Quadruple therapies show a higher eradication rate compared to standard triple therapy for Helicobacter pylori infection within the LEGACy consortium. A multicenter observational study in European and Latin American countries.

INTRODUCTION: Gastric cancer (GC) is one of the most lethal malignancies worldwide. Helicobacter pylori is the primary cause of GC; therefore, its eradication reduces the risk of developing this neoplasia. There is extensive evidence regarding quadruple therapy with relevance to the European population. However, in Latin America, data are scarce. Furthermore, there is limited information about the eradication rates achieved by antibiotic schemes in European and Latin American populations. OBJECTIVE: To compare the effectiveness of standard triple therapy (STT), quadruple concomitant therapy (QCT), and bismuth quadruple therapy (QBT) in six centers in Europe and Latin America. METHODS: A retrospective study was carried out based on the LEGACy registry from 2017 to 2022. Data from adult patients recruited in Portugal, Spain, Chile, Mexico, and Paraguay with confirmed H. pylori infection who received eradication therapy and confirmatory tests at least 1 month apart were included. Treatment success by each scheme was compared using a mixed multilevel Poisson regression, adjusting for patient sex and age, together with country-specific variables, including prevalence of H. pylori antibiotic resistance (clarithromycin, metronidazole, and amoxicillin), and CYP2C19 polymorphisms. RESULTS: 772 patients were incorporated (64.64% females; mean age of 52.93 years). The total H. pylori eradication rates were 75.20% (255/339) with STT, 88.70% (159/178) with QCT, and 91.30% (191/209) with QBT. Both quadruple therapies (QCT-QBT) showed significantly higher eradication rates compared with STT, with an adjusted incidence risk ratio (IRR) of 1.25 (p: <0.05); and 1.24 (p: <0.05), respectively. The antibiotic-resistance prevalence by country, but not the prevalence of CYP2C19 polymorphism, showed a statistically significant impact on eradication success. CONCLUSIONS: Both QCT and QBT are superior to STT for H. pylori eradication when adjusted for country-specific antibiotic resistance and CYP2C19 polymorphism in a sample of individuals residing in five countries within two continents.

Impact of rifaximin use in infections and mortality in patients with decompensated cirrhosis and hepatic encephalopathy.

Introduction: Infections in patients with cirrhosis are associated with high morbidity and mortality. Rifaximin is an antibiotic used to treat and prevent hepatic encephalopathy (HE); however, it has been suggested that it may play a crucial role in reducing infections in these populations. Aim: To evaluate the role of rifaximin in preventing frequent cirrhosis-related infections [spontaneous bacterial peritonitis, pneumonia, urinary tract infection (UTI), and bacteremia], Clostridioides difficile infection, and all-cause mortality, as well as determining adverse effects and adherence to the drug. Methods: A retrospective cohort study was conducted on decompensated cirrhotic patients with history of HE between January 2017 and November 2022 at a university center. Patients with cirrhosis, regardless of their etiology and severity, were included in the study, encompassing both hospitalized and outpatient cases. The statistical analysis included adjusted general linear models, Poisson regressions, and propensity score matching. Results: We included 153 patients. The mean age in the cohort was 60.2 ± 12.3 years and 67 (43.8%) were women. The main cause of cirrhosis was metabolic dysfunction-associated steatotic liver disease 52 (38%), and the median Model of End-Stage Liver Disease sodium was 16.5 (7-32). In the cohort, 65 (45%) patients used rifaximin. The mean follow-up was 32 months. Eighty-five patients with infectious events were recorded, and a total of 164 infectious events were registered. The main infectious events were UTIs (62, 37.8%) and pneumonia (38, 23.2%). The use of rifaximin was associated with lower infection rates, displaying an incidence rate ratio (IRR) of 0.64 [95% confidence interval (CI) (0.47-0.89); p = 0.008]. However, no discernible impact on mortality outcome was observed [IRR 1.9, 95% CI (0.9-4.0); p = 0.09]. There were no reported adverse effects, and no patient discontinued the therapy due to adverse effects. Conclusion: The use of rifaximin significantly reduces infections in patients with cirrhosis and HE. Despite rifaximin was associated with a decreased all-cause mortality, this impact was not statistically significant in the adjusted analysis.

Assessing the impact of rifaximin on infections in cirrhosis This study aimed to investigate the role of rifaximin, an antibiotic commonly used to treat hepatic encephalopathy, in preventing infections and mortality in patients with cirrhosis. The retrospective cohort study included 153 decompensated cirrhotic patients with a history of hepatic encephalopathy, covering the period from January 2017 to November 2022 at a university center. Results showed that 45% of the patients in the cohort used rifaximin, and the mean follow-up duration was 32 months. A total of 164 infectious events were recorded during the study, with urinary tract infections (37.8%) and pneumonia (23.2%) being the most common. The use of rifaximin was associated with a significant reduction in infection rates, with an incidence rate ratio of 0.64 (95% CI [0.47-0.89]; p=0.008). However, there was no statistically significant impact on all-cause mortality (IRR 1.9, 95% CI [0.9-4.0]; p=0.09). Notably, no adverse effects were reported, and no patient discontinued rifaximin therapy due to adverse effects. In conclusion, rifaximin demonstrated a noteworthy reduction in infections among cirrhotic patients with hepatic encephalopathy. Although a decrease in all-cause mortality was observed with rifaximin use, this effect did not reach statistical significance in the adjusted analysis. The study supports the potential benefits of rifaximin in preventing infections in this vulnerable patient population without apparent adverse effects. Further research may provide additional insights into the long-term impact of rifaximin on mortality outcomes in cirrhotic patients.

Vancomicina contra metronidazol en infección por Clostridioides difficile leve-moderada de manejo ambulatorio / Vancomycin or metronidazole in the outpatient treatment of mild-moderate Clostridioides difficile infection

INTRODUCCIÓN: En la diarrea asociada a Clostridioides dfficile (DACD) leve-moderada se recomienda tratar con vancomicina por sobre metronidazol, a pesar de su difícil acceso y poca evidencia en el medio ambulatorio. OBJETIVO: Comparar la tasa de cura clínica y recurrencia entre vancomicina y metronidazol en adultos chilenos con primer episodio leve-moderado de DACD de manejo ambulatorio. MÉTODOS: Cohorte retrospectiva entre enero 2015 y diciembre 2020 en centros de una red de salud universitaria de pacientes de ≥ 18 años con DACD tratados ambulatoriamente. RESULTADOS: Se obtuvieron 161 pacientes, 59% mujeres, edad promedio de 53 años (entre 18 y 94 años). De ellos, 109 (67,7%) usaron metronidazol y 52 (32,3%) vancomicina. En el análisis multivariado ajustado por edad y comorbilidades se obtuvo un OR 3,00 (IC 95% 1,12-9,59) para cura clínica y 0,27 (IC 95% 0,06-0,88) para recurrencia a ocho semanas, ambos a favor de vancomicina, sin diferencias en recurrencia a 12 meses, necesidad de hospitalización o mortalidad. CONCLUSIÓN: La terapia con vancomicina comparada contra metronidazol en el tratamiento ambulatorio de la infección leve-moderada por C. dfficile se asocia a mayor cura clínica y menor tasa de recurrencia a corto plazo, sin diferencias en desenlaces a largo plazo.

BACKGROUND: Recommended treatment against mild cases of Clostridioides difficile associated diarrhea is vancomycin despite the difficulties of access compared to metronidazole. AIM: To compare the effectiveness of vancomycin and metronidazole in Chilean adults with first mild-moderate episode of Clostridiodes difficile infection (CDI). METHODS: Retrospective cohort of patients with CDI between January 2015 and December 2020 treated in centers of a university health network. The patients were adults treated for C. difficile infection on an outpatient basis. Recurrent and severe cases were excluded. Outcomes included clinical cure and recurrence rate. RESULTS: Data from 161 patients was recovered. Fifty-nine percent were women and average age was 53 (18-94). One hundred and nine patients were treated with metronidazole (67.7%) and 52 (32.3%) used vancomycin. Multivariate analysis adjusted by age and comorbidities showed an Odds Ratio of 3.00 (IC 95% 1.12-9.59) for clinical cure and 0.27 (IC 95% 0.06-0.88) for 8-week recurrence rate, both in favor of vancomycin, without differences in 12-month recurrence rate, hospitalization rate nor mortality. CONCLUSIONS: Vancomycin is associated with better short-term outcomes in the treatment of outpatient mild-moderate first episode C. difficile infection, without differences in long term recurrence or mortality when compared with metronidazole.

Association between public health policies on alcohol and worldwide cancer, liver disease and cardiovascular disease outcomes.

BACKGROUND & AIMS: The long-term impact of alcohol-related public health policies (PHPs) on disease burden is unclear. We aimed to assess the association between alcohol-related PHPs and alcohol-related health consequences. METHODS: We conducted an ecological multi-national study including 169 countries. We collected data on alcohol-related PHPs from the WHO Global Information System of Alcohol and Health 2010. Data on alcohol-related health consequences between 2010-2019 were obtained from the Global Burden of Disease database. We classified PHPs into five items, including criteria for low, moderate, and strong PHP establishment. We estimated an alcohol preparedness index (API) using multiple correspondence analysis (0 lowest and 100 highest establishment). We estimated an incidence rate ratio (IRR) for outcomes according to API using adjusted multilevel generalized linear models with a Poisson family distribution. RESULTS: The median API in the 169 countries was 54 [IQR 34.9-76.8]. The API was inversely associated with alcohol use disorder (AUD) prevalence (IRR 0.13; 95% CI 0.03-0.60; p = 0.010), alcohol-associated liver disease (ALD) mortality (IRR 0.14; 95% CI 0.03-0.79; p = 0.025), mortality due to neoplasms (IRR 0.09; 95% CI 0.02-0.40; p = 0.002), alcohol-attributable hepatocellular carcinoma (HCC) (IRR 0.13; 95% CI 0.02-0.65; p = 0.014), and cardiovascular diseases (IRR 0.09; 95% CI 0.02-0.41; p = 0.002). The highest associations were observed in the Americas, Africa, and Europe. These associations became stronger over time, and AUD prevalence was significantly lower after 2 years, while ALD mortality and alcohol-attributable HCC incidence decreased after 4 and 8 years from baseline API assessment, respectively (p <0.05). CONCLUSIONS: The API is a valuable instrument to quantify the robustness of alcohol-related PHP establishment. Lower AUD prevalence and lower mortality related to ALD, neoplasms, alcohol-attributable HCC, and cardiovascular diseases were observed in countries with a higher API. Our results encourage the development and strengthening of alcohol-related policies worldwide. IMPACT AND IMPLICATIONS: We first developed an alcohol preparedness index, an instrument to assess the existence of alcohol-related public policies for each country. We then evaluated the long-term association of the country's alcohol preparedness index in 2010 with the burden of chronic liver disease, hepatocellular carcinoma, other neoplasms, and cardiovascular disease. The strengthening of alcohol-related public health policies could impact long-term mortality rates from cardiovascular disease, neoplasms, and liver disease. These conditions are the main contributors to the global burden of disease related to alcohol use. Over time, this association has not only persisted but also grown stronger. Our results expand the preliminary evidence regarding the importance of public health policies in controlling alcohol-related health consequences.

Implementation of the updated Sydney system biopsy protocol improves the diagnostic yield of gastric preneoplastic conditions: Results from a real-world study.

BACKGROUND: The updated Sydney system biopsy protocol (USSBP) standardizes the sampling of gastric biopsies for the detection of preneoplastic conditions (e.g., gastric intestinal metaplasia [GIM]), but the real-world diagnostic yield is not well-described. AIM: To determine whether regular application of USSBP is associated with higher detection of chronic atrophic gastritis (CAG), GIM and autoimmune gastritis (AIG). METHODS: We performed a real-world retrospective study at an academic urban tertiary hospital in Chile. We manually reviewed medical records from consecutive patients undergoing esophagogastroduodenoscopy (EGD) from January to December 2017. Seven endoscopists who performed EGDs were categorized into two groups (USSBP 'regular' and USSBP 'infrequent') based on USSBP adherence, using minimum 20% adherence as the prespecified threshold. Multivariable logistic regression models were used to estimate the odds ratios (aOR) and 95% confidence intervals (CI) for the association between endoscopist groups and the likelihood of diagnosing CAG, GIM or AIG. RESULTS: 1206 patients were included in the study (mean age: 58.5; 65.3% female). The USSBP regular group demonstrated a higher likelihood of detecting CAG (20% vs. 5.3%; aOR 4.03, 95%CI: 2.69-6.03), GIM (12.2% vs. 3.4%; aOR 3.91, 95%CI: 2.39-6.42) and AIG (2.9% vs. 0.8%; aOR 6.52, 95%CI: 1.87-22.74) compared to infrequent group. Detection of advanced-stage CAG (Operative Link for Gastritis Assessment stage III/IV) was significantly higher in the USSBP regular vs. infrequent group (aOR 5.84, 95%CI: 2.23-15.31). CONCLUSIONS: Routine adherence to USSBP increases the detection rates of preneoplastic conditions, including CAG, GIM and AIG. Standardized implementation of USSBP should be considered in high gastric cancer risk populations.

Bridging gaps to universal palliative care access in Chile: serious health-related suffering and the cost of expanding the package of care services.

Background: The Lancet Commission on Palliative Care (PC) and Pain Relief quantified the burden of serious health-related suffering (SHS), proposing an Essential Package of PC (EPPC) to narrow the global PC divide. We applied the EPPC framework to analyze PC access in Chile, identify gaps in coverage, and provide recommendations to improve PC access. Methods: Total SHS and population in need of PC was estimated using official 2019 government data. We differentiated between cancer and non-cancer related SHS given guaranteed Chilean PC coverage for cancer. We calculated differences between the Chilean PC package and the Lancet Commission EPPC to estimate the cost of expanding to achieve national coverage of palliative care. Findings: In 2019, nearly 105,000 decedent and non-decedent Chileans experienced SHS with a lower-bound estimate of 12.1 million days and an upper-bound estimate of 42.4 million days of SHS. Each individual experienced between 116 and 520 days of SHS per year. People living with a cancer diagnosis had PC access with financial protection, accounting for almost 42% of patients in need. People with non-cancer diagnoses-about 61 thousand patients-lacked PC coverage. Expanding coverage of the EPPC for all patients in need would cost just above $123 million USD, equivalent to 0.47% of Chilean National Health Expenditure. Interpretation: Achieving universal PC access is urgent and feasible for Chile, classified as a high-income country. Expanding PC services and coverage to the EPPC standard are affordable and critical health system responses to ensuring financial protection for patients with SHS. In Chile, this requires closing large gaps in PC coverage pertaining to patients with non-cancer conditions and treatment of symptoms that go beyond pain. Our research provides an empirical approach for applying the Lancet Commission SHS framework to estimate the cost of achieving national universal PC access anchored in a package of health care services. Funding: This research was partially funded by the Chilean Government through the Fondo Nacional de Ciencia y Tecnología (Fondecyt Regular) grant number 1201721, the U.S. Cancer Pain Relief Committee grant AWD-003806 awarded to the University of Miami and by the University of Miami Institute for Advanced Study of the Americas. We acknowledge NIH/NCI award P30CA008748.

Liver Diseases in Latin America: Current Status, Unmet Needs, and Opportunities for Improvement.

Purpose of review: To assess the current challenges regarding liver diseases, including the burden of disease, access to care, screening, and treatment needs in Latin America. Recent findings: Latin America is a region with a rich multicultural heritage and important socioeconomic differences. The burden of liver diseases is high and mainly determined by a high level of alcohol intake and the surge of risk factors associated with NAFLD (i.e., sedentary lifestyles, broader access to highly processed foods, obesity, and type 2 diabetes mellitus). Hepatotropic viruses also play a role in the development of chronic liver diseases, although their comparative frequency has been decreasing over the last decades. There are important disparities in access to screening and treatment for liver diseases in Latin America, which are reflected in low access to critical treatments such as direct-acting antiviral agents and drugs to treat hepatocellular carcinoma. Also, important barriers to liver transplantation are present in multiple countries, including a low deceased donors' rate and a lack of availability in several countries (especially in Central America). Our region also has disadvantages in research and education in liver diseases, which limits regional academic development and improvement in quality of care of liver diseases. Summary: In order to tackle an increasing health burden due to liver diseases, Latin America urgently needs tailored interventions aiming to control the main risk factors for these disorders through the establishment of effective public health policies. Also, development of liver transplantation programs and improvement of medical education and research capabilities as well as extensive collaboration between all stakeholders are keys to address the liver disease agenda in the region.

Impact of Public Health Policies on Alcohol-Associated Liver Disease in Latin America: An Ecological Multinational Study.

BACKGROUND AND AIMS: Alcohol-associated liver disease (ALD) is the leading cause of liver-related mortality in Latin America, yet the impact of public health policies (PHP) on liver disease is unknown. We aimed to assess the association between alcohol PHP and deaths due to ALD in Latin American countries. APPROACH AND RESULTS: We performed an ecological multinational study including 20 countries in Latin America (628,466,088 inhabitants). We obtained country-level sociodemographic information from the World Bank Open Data source. Alcohol-related PHP data for countries were obtained from the World Health Organization Global Information System of Alcohol and Health. We constructed generalized linear models to assess the association between the number of PHP (in 2010) and health outcomes (in 2016). In Latin America, the prevalence of obesity was 27% and 26.1% among male and female populations, respectively. The estimated alcohol per capita consumption among the population at 15 years old or older was 6.8 L of pure alcohol (5.6 recorded and 1.2 unrecorded). The overall prevalence of alcohol use disorders (AUD) was 4.9%. ALD was the main cause of cirrhosis in 64.7% of male and 40.0% of female populations. A total of 19 (95%) countries have at least one alcohol-related PHP on alcohol. The most frequent PHP were limiting drinking age (95%), tax regulations (90%), drunk-driving policies and countermeasures (90%), and government monitoring systems and community support (90%). A higher number of PHP was associated with a lower ALD mortality (PR, 0.76; 95% CI, 0.61-0.93; P = 0.009), lower AUD prevalence (PR, 0.80; 95% CI, 0.65-0.99; P = 0.045), and lower alcohol-attributable road traffic deaths (PR, 0.81; 95% CI, 0.65-1.00; P = 0.051). CONCLUSIONS: Our study indicates that in Latin America, countries with higher number of PHP have lower mortality due to ALD, lower prevalence of AUD, and lower alcohol-attributable road traffic mortality.

Análisis de sobrevida en pacientes incidentes de hemodiálisis en Chile, 2013-2019

Background: Renal replacement therapies, especially hemodialysis (HD) in end-stage kidney disease, avoid an inevitable death caused by the disease. However, in elderly patients with multiple comorbidities, this therapy could derive in a comparable survival than conservative management. Considering that HD represents a high cost for the health system, it is worth analyzing the effects of HD on survival. Aim: To analyze the survival and mortality of all national health security system's patients (FONASA) admitted to HD in Chile from 2013 to 2019. Material and Methods: We requested to the Ministry of Health information about all patients affiliated to the public health insurance system that started dialysis between 2013 and 2019. We evaluated the influence of age when starting HD, sex, presence of hypertension, presence of diabetes mellitus (DM), the region of residence, and year of admission on mortality. Results: A total of 24,113 patients aged 61 ± 15 years (45% women) were analyzed. Forty five percent of patients were aged > 65 years. After 5 years of follow-up, the median survival in this age group was 36.1 months. Among patients who started HD at age > 85 years, the median survival was 14.8 months. Diabetic patients had a median survival of 52.3 months. Advanced age and DM were associated with higher annual mortality. Also, the region of residence and year of admission were associated with higher mortality at 3 and 12 months. Conclusions: The median survival of patients on HD is dependent on age and the presence of comorbidities, among other factors. We performed an analysis to determine if starting HD in older patients with comorbidities has a real benefit over conservative management in terms of survival.

Metahemoglobinemia secundaria a inhalación de "poppers": caso clínico y revisión de la literatura / Methemoglobinemia secondary to amyl nitrite inhalation. A case report and literature review

El nitrito de amilo, conocida como "poppers", se ha masificado como droga recreacional en parte por sus efectos con objetivos sexuales. Su consumo se asocia a complicaciones psiquiátricas y médicas. Reportamos el caso de un paciente que se presenta con metahemog-lobinemia moderada secundaria a la inhalación de nitrito de amilo asociado a alcohol. Al ingreso presenta cianosis peribucal y en extremidades, disociación entre oximetría de pulso y presión parcial de oxígeno en gases arteriales, además de metahemoglobinemia 29,9%. Se descartan otras intoxicaciones y causas primarias de metahemoglobinemia. Se maneja con oxigenoterapia, hidratación y ácido ascórbico, presentando una evolución favorable. Presentamos el primer caso en Chile de metahemoglobinemia secundaria al consumo de nitrito de amilo con fines recreativos.

Amyl nitrite, known as "poppers", has become popular as a recreational drug for sexual purposes. Its consumption is associated with psychiatric and medical complications. We report the case of a patient presenting with moderate methemoglobinemia secondary to amyl nitrite inhalation associated with alcohol. At admission, perioral and extremities cyanosis, a dissociation between pulse oximetry and partial pressure of oxygen in arterial gases, and methemoglobinemia 29.9% were present. Other intoxications and primary causes of methemoglobinemia were ruled out. The patient receives oxygen therapy, hydration, and ascorbic acid, presenting a favorable evolution. We report the first Chilean's case of methemoglobinemia secondary to amyl nitrite consumption for recreational purposes

[Survival analysis of patients starting hemodialysis in Chile between 2013 and 2019]. / Análisis de sobrevida en pacientes incidentes de hemodiálisis en Chile, 2013-2019.

BACKGROUND: Renal replacement therapies, especially hemodialysis (HD) in end-stage kidney disease, avoid an inevitable death caused by the disease. However, in elderly patients with multiple comorbidities, this therapy could derive in a comparable survival than conservative management. Considering that HD represents a high cost for the health system, it is worth analyzing the effects of HD on survival. AIM: To analyze the survival and mortality of all national health security system's patients (FONASA) admitted to HD in Chile from 2013 to 2019. MATERIAL AND METHODS: We requested to the Ministry of Health information about all patients affiliated to the public health insurance system that started dialysis between 2013 and 2019. We evaluated the influence of age when starting HD, sex, presence of hypertension, presence of diabetes mellitus (DM), the region of residence, and year of admission on mortality. RESULTS: A total of 24,113 patients aged 61 ± 15 years (45% women) were analyzed. Forty five percent of patients were aged > 65 years. After 5 years of follow-up, the median survival in this age group was 36.1 months. Among patients who started HD at age > 85 years, the median survival was 14.8 months. Diabetic patients had a median survival of 52.3 months. Advanced age and DM were associated with higher annual mortality. Also, the region of residence and year of admission were associated with higher mortality at 3 and 12 months. CONCLUSIONS: The median survival of patients on HD is dependent on age and the presence of comorbidities, among other factors. We performed an analysis to determine if starting HD in older patients with comorbidities has a real benefit over conservative management in terms of survival.

PET-CT for the management of testicular seminoma patients with post-chemotherapy residual masses. / PET-CT for the management of testicular seminoma patients with post-chemotherapy residual masses.

INTRODUCTION: The use of PET-CT could select a subgroup of advanced testicular seminoma patients that display post-chemotherapy residual masses measuring >3 cm and could be managed with surveillance, avoiding unnecessary surgical resection of unviable tumor masses. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified three systematic reviews that included eleven primary studies; none of these were randomized trials. We concluded the assessment of postchemotherapy residual masses by PET-CT in testicular seminoma patients may prevent unnecessary surgeries, but the certainty of the evidence is low. Furthermore, PET-CT could also offer a favorable risk/benefit and cost/benefit ratio for the management of testicular seminoma patients. However, systematic reviews and primary studies assessing the direct diagnostic impact of PET-CT are required.

INTRODUCCIÓN: En pacientes con cáncer testicular avanzado tipo seminoma que tienen lesiones residuales post quimioterapia de más de 3 cm, el PET-CT podría seleccionar un subgrupo susceptible de ser manejado con seguimiento, evitando una resección quirúrgica innecesaria de tumor no viable. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos tres revisiones sistemáticas que en conjunto incluyeron 11 estudios primarios, de los cuales, ninguno es un ensayo aleatorizado. Concluimos que el uso de PET-CT en la evaluación de masas residuales post quimioterapia en pacientes con cáncer testicular tipo seminoma podría evitar un porcentaje importante de cirugías innecesarias (certeza de la evidencia baja). Además, el uso de PET-CT podría presentar balances riesgo/beneficio y costo/beneficio favorables en el manejo de pacientes con cáncer testicular tipo seminoma. Sin embargo, se requieren revisiones sistemáticas y estudios primarios que evalúen directamente el impacto diagnóstico del test.

Are cannabinoids effective for HIV wasting syndrome? / ¿Es efectivo el uso de cannabinoides en el síndrome de emaciación (wasting) en VIH/SIDA?

INTRODUCTION: Wasting syndrome is a common problem in HIV. It leads to substantive morbidity and mortality. The use of cannabinoids has been suggested as a treatment for weight, but it is not clear whether they are really safe and effective. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified eight systematic reviews including ten studies overall, of which six were randomized trials. We concluded it is not clear whether cannabinoids increase appetite or weight in HIV wasting syndrome because the certainty of the evidence is very low, and they probably lead to frequent adverse effects.

INTRODUCCIÓN: El síndrome de emaciación (wasting) en VIH/SIDA aún permanece como un problema común, constituyéndose como un factor de mortalidad en esta población. Se ha postulado el uso de cannabinoides como tratamiento de la baja de peso secundaria a la infección por VIH, lo que aún es controvertido. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios y preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos ocho revisiones sistemáticas que en conjunto incluyen 10 estudios primarios, de los cuales, seis son ensayos aleatorizados. Concluimos que no está claro si los cannabinoides aumentan el apetito o incrementan el peso en el síndrome de wasting en pacientes con VIH, y probablemente los efectos adversos son frecuentes.

Are cannabinoids effective for the management of chemotherapy induced nausea and vomiting? / ¿Son efectivos los cannabinoides para el manejo de náuseas y vómitos inducidos por quimioterapia?

INTRODUCTION: Nausea and vomiting are common side effects in cancer patients treated with chemotherapy. Proper control of these symptoms might improve quality of life in these patients. Addition of cannabinoids to standard antiemetic treatment has been proposed in order to improve control of these symptoms. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified 16 systematic reviews that include 61 primary studies. Out of these, four were randomized trials that answered our question. At present, given that the certainty of the evidence is very low, it is unclear whether the addition of cannabinoids to standard antiemetic regimes benefits patients with chemotherapy induced nausea and vomiting. Cannabinoids probably increase adverse effects substantively.

INTRODUCCIÓN: El tratamiento de las náuseas y vómitos inducidos por quimioterapia podría mejorar la calidad de vida de los pacientes oncológicos; para lograrlo se ha propuesto la adición de cannabinoides a los esquemas de antieméticos habituales. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos 16 revisiones sistemáticas que en conjunto incluyen 61 estudios primarios, de los cuales cuatro son ensayos aleatorizados que responden a la pregunta de interés. Concluimos que no hay claridad respecto a si los cannabinoides otorgan un beneficio al añadirlos a esquemas antieméticos habituales para el control de náuseas y vómitos inducidos por quimioterapia, porque la certeza de la evidencia es muy baja. Probablemente aumentan los efectos adversos de manera sustantiva.

Are cannabinoids an alternative for cachexia-anorexia syndrome in patients with advanced cancer? / ¿Son los cannabinoides una opción para el síndrome anorexia-caquexia en pacientes con cáncer avanzado?

INTRODUCTION: Cachexia and anorexia are among the most frequent symptoms in patients with cancer. Cannabinoids have been used in patients with advanced cancer; however, their role is still controversial. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified ten systematic reviews including three studies overall, of which two were randomized trials. We concluded it is not clear whether cannabinoids have any positive effect on increasing weight because the certainty of the evidence is very low. They might not have any effect on appetite, and are probably associated to frequent adverse effects.

INTRODUCCIÓN: La caquexia y la anorexia se encuentran dentro de los síntomas más frecuentes en los pacientes oncológicos. Los cannabinoides han sido propuestos para su manejo en los pacientes con cáncer avanzado, sin embargo, su rol es controvertido. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud a nivel mundial, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos diez revisiones sistemáticas, que en conjunto incluyen tres estudios, entre ellos dos ensayos aleatorizados. Concluimos que no está claro si los cannabinoides logran o no un aumento de peso en pacientes con anorexia-caquexia porque la certeza de la evidencia es muy baja, podrían no tener tampoco efecto sobre el apetito, y probablemente se asocian a efectos adversos frecuentes.

Is it worth adding loperamide to antibiotic treatment of traveler’s diarrhea? / ¿Vale la pena agregar loperamida al tratamiento antibiótico de la diarrea del viajero?

Travelers' diarrhea is a frequent condition, especially in those traveling to high-risk areas. Although antibiotic treatment reduces the duration of diarrhea, it has been suggested adding loperamide could further reduce the symptoms. To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We identified two systematic reviews including 28 studies overall, of which 15 were randomized trials relevant for the question of interest. We extracted data from the systematic reviews, reanalysed data of primary studies and generated a summary of findings table using the GRADE approach. We concluded adding loperamide to antibiotic treatment might accelerate resolution of symptoms in traveler’s diarrhea with minimal or no adverse effects.

La diarrea del viajero es una patología frecuente, en especial en quienes se dirigen a regiones de alto riesgo. Si bien el tratamiento antibiótico reduce la duración del cuadro, se ha planteado que la asociación de loperamida podría reducir aún más los síntomas. Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Identificamos dos revisiones sistemáticas que en conjunto incluyen 28 estudios primarios, de los cuales 15 corresponden a ensayos aleatorizados. Extrajimos los datos desde las revisiones identificadas y preparamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que agregar loperamida al tratamiento con antibióticos podría acelerar la resolución del cuadro, sin asociarse probablemente a efectos adversos importantes.

Is it useful to add acetaminophen to high-potency opioids in cancer-related pain? / ¿Sirve agregar paracetamol a opioides fuertes en pacientes con dolor oncológico?

Pain is one of the most frequent and relevant symptoms in cancer patients. The World Health Organization's analgesic ladder proposes the use of strong opioids associated with adjuvants such as acetaminophen or nonsteroidal anti-inflammatory drugs in step III. However, it is unclear whether adding acetaminophen to an analgesic regimen based on strong opioids has any benefit in cancer patients with moderate to severe pain. To answer this question we searched in Epistemonikos database, which is maintained by screening multiple information sources. We identified two systematic reviews including five randomized trials overall. We extracted data and generated a summary of findings table using the GRADE approach. We concluded that adding acetaminophen to strong opioids might make little or no difference in improving pain management in cancer patients.

El dolor es uno de los síntomas más frecuentes y relevantes en pacientes oncológicos. La estrategia analgésica escalonada de la Organización Mundial de la Salud postula el uso de opioides fuertes asociado a coadyuvantes como el paracetamol o los antiinflamatorios no esteroidales en el peldaño III. Sin embargo, existe la duda si agregar paracetamol a un esquema analgésico basado en opioides fuertes presenta algún beneficio en pacientes oncológicos con dolor moderado a severo. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples fuentes de información, identificamos dos revisiones sistemáticas que en conjunto incluyen cinco estudios aleatorizados. Extrajimos los datos relevantes y resumimos los resultados utilizando el método GRADE. Concluimos que agregar paracetamol a los opioides fuertes podría hacer poca o nula diferencia en el control del dolor en pacientes oncológicos.

Are cannabinoids effective in multiple sclerosis? / ¿Son efectivos los cannabinoides en la esclerosis múltiple?

Multiple beneficial effects have been proposed lately for cannabinoids in different clinical situations. Among them, it has been postulated they would control symptoms of multiple sclerosis. However, there is no consensus about their real clinical role. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple databases. We identified 25 systematic reviews including 35 studies overall, of which 26 were randomized trials. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded cannabinoids in multiple sclerosis do not reduce spasticity or pain, and are probably associated to frequent adverse effects.

En el último tiempo, se han descrito diversos beneficios con el uso de cannabinoides en diferentes situaciones clínicas. Dentro de ellas se ha planteado un posible efecto en el control de la esclerosis múltiple, pero la real utilidad clínica es tema de debate. Para responder a esta pregunta utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos. Identificamos 25 revisiones sistemáticas que en conjunto incluyen 35 estudios que responden la pregunta de interés, entre ellos 26 estudios aleatorizados. Extrajimos los datos, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Concluimos que el uso de cannabinoides en esclerosis múltiple no reduce la espasticidad ni el dolor, y probablemente se asocia a efectos adversos frecuentes.

Cirugía cardíaca en pacientes infectados por virus de inmunodeficiencia humana / Cardiac Surgery in HIV positive patients

La infección del virus de inmunodeficiencia humana (VIH) se adquiere principalmente a través del contagio sexual y los pacientes infectados siguen aumentando en el mundo. El tratamiento antirretroviral (TARV) moderno es capaz de suprimir la replicación viral y mejorar el recuento de linfocitos T CD4+, aumentando la supervivencia de los pacientes. De esta manera, aumenta el riesgo de presentar enfermedades crónicas siendo las cardiovasculares las más frecuentes. Objetivo: Comunicar nuestra experiencia en pacientes con infección por VIH sometidos a cirugía cardiovascular. Pacientes y Método: Estudio retrospectivo en que se revisó la base de datos del Servicio de Cirugía Cardiovascular entre los años 2009 y 2015. Identificamos a los pacientes con infección por VIH sometidos a cirugía cardiovascular. Resultados: Catorce pacientes presentaban esa condición. La mayoría estaba en control y con TARV (11 casos) logrando que la carga viral fuera indetecta-ble. La principal vía de infección fue la sexual (13/14 casos). Durante la cirugía se tomaron las precauciones universales de protección para el equipo quirúrgico, las que fueron efectivas en todos los casos. La enfermedad más frecuentemente tratada fue la cardiopatía coronaria (9 casos), seguido de valvulopatías severas (4 casos) en que solo uno presentaba Endocarditis Infecciosa. No hubo mortalidad asociada al procedimiento ni en el seguimiento a tres años de la cirugía. Conclusión: Los pacientes con infección por VIH están expuestos a desarrollar enfermedades cardiovasculares que requieren de tratamiento quirúrgico. Estos pueden ser realizados en forma segura con gran beneficio en su calidad de vida y de su supervivencia.

Infection with human immunodeficiency virus (HIV+) is primarily acquired through sexual transmission and the number of infected people continues to increase. Anti-retroviral therapy (HAART) suppress viral replication and improves CD4 T cell count, increasing survival and the risk of developing chronic diseases. Cardiovascular disease is prevalent among these patients. Objective: To report our experience in patients positive for HIV undergoing cardiovascular surgery. Patients and Methods: We reviewed the Cardiovascular Surgery Service database from 2009 to 2015 to identify HIV-infected patients that underwent cardiovascular surgery. Results: There were 14 HIV positive patients. Most of them were receiving HAART and the viral load was undetectable in 11 patients Thee main route of infection was sexual (13/14 cases). Universal precautions to protect the surgical team were taken during surgery. These were effective in all cases. Coronary artery disease was the most common condition treated (9 cases), followed by severe valve disease (4). Only one patients had infective endocarditis. There was no mortality associated with the procedure. Al patients were alive and asymptomatic 3 years after surgery. Conclusion: Patients with HIV infection are likely to develop cardiovascular diseases requiring surgical treatment. These can be performed safely with great benefit in quality of life and survival.