis of shellfish extracts tested positive with the official DSP mouse bioassay. The shellfish samples were collected in Chiloe Island, Southern of Chile. The amount of Dinophysistoxin-3 (DTX-3) measured in the shellfish extracts were in average above the international safe limits for DSP content in the shellfish extracts analyzed. As internal control of detection and recovery, DTX-1 analytical standard was spiked into dichloromethane-clean shellfish extracts in order to calculate de extraction recovery of DTX-1. The average recovery was 97%. From all DSP toxins analyzed, the hydrolyzed extract samples appeared mainly DTX-3 in concentrations ranging from 99.40 +/- 1.22 to 257.73 +/- 12.46 ng/g digestive-glands. The acyl-Okadaic Acid (acyl-OA) was also detected in some samples, ranging from 1.02 +/- 1.4 to 3.07. +/- 1.6 ng of DSP toxin/g digestive-glands. This is the first report of acyl-OA ever found in Chilean shellfish samples. This data shows that shellfish samples were contaminated with a complex DSP toxins profile, in which DTX-3 is the major DSP toxin component, followed by DTX-1 and the acyl-OA as the minor one. The important findings showed in this study are the presence of both acyl-derivates (DTX-3 and Acyl-OA) which are the product of a main metabolic biotransformation that occurred inside the shellfish, in order to chelate DTX-1 and OA, transforming them into DTX-3 and the acyl-OA respectively. This metabolic biotransformation must be performed to avoid self-inhibition of their Protein Phosphatase 2A done by DTX-1 and OA, since both acyl-derivates (DTX-3 and acyl-OA) do not inhibit Protein Phosphatase 2A. This complex DSP toxins profile and the permanent presence of both acyl-derivates (DTX-3 and Acyl-OA) could explain the permanent diarrhea symptoms that experience patients who have ingested cooked shellfish in the southern of Chile. This diarrhea is not associated to Vibrio parahaemolyticus or other enteropathogens as had been suggested before. The massive shellfish consumption is an important Chilean cultural habit and now has become a major health issue in the southern of Chile.