Guía de práctica clínica para la prevención primaria y secundaria y diagnóstico temprano de cáncer gástrico / Clinical practice guide for primary and secondary prevention and early diagnosis of gastric cancer

Resumen Objetivo: Generar recomendaciones basadas en la evidencia, para la prevención primaria y secundaria, el tratamiento de las lesiones preneoplásicas y el diagnóstico temprano del cáncer gástrico en población adulta, con el propósito de reducir la carga de la enfermedad. Materiales y métodos: El grupo desarrollador estuvo integrado por profesionales de la salud y tomadores de decisiones. Se construyeron preguntas clínicas contestables y se realizó la graduación de los desenlaces. Se elaboró la búsqueda de la información en MEDLINE; EMBASE y CENTRAL, siendo actualizada el 18 de octubre de 2018. La pesquisa también abarcó otras fuentes de información como la Revista Colombiana de Gastroenterología y la lectura en "bola de nieve" de las referencias incluidas. Se contactó a expertos en la materia con el objetivo de identificar estudios relevantes no publicados. Para la construcción de las recomendaciones, se realizó un consenso acorde con los lineamientos propuestos por la metodología GRADE, sopesando los beneficios, los efectos adversos derivados de la intervención, las preferencias de los pacientes y el potencial impacto de las intervenciones sobre los costos. Resultados: Se presenta la versión corta de la "Guía de práctica clínica para la prevención primaria, secundaria y diagnóstico temprano de cáncer gástrico", junto con su evidencia de soporte y respectivas recomendaciones. Conclusiones: Como recomendación central para la implementación, se recomienda erradicar la infección por H. pylori en los pacientes con o sin factores de riesgo, como estrategia de prevención de las condiciones precursoras de cáncer gástrico. La Guía deberá actualizarse en tres años.

Abstract Objetive: Generate recommendations for primary and secondary prevention, treatment of gastric preneoplastic lesions, and early diagnosis of gastric cancer in the adult population, to increase the detection of gastric cancer in early stages. Material and methods: The developer group was made up of health professionals, decision-makers, and a representative of the patients. Answerable clinical questions were constructed and outcomes were graded. The search for information in MEDLINE was carried out; EMBASE and CENTRAL, being updated on October 18, 2018. The search also covered other sources of information such as the Colombian Journal of Gastroenterology and the "snowball" reading of the references included. Experts in the field were contacted to identify studies. For the construction of the recommendations, a consensus was made according to the guidelines proposed by the GRADE methodology, weighing the benefits, the adverse effects derived from the intervention, the preferences of the patients, and the potential impact of the interventions on costs. Results: The short version of the "Clinical practice guidelines for the primary, secondary, and early diagnosis of gastric cancer" is presented together with its supporting evidence and respective recommendations. Conclusions: As a central recommendation for implementation, it is recommended to eradicate H. pylori infection in patients with or without risk factors in whom it is detected to prevent gastric cancer precursor conditions. The Guide will need to be updated in three years.

Critical reflections on the Municipal Epidemiological Resilience Index used for public policy decision-making regarding the control of the COVID-19 pandemic in Colombia

On June 2, 2021, the Colombian Ministry of Health and Social Protection, through Resolution No. 777, laid down the requirements to resume all restricted economic and social activities. Similarly, said Resolution established the Municipal Epidemiological Resilience Index (IREM by its acronym in Spanish) as a tool to support decision-making regarding this economic reactivation amid the third epidemic peak of COVID-19 in the country. The purpose of this article is to perform a critical analysis of the technical aspects of the IREM and to explore the feasibility of its implementation as a support for the resumption of economic and social activities as proposed in the Resolution. The present critical analysis emphasizes on the lack of a clear definition of epidemiological resilience that is consistent with the scientific literature. Furthermore, the face and content validity of the index, as well as the construct validity of the index and of its dimensions, are called into question and, therefore, the feasibility of using it to determine said resumption.

El 2 de junio de 2021, el Ministerio de Salud y Protección Social de Colombia expidió la Resolución 777, mediante la cual se determinan las condiciones para el reinicio de todas las actividades económicas y sociales restringidas. Asimismo, en esta resolución se define el Índice de resiliencia epidemiológica municipal (IREM) como la herramienta para apoyar la toma de decisiones relacionadas con esta reactivación económica en medio del tercer pico epidémico de la COVID-19 en el país. El objetivo de este artículo es hacer un análisis crítico de los aspectos técnicos del IREM y explorar la conveniencia de su implementación como soporte del reinicio de las actividades económicas y sociales propuesto en la resolución. Dentro de este análisis crítico se destaca la falta de una clara definición de resiliencia epidemiológica que se ajuste a la literatura científica. Además, se cuestiona tanto la validez de apariencia, contenido y constructo del índice global, como la validez del constructo de sus dimensiones y, por tanto, la pertinencia de usarlo como herramienta para definir dicho reinicio.

Differential Methylation Levels in CpGs of the BIN1 Gene in Individuals With Alzheimer Disease.

INTRODUCTION: Late-onset Alzheimer disease (LOAD) is the most common dementia worldwide. APOE-[Latin Small Letter Open E]4 and BIN1 (Bridging Integrator 1) have been implicated in the pathogenesis of this disease, but, although DNA methylation of dinucleotide CpGs in the BIN1 gene influences alterations, it has not been studied in Hispanics. OBJECTIVE: The objective of this study was to evaluate the BIN1 3' intergenic region DNA methylation patterns in a Colombian sample of LOAD patients. METHODS: A case-control study was conducted in 50 individuals with LOAD and 50 age-sex matched controls to determine associations of LOAD with DNA methylation. DNA was isolated from peripheral blood, and methylation levels of 8 CpGs were estimated by bisulfite conversion followed by Sanger sequencing with direct PCR analysis. Logistic regression models adjusted by age, sex, and APOE were used to calculate risk associations between methylation levels and LOAD. RESULTS: Overall, participants with LOAD had significantly lower methylation levels on CpG26 (0.86±0.11 vs. 0.95±0.05; P>0.001), CpG44 (0.84±0.09 vs. 0.94±0.06; P=0.001), and CpG87 (0.64±0.12 vs. 0.82±0.10; P>0.001). Adjusted regression models showed that decreased methylation levels of these CpGs remained as risk factors for LOAD (P<0.05). CONCLUSIONS: Hypomethylation of CpGs in BIN1 might play an important role in the expression of BIN1 and may be a biomarker for identifying individuals at high risk of developing LOAD.

Differential Methylation in APOE (Chr19; Exon Four; from 44,909,188 to 44,909,373/hg38) and Increased Apolipoprotein E Plasma Levels in Subjects with Mild Cognitive Impairment.

BACKGROUND: Biomarkers are essential for identification of individuals at high risk of mild cognitive impairment (MCI) for potential prevention of dementia. We investigated DNA methylation in the APOE gene and apolipoprotein E (ApoE) plasma levels as MCI biomarkers in Colombian subjects with MCI and controls. METHODS: In total, 100 participants were included (71% women; average age, 70 years; range, 43⁻91 years). MCI was diagnosed by neuropsychological testing, medical and social history, activities of daily living, cognitive symptoms and neuroimaging. Using multivariate logistic regression models adjusted by age and gender, we examined the risk association of MCI with plasma ApoE and APOE methylation. RESULTS: MCI was diagnosed in 41 subjects (average age, 66.5 ± 9.6 years) and compared with 59 controls. Elevated plasma ApoE and APOE methylation of CpGs 165, 190, and 198 were risk factors for MCI (p < 0.05). Higher CpG-227 methylation correlated with lower risk for MCI (p = 0.002). Only CpG-227 was significantly correlated with plasma ApoE levels (correlation coefficient = -0.665; p = 0.008). CONCLUSION: Differential APOE methylation and increased plasma ApoE levels were correlated with MCI. These epigenetic patterns require confirmation in larger samples but could potentially be used as biomarkers to identify early stages of MCI.

Concurrent Guillain-Barré syndrome, transverse myelitis and encephalitis post-Zika: A case report and review of the pathogenic role of multiple arboviral immunity.

We review post-infectious and post-vaccination neurological syndromes involving peripheral and central nervous system (CNS) and report an illustrative case of simultaneous occurrence of Guillain-Barré syndrome (GBS), confirmed by nerve conduction velocities, plus MRI-demonstrated transverse myelitis (TM) and acute encephalitis [acute disseminated encephalomyelitis] (ADEM+GBS) affecting a 24-year-old woman from Cúcuta, Colombia, who developed acute Zika virus (ZIKV) infection confirmed by serum reverse transcriptase-polymerase chain reaction (RT-PCR) and convalescent ZIKV IgG antibodies. With intensive care treatment, respiratory support, steroids, and intravenous immunoglobulin (IVIg), patient survived with residual flaccid paraparesis. She had preexisting immunity against Chikungunya virus (CHIKV) and Dengue virus (DENV) acquired before the arrival of ZIKV in Colombia. From reports in the Caribbean, Central and South America we review 19 cases of ZIKV-associated TM, encephalitis and ADEM occurring after a mean latent period of 10.5 days (range 1-96) post-infection. Although GBS and ADEM are usually considered post-infectious and associated with development of antibodies against peripheral nerve and CNS epitopes, we postulate that our case of ADEM+GBS is para-infectious, induced by acute ZIKV neurotropism boosted by active immunity against other arboviruses. Animal models of ZIKV demonstrated strong viral neurotropism enhanced by passive immunity with antibodies against arboviruses such as West Nile virus, CHIKV, or DENV. These considerations are relevant to prevent potential ZIKV vaccine-induced reactions involving central and peripheral nervous system.

Deterioro cognoscitivo en trastorno afectivo bipolar de larga evolución y demencia frontotemporal variante conductual / Cognitive impairment in long-standing bipolar disorder and behavioral variant of frontotemporal dementia

RESUMEN INTRODUCCIÓN: Los pacientes con trastorno afectivo bipolar pueden presentar alteraciones cognoscitivas que en algunos casos tienen un curso progresivo, por lo cual se ha cuestionado si la evolución de esta enfermedad se asocia a demencia, particularmente aquellas pertenecientes al espectro de la degeneración lobar frontotemporal. En este contexto, discriminar si un paciente presenta una demencia secundaria a la enfermedad psiquiátrica de base o si cursa una enfermedad neurodegenerativa además del trastorno afectivo bipolar, es un desafío para el diagnóstico diferencial. OBJETIVO: Comparar los desempeños cognoscitivos en pacientes con trastorno afectivo bipolar, con veinte años o más de evolución de la enfermedad y pacientes con demencia frontotemporal variante conductual. MATERIALES Y MÉTODOS: Estudio exploratorio, descriptivo y transversal en una cohorte seleccionada de casos por método no probabilístico. Los datos se analizan por medio de estadísticos no paramétricos. RESULTADOS: Eespecto al grupo control (N:27), los pacientes con demencia frontotemporal (N:24) presentan desempeños significativamente bajos en memoria verbal, funciones ejecutivas, praxias visoconstruccionales y atención (p <0,01). El grupo de trastorno bipolar (N:17) tiene bajos desempeños en estos procesos, pero no presenta fenómenos patológicos significativos asociados a intrusiones y perseveraciones. Entre los grupos clínicos no se identifican diferencias significativas. CONCLUSIÓN: Aunque los grupos clínicos comparten el compromiso en los procesos cognoscitivos evaluados, los desempeños son más bajos en el grupo de demencia frontotemporal, lo que sugiere que en una enfermedad degenerativa de menor tiempo de evolución y aparición en etapa presenil el déficit cognitivo es mayor que en una enfermedad psiquiátrica crónica.

SUMMARY INTRODUCTION: Patients with Bipolar Disorder may present cognitive alterations that in some cases have a progressive course, whereby it has been questioned if the evolution of this disease is associated with dementia, in particular those that belong to the spectrum of frontotemporal lobar degeneration. Thereby, discriminate if a patient has a dementia secondary to the underlying psychiatric illness or if the patient presents a neurode-generative disease besides the bipolar disorder is a challenge for the differential diagnosis. OBJECTIVE: To compare the cognitive performance in a sample of patients with Bipolar Disorder and twenty years or more of disease progression, and patients with behavioral variant of frontotemporal dementia. MATERIALS AND METHODS: Exploratory, descriptive and transversal study in a cohort of cases selected with a non probabilistic method. Dates are compared through non parametric statistics. RESULTS: Relative to Control group (N:27), Frontotemporal Dementia Patients (N:24) have significantly lower performances in verbal memory, executive functions, visoconstructional praxis and attention tasks (p <0,01). Bipolar Disorder group (N:17) has lower performances in this processes but don't present pathological markers such as intrusions and perseverative responses. There are no significant differences when comparing between clinical groups. CONCLUSION: Although clinical groups share the compromise in most of the cognitive process evaluated, the performances are lower in Frontotemporal dementia group, which suggests that in a degenerative disease of less evolution time and onset in presenile stage, the cognitive deficit is greater than in a chronic psychiatric illness.

Zika. Una pandemia en progreso y un reto epidemiológico / Zika. A pandemic in progress and an epidemiological challenge

The recent Zika pandemic has become the focus of attention for multilateral health organizations, researchers in centres and universities, specialized publications, mass media, and in particular for populations where it is now a reality, and those that are potentially at risk.

Guía de práctica clínica para el diagnóstico, tratamiento y rehabilitación del episodio agudo de ataque cerebrovascular en población mayor de 18 años: de las recomendaciones a su implementación / Clinical practice guideline for the diagnosis, treatment and rehabilitation of the acute ischemic stroke episode in older than 18 years: from recomendations to its implementation

Con el objeto de mejorar la calidad, eficacia, equidad, seguridad y sostenibilidad económica en la atención de pacientes con ataque cerebrovascular, se desarrolló una Guía de práctica clínica con recomendaciones sustentadas en la mejor evidencia disponible. Sin embargo, la formulación de dichas recomendaciones no garantiza el cambio esperado. Nace entonces el reto de generar estrategias de aceptación, implementación, seguimiento y ajuste de las recomendaciones en la práctica asistencial diaria, con la aplicación de facilitadores de implementación que sobrepasen las barreras y permitan lograr el efecto deseado. La Guía de práctica clínica para el diagnóstico, tratamiento y rehabilitación del episodio agudo de ataque cerebrovascular isquémico en población mayor de 18 años se desarrolla bajo un modelo de gestión que identifica las recomendaciones claves en escenarios específicos e incluye procesos de participación, revisión y socialización como facilitadores de la implementación.

In order to improve the quality, efficiency, equity, security and economic sustainability in the care of patients with stroke, a clinical practice guideline was developed in Colombia, with evidence based recommendations. However, the formulation of these recommendations does not ensure the expected clinical outcomes. It is necessary to design strategies of adherence, implementation, monitoring and adjustment of the recommendations in the daily clinical practice, with the aim to overcome the barriers and enable the expectedimpact. The Clinical Practice Guideline for the Diagnosis, Treatment and Rehabilitation of acute episode of ischemic stroke in population over 18 was developed under a management model, identifying the key recommendations, and including the participation, review and socialization processes as the cornerstone for implementation.

Las guías de práctica clínica: una herramienta de participación en la construcción de una política pública / Clinical practice guidelines: a participation tool in the construction of public policy

Las guías en práctica clínica buscan brindar recomendaciones basadas en evidencia para abordar los procesos de atención para así alcanzar los más altos estándares de calidad. Son procesos participativos e interdisciplinarios. El objetivo de este documento es describir los procesos metodológicos que facilitan desarrollar las recomendaciones de las guías y ofrecer un análisis del contexto que puede modificar el proceso en su conjunto, deteniéndose en los tipos de relacionamiento que lo hacen posible. Se presenta un análisis del desarrollo de la estrategia de elaboración de guías en práctica clínica en Colombia como herramienta del subsistema de calidad y se revisan los antecedentes y avances a la fecha. Se discuten los aspectos teóricos y prácticos de los mecanismos de participación y su alcance en la formulación de recomendaciones. Se ilustra a manera de ejemplo el caso de la Guía de atención en enfermedad cerebro vascular. Se dispone de un Manual de Elaboración de Guías y de un Manual de Implementación, así como de un número de productos para patologías específicas y se esperan nuevas guías en el próximo año. Los mecanismos de participación se enmarcan en las dinámicas de empoderamiento de actores dentro del ámbito social. Las guías son herramientas útiles para resolver problemas específicos en la atención de problemas de salud desde una perspectiva amplia de construcción social de políticas públicas en salud que enfrentan retos y dificultades que deben superarse.

Clinical practice guidelines (CPG) seek to provide evidence-based recommendations for clinicians and decision-makers aiming at the highest quality standards of care. CPG are developed by multidisciplinary teams and through social participation. To describe the methodological process and contextual analysis of the development of CPG. To analyze the social participation process in the formulation of health policy. This paper presents an analysis of a new strategy for the development of CPG in Colombia as a tool for the sub-system of quality in health. The starting point and the current advances of the CPG movement in Colombia are described. We discuss the theoretical and practical mechanisms of social participation and their influence in the formulation of CPG recommendations. We report the case-study of the development of Stroke Clinical Practice Guideline for Colombia. We used, as framework, a CPG Development Manual and an Implementation Manual, as well, as several technical reports of specific pathologies. The mechanisms of social participation are based on the dynamics of stakeholders' empowerment into the Colombian social context. Clinical practice guidelines are useful tools for solving specific issues with health care providers. From the point of view of the social construction of health policies, CPG implementation has still several barriers to overcome.