Position paper on perioperative management and surgical risk in the patient with cirrhosis.

INTRODUCTION: Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context. AIMS: The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients. RESULTS: Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care. CONCLUSIONS: The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.

Guidelines for the management of coagulation disorders in patients with cirrhosis.

Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.

Identification of the ATPase alpha subunit of Trypanosoma cruzi as a potential biomarker for the diagnosis of Chagas disease.

BACKGROUND: Chagas disease (CD) is considered by the World Health Organisation (WHO) a neglected disease endemic to the Americas, but it has spread throughout the world due to migrations. The disease is almost 100% curable if detected in time. Still, the lack of rapid diagnostic tests with sufficient sensitivity and specificity leads to a chronic phase with a mortality of about 50,000 people worldwide per year. METHODS: Using the total proteins extracted from serum samples of patients confirmed with chronic phase CD; we performed the Bio-SELEX strategy. The best aptamers were selected using next-generation sequencing (NGS) based on their most abundant sequences (reads and rpm). Then, selected aptamers were used to isolate potential biomarkers directly from serum samples of patients with chronic phase CD using pull-down and mass spectrometry experiments. RESULTS: CH1 aptamer was the aptamer selected after the NGS results analysis. The pull-down and mass spectrometry experiments identified the presence of the ATPase alpha subunit of T. cruzi circulating in serum samples of patients with chronic phase CD. CONCLUSIONS: We report the ATPase alpha subunit of T. cruzi as a potential biomarker for chronic phase CD and CH1 aptamer as a potential tool for diagnosing CD.

Current vision on diagnosis and comprehensive care in hepatic encephalopathy.

The first clinical guidelines on hepatic encephalopathy were published in 2009. Almost 14 years since that first publication, numerous advances in the field of diagnosis, treatment, and special condition care have been made. Therefore, as an initiative of the Asociación Mexicana de Gastroenterología A.C., we present a current view of those aspects. The manuscript described herein was formulated by 24 experts that participated in six working groups, analyzing, discussing, and summarizing the following topics: Definition of hepatic encephalopathy; recommended classifications; epidemiologic panorama, worldwide and in Mexico; diagnostic tools; conditions that merit a differential diagnosis; treatment; and primary and secondary prophylaxis. Likewise, these guidelines emphasize the management of certain special conditions, such as hepatic encephalopathy in acute liver failure and acute-on-chronic liver failure, as well as specific care in patients with hepatic encephalopathy, such as the use of medications and types of sedation, describing those that are permitted or recommended, and those that are not.

[Epidemiological, clinical and therapeutic characteristics of Achilles tendon rupture]. / Características epidemiológicas, clínicas y terapéuticas de la ruptura de tendón de Aquiles.

INTRODUCTION: The rupture of the Achilles tendon is one of the most frequent of the lower limb, the increase in its incidence invites to evaluate its associated characteristics that act as triggers or as risk factors. METHODS: Descriptive, retrospective, cross-sectional study, based on clinical history data, using mean, standard deviation and percentages. RESULTS: We evaluated 49 patients: males 83.7%, administrative profession 46.9%, sport injury 61.2% (soccer 38.8%). 75.5% were acute injuries, affecting the left tendon (57.1%). The most referred symptom is sudden pain (95.9%) and the most common sign is Thompson's (89.8%). Ultrasonography was used in 42.9%. 95.5% received treatment by open surgery and spinal anesthesia 85.1%. Intraoperatively they reported complete rupture 95.7%, at 2-5 cm insertion 66%, 98% of them had no associated injuries. The repair was simple tenorrhaphy with Kessler's point (51%) and Vycril as suture material (95.7%). Immobilization was performed with warm-pedium plaster (98%) for a period of 6-8 weeks (91.9%). Surgical waiting was 3.6 days and hospital stay 4.9 days. CONCLUSIONS: Achilles tendon rupture occurred more frequently in sedentary males between 29-48 years, acute presentation in sports activity, affecting the left tendon. Most were complete ruptures located between 2-5 cm from its insertion, performing simple tenorrhaphy.

INTRODUCCIÓN: La ruptura del tendón de Aquiles es una de las más frecuentes del miembro inferior, el aumento de su incidencia invita a evaluar sus características asociadas que actúan como desencadenantes o como factores de riesgo. MÉTODOS: Estudio descriptivo, retrospectivo, transversal, según datos de historias clínicas, utilizando media, desviación estándar y porcentajes. RESULTADOS: Evaluamos 49 pacientes: varones 83.7%, profesión administrativa 46.9%, 61.2% lesión de deporte (fútbol 38.8%). De las lesiones, 75.5% fueron agudas afectando el tendón izquierdo (57.1%). El síntoma más referido fue dolor súbito (95.9%) y el signo más encontrado fue el de Thompson (89.8%). Se usó ecografía en 42.9%. Recibieron tratamiento por cirugía abierta 95.5% y anestesia espinal 85.1%. Intraoperatoriamente reportaron ruptura completa 95.7%, a 2-5 cm de inserción 66%, 98% de ellas no presentaron lesiones asociadas. La reparación fue tenorrafía simple con punto de Kessler (51%) y vycril como material de sutura (95.7%). Se realizó inmovilización con yeso tibio-pedio (98%) por lapso de seis a ocho semanas (91.9%). La espera quirúrgica fue 3.6 días y la estancia hospitalaria 4.9 días. CONCLUSIONES: La ruptura del tendón de Aquiles se observó con mayor frecuencia en varones sedentarios entre 29-48 años, presentación aguda en actividad deportiva afectando el tendón izquierdo. La mayoría fueron rupturas completas ubicadas entre 2-5 cm de su inserción, realizando tenorrafía simple.

Review: Strategies for enteric methane mitigation in cattle fed tropical forages.

Methane (CH4) is a greenhouse gas (GHG) produced and released by eructation to the atmosphere in large volumes by ruminants. Enteric CH4 contributes significantly to global GHG emissions arising from animal agriculture. It has been contended that tropical grasses produce higher emissions of enteric CH4 than temperate grasses, when they are fed to ruminants. A number of experiments have been performed in respiration chambers and head-boxes to assess the enteric CH4 mitigation potential of foliage and pods of tropical plants, as well as nitrates (NO3-) and vegetable oils in practical rations for cattle. On the basis of individual determinations of enteric CH4 carried out in respiration chambers, the average CH4 yield for cattle fed low-quality tropical grasses (>70% ration DM) was 17.0 g CH4/kg DM intake. Results showed that when foliage and ground pods of tropical trees and shrubs were incorporated in cattle rations, methane yield (g CH4/kg DM intake) was decreased by 10% to 25%, depending on plant species and level of intake of the ration. Incorporation of nitrates and vegetable oils in the ration decreased enteric CH4 yield by ∼6% to ∼20%, respectively. Condensed tannins, saponins and starch contained in foliages, pods and seeds of tropical trees and shrubs, as well as nitrates and vegetable oils, can be fed to cattle to mitigate enteric CH4 emissions under smallholder conditions. Strategies for enteric CH4 mitigation in cattle grazing low-quality tropical forages can effectively increase productivity while decreasing enteric CH4 emissions in absolute terms and per unit of product (e.g. meat, milk), thus reducing the contribution of ruminants to GHG emissions and therefore to climate change.

Clinical isolates of Escherichia coli are resistant both to antibiotics and organotin compounds.

Antibiotic-resistant Escherichia coli are common causative agents of human urinary tract infections. Organotin compounds (OTCs) are man-made chemicals that may affect the renal function of exposed humans and rodents. OTCs are widely recognized as bactericides. However, many environmental and a few clinically relevant bacteria have been found resistant to high concentrations of some OTCs. We examined the susceptibility from 47 E. coli clinical isolates to 12 antibiotics and 5 OTCs. Minimum inhibitory concentrations were determined by the fully automated Sensititre™ ARIS™ 2X system, and E. coli strains were classified as resistant, intermediate resistant, or sensitive, according to the M07-A10 and M100-S26 criteria from the National Committee for Clinical Laboratory Standards. All 47 E. coli strains were susceptible to amikacin but resistant to imipenem and intermediate resistant to ampicillin, cefuroxime, and chloramphenicol. In addition, 26 strains were resistant and 21 intermediate resistant to aztreonam, 24 strains were resistant and 23 intermediate resistant to ceftazidime, 44 strains were intermediate resistant and 3 sensitive to cephalothin, and 43 strains were intermediate resistant and 4 sensitive to ciprofloxacin. Approximately half of the strains were susceptible to cefepime, cefotaxime, and gentamicin. E. coli strains were also found resistant to triphenyltin, tributyltin, dibutyltin, trimethyltin, or dimethyltin at final concentration between 10 µmol/L and 1 mmol/L, during 72-h in vitro culture. However, higher in vitro growth inhibition was induced by these OTCs in the presence of the efflux pump inhibitor carbonyl cyanide-m-chlorophenyl hydrazone, which suggests that efflux pumps contribute to making antibiotic-resistant E. coli also resistant to OTCs.

A pilot study on the foraging behaviour of heifers in intensive silvopastoral and monoculture systems in the tropics.

Intensive silvopastoral systems (ISS) are a sustainable alternative to monoculture systems (MS). The presence of trees and legumes improves animal welfare due to the increased food quality and quantity and the presence of shade while providing a variety of environmental services. As cattle behaviour is greatly affected by environmental conditions, knowledge on the behavioural trade-offs that cattle make to meet their demands while foraging in different grazing systems is important, as this will help us understand the perceived advantages of ISS. This pilot study assessed the behaviour of heifers in an ISS (n=8 heifers) and MS (n=8 heifers) in the Mexican tropics during the dry and rainy seasons, and its relationship with forage availability, mean travelled distance and the temperature humidity index (THI). In both seasons, daily foraging times were longer in the MS than the ISS (P<0.01). The duration of rumination was higher for ISS (P<0.01) and the duration of lying was higher for the dry season (P<0.05). The decrease in foraging times in relation to THI was significantly higher in the ISS than in the MS (mean slope±SE: ISS=-4.64±0.34; MS=-2.34±0.22; t=-14.20, P<0.001). The results suggest that the forage availability and access to shade in the ISS allow cattle to rest longer and increase rumination, whereas cattle in MS spend more time searching for food and foraging at times of the day were the temperatures were higher as a compensatory strategy, which potentially decreases cattle's welfare and production qualities when compared with the ISS. In conclusion, ISS are likely to generate positive behavioural trade-offs that result in better welfare conditions and higher productive potential.

Disease-Free and Overall Survival Among Patients With Operable HER2-Positive Breast Cancer Treated With Sequential vs Concurrent Chemotherapy: The ACOSOG Z1041 (Alliance) Randomized Clinical Trial.

Importance: Pathologic complete response rate (pCR), the primary end point of the ACOSOG (American College of Surgeons Oncology Group) Z1041 (Alliance) trial, and disease-free survival (DFS) and overall survival (OS) in women with operable HER2-positive breast cancer are similar between treatment regimens. Objective: To assess DFS and OS for patients treated with sequential vs concurrent anthracycline plus trastuzumab. Design, Setting, and Participants: Phase 3 randomized clinical trial conducted at 36 centers in the continental United States and Puerto Rico. Women 18 years or older with invasive operable HER2-positive breast cancer were enrolled from September 15, 2007, to December 15, 2011, and randomized to 1 of 2 treatment arms. The analysis data set was locked on October 15, 2017, and analysis was completed on December 15, 2017. Interventions: Patients randomized to arm 1 received 500 mg/m2 of fluorouracil, 75 mg/m2 of epirubicin, and 500 mg/m2 of cyclophosphamide (FEC) every 3 weeks for 12 weeks followed by the combination of 80 mg/m2 of paclitaxel and 2 mg/kg (except initial dose of 4 mg/kg) of trastuzumab weekly for 12 weeks. Patients randomized to arm 2 received the same combination of paclitaxel with trastuzumab weekly for 12 weeks followed by FEC every 3 weeks with weekly trastuzumab for 12 weeks. Women with hormone receptor-positive disease received endocrine therapy, and radiotherapy was delivered at physician discretion. Main Outcomes and Measures: The primary outcomes were DFS and OS and pCR in the breast and nodes. Results: Two hundred eighty-two women with HER2-positive breast cancer were enrolled in the trial, and 2 withdrew consent before treatment. Among the remaining 280 women, the median age was 50 years (range, 28-76 years), 232 (82.9%) were white, 29 (10.3%) were black, 8 (2.9%) were Asian, 4 (1.4%) were American Indian or Alaskan Native, and 7 (2.5%) did not report race/ethnicity. There were 22 disease events in arm 1 and 27 in arm 2. Disease-free survival rates did not differ with respect to treatment arm (stratified log-rank P = .96; stratified hazard ratio [HR] [arm 2 to arm 1], 1.02; 95% CI, 0.56-1.83). Overall survival did not differ with respect to treatment arm (stratified log-rank P = .73; stratified HR [arm 2 to arm 1], 1.17; 95% CI, 0.48-2.88). Conclusions and Relevance: Across a median follow-up of 5.1 years (range, 26 days to 6.2 years), pCR, DFS, and OS did not differ with respect to sequential or concurrent administration of FEC with trastuzumab. Trial Registration: ClinicalTrials.gov identifier: NCT00513292.

Effect of tree foliage supplementation of tropical grass diet on in vitro digestibility and fermentation, microbial biomass synthesis and enteric methane production in ruminants.

The objective of this study was to evaluate the influence of tree foliage species supplemented in ruminant diets based on Pennisetum purpureum on the in vitro digestibility and fermentation, microbial biomass synthesis and enteric methane production. Seven experimental diets were evaluated, including a control treatment based on P. purpureum (PT) grass, and six additional treatments supplemented with 30.0% foliage from Neomillspaughia emargiata (NE), Tabernaemontana amygdalifolia (TA), Caesalpinia gaumeri (CG), Piscidia piscipula (PP), Leucaena leucocephala (LL) and Havardia albicans (HA). A randomised complete block design repeated in two periods (block) was used. The highest gas production (P < 0.05) was recorded in treatments TA and PT (237 and 228 mL g-1, respectively). The highest in vitro digestibility of dry matter (IVDMD) and organic matter (IVOMD) (P < 0.05) was recorded in the control treatment PT (57.9% and 66.1%, respectively). Treatments LL, NE, TA and PP promoted greater microbial biomass synthesis (290, 223, 220 and 213 mg g-1, respectively) (P < 0.05). The proportion of propionic acid also increased in these latter treatments and in treatments CG and HA (P < 0.05). Additionally, treatments LL, PP, NE and TA decreased methane production (25.8, 29.5, 30.6 and 31.8 L kg-1 of digested dry matter, respectively). In conclusion, supplementation with L. leucocephala, P. piscipula, N. emargiata and T. amygdalifolia in ruminant diets based on P. purpureum is one feed alternative that can promote greater efficiency and synthesis of microbial biomass, increase the proportions of propionic and butyric acid and decrease the production of enteric methane by 15.6 to 31.6%.

Effects of quebracho tannin extract on intake, digestibility, rumen fermentation, and methane production in crossbred heifers fed low-quality tropical grass.

The aim of this work was to evaluate the effect of quebracho tannins extract (QTE) on feed intake, dry matter (DM) digestibility, and methane (CH4) emissions in cattle fed low-quality Pennisetum purpureum grass. Five heifers (Bos taurus × Bos indicus) with an average live weight (LW) of 295 ± 19 kg were allotted to five treatments (0, 1, 2, 3, and 4% QTE/kg DM) in a 5 × 5 Latin square design. Intake, digestibility, and total methane emissions (L/day) were recorded for periods of 23 h when cattle were housed in open-circuit respiration chambers. Dry matter intake (DMI), organic matter intake (OMI), dry matter digestibility (DMD), and organic matter digestibility (OMD) were different between treatments with 0 and 4% of QTE/kg DM (P < 0.05). Total volatile fatty acid and the molar proportion of acetate in the rumen was not affected (P < 0.05); however, the molar proportion of propionate increased linearly (P < 0.01) for treatments with 3 and 4% QTE. Total CH4 production decreased linearly (P < 0.01) as QTE increased in the diet, particularly with 3 and 4% concentration. When expressed as DMI and OMI by CH4, production (L/kg) was different between treatments with 0 vs 3 and 4% QTE (P < 0.05). It is concluded that the addition of QTE at 2 or 3% of dry matter ration can decrease methane production up to 29 and 41%, respectively, without significantly compromising feed intake and nutrients digestibility.

Recommendations for the prevention and diagnosis of asthma in children: Evidence from international guidelines adapted for Mexico.

BACKGROUND: With the availability of high-quality asthma guidelines worldwide, one possible approach of developing a valid guideline, without re-working the evidence, already analysed by major guidelines, is the ADAPTE approach, as was used for the development of National Guidelines on asthma. METHODS: The guidelines development group (GDG) covered a broad range of experts from medical specialities, primary care physicians and methodologists. The core group of the GDG searched the literature for asthma guidelines 2005 onward, and analysed the 11 best guidelines with AGREE-II to select three mother guidelines. Key clinical questions were formulated covering each step of the asthma management. RESULTS: The selected mother guidelines are British Thoracic Society (BTS), GINA and GEMA 2015. Responses to the questions were formulated according to the evidence in the mother guidelines. Recommendations or suggestions were made for asthma treatment in Mexico by the core group, and adjusted during several rounds of a Delphi process, taking into account: 1. Evidence; 2. Safety; 3. Cost; 4. Patient preference - all these set against the background of the local reality. Here the detailed analysis of the evidence present in BTS/GINA/GEMA sections on prevention and diagnosis in paediatric asthma are presented for three age-groups: children with asthma ≤5 years, 6-11 years and ≥12 years. CONCLUSIONS: For the prevention and diagnosis sections, applying the AGREE-II method is useful to develop a scientifically-sustained document, adjusted to the local reality per country, as is the Mexican Guideline on Asthma.

Effects of feeding ground pods of Enterolobium cyclocarpum Jacq. Griseb on dry matter intake, rumen fermentation, and enteric methane production by Pelibuey sheep fed tropical grass.

An experiment was carried out to determine the effect of supplementing ground pods of Enterolobium cyclocarpum in a basal ration of Pennisetum purpureum grass on feed intake, rumen volatile fatty acids (VFAs), and protozoa and methane (CH4) production by hair sheep. Four male sheep (Pelibuey × Katahdin) with a mean live weight of 27.0 kg (SD ± 0.5) were supplemented with 0.00, 0.15, 0.30, and 0.45 kg of dry matter (DM) of E. cyclocarpum pods daily; equivalent to 0.00, 4.35, 8.70, and 13.05 g of crude saponins, respectively. Dry matter intake (DMI), organic matter intake (OMI), and molar proportions of propionic acid increased linearly (P < 0.05) as pods of E. cyclocarpum in the ration were increased. Higher intakes of DM and OM were found when lambs were fed 0.45 kg DM per day of E. cyclocarpum, and the highest proportion of propionic acid (0.21 and 0.22, respectively) was obtained with 0.15 and 0.30 kg of DM per lamb of E. cyclocarpum, while apparent digestibility of neutral detergent fiber (NDF) and molar proportion of acetic acid were reduced (P < 0.05). Rumen CH4 production decreased (P < 0.05) when 0.30 and 0.45 kg of DM/lamb/day of E. cyclocarpum were fed (21.8 and 25.3 L CH4/lamb/day, respectively). These results suggest that to improve the feeding of sheep fed tropical grass, it is advisable to supplement the basal ration with up to 0.30 kg DM of E. cyclocarpum pods.

Claudin-6 enhances cell invasiveness through claudin-1 in AGS human adenocarcinoma gastric cancer cells.

Claudins participate in tissue barrier function. The loss of this barrier is associated to metalloproteases-related extracellular matrix and basal membranes degradation. Claudin-1 is a pro-MMP-2 activator and claudin-6 transfected AGS (AGS-Cld6) cells are highly invasive. Our aim was to determine if claudin-6 was direct or indirectly associated with MMP-2 activation and cell invasiveness. Cytofluorometry, cell fractioning, immunoprecipitation, gelatin-zymography, cell migration and invasiveness assays were performed, claudin-2, -6, -7 and -9 transfected AGS cells, anti-MMP-2, -9 and -14, anti-claudins specific antibodies and claudin-1 small interfering RNA were used. The results showed a significant (p<0.001) overexpression of claudin-1 in AGS-Cld6 cell membranes. A strong MMP-2 activity was identified in culture supernatants of AGS-Cld6. Claudin-1 co-localized with MMP-2 and MMP-14; interestingly a significant increase in cell membrane and cytosol MMP-14 expression was detected in AGS-Cld6 cells (p<0.05). Silencing of claudin-1 in AGS-Cld6 cells showed a 60% MMP-2 activity decrease in culture supernatants and a significant decrease (p<0.05) in cell migration and invasiveness. Our results suggest that claudin-6 induces MMP-2 activation through claudin-1 membrane expression, which in turn promotes cell migration and invasiveness.

Evidences of Polymorphism Associated with Circadian System and Risk of Pathologies: A Review of the Literature.

The circadian system is a supraphysiological system that modulates different biological functions such as metabolism, sleep-wake, cellular proliferation, and body temperature. Different chronodisruptors have been identified, such as shift work, feeding time, long days, and stress. The environmental changes and our modern lifestyle can alter the circadian system and increase the risk of developing pathologies such as cancer, preeclampsia, diabetes, and mood disorder. This system is organized by transcriptional/tranductional feedback loops of clock genes Clock, Bmal1, Per1-3, and Cry1-2. How molecular components of the clock are able to influence the development of diseases and their risk relation with genetic components of polymorphism of clock genes is unknown. This research describes different genetic variations in the population and how these are associated with risk of cancer, metabolic diseases such as diabetes, obesity, and dyslipidemias, and also mood disorders such as depression, bipolar disease, excessive alcohol intake, and infertility. Finally, these findings will need to be implemented and evaluated at the level of genetic interaction and how the environment factors trigger the expression of these pathologies will be examined.

Social behaviour of cattle in tropical silvopastoral and monoculture systems.

Silvopastoral systems can be a good alternative for sustainable livestock production because they can provide ecosystem services and improve animal welfare. Most farm animals live in groups and the social organization and interactions between individuals have an impact on their welfare. Therefore, the objective of this study was to describe and compare the social behaviour of cattle (Bos indicus×Bos taurus) in a silvopastoral system based on a high density of leucaena (Leucaena leucocephala) combined with guinea grass (Megathyrsus maximus), star grass (Cynodon nlemfuensis) and some trees; with a monoculture system with C. nlemfuensis, in the region of Merida, Yucatán. Eight heifers in each system were observed from 0730 to 1530 h each day for 12 consecutive days during the dry season and 12 consecutive days during the rainy season. The animals followed a rotation between three paddocks, remaining 4 days in each paddock. The vegetation was characterized in the paddocks of the silvopastoral system to estimate the average percentage of shade provided. To make a comparison between systems, we used a t test with group dispersion, and Mann-Whitney tests with the frequency of affiliative and agonistic behaviours. We assessed differences in linearity and stability of dominance hierarchies using Landau's index and Dietz R-test, respectively. The distance of cows with respect to the centroid of the group was shorter, and non-agonistic behaviours were 62% more frequent in the intensive silvopastoral system than in the monoculture one. Heifers in the silvopastoral system had a more linear and non-random dominance hierarchy in both seasons (dry season: h'=0.964; rainy season: h'=0.988), than heifers in the monoculture system (dry season: h'=0.571, rainy season: h'=0.536). The dominance hierarchy in the silvopastoral system was more stable between seasons (R-test=0.779) than in the monoculture system (R-test=0.224). Our results provide the first evidence that heifers in the silvopastoral system maintain more stable social hierarchies and express more sociopositive behaviours, suggesting that animal welfare was enhanced.

Circadian System and Melatonin Hormone: Risk Factors for Complications during Pregnancy.

Pregnancy is a complex and well-regulated temporal event in which several steps are finely orchestrated including implantation, decidualization, placentation, and partum and any temporary alteration has serious effects on fetal and maternal health. Interestingly, alterations of circadian rhythms (i.e., shiftwork) have been correlated with increased risk of preterm delivery, intrauterine growth restriction, and preeclampsia. In the last few years evidence is accumulating that the placenta may have a functional circadian system and express the clock genes Bmal1, Per1-2, and Clock. On the other hand, there is evidence that the human placenta synthesizes melatonin, hormone involved in the regulation of the circadian system in other tissues. Moreover, is unknown the role of this local production of melatonin and whether this production have a circadian pattern. Available information indicates that melatonin induces in placenta the expression of antioxidant enzymes catalase and superoxide dismutase, prevents the injury produced by oxidative stress, and inhibits the expression of vascular endothelial growth factor (VEGF) a gene that in other tissues is controlled by clock genes. In this review we aim to analyze available information regarding clock genes and clock genes controlled genes such as VEGF and the possible role of melatonin synthesis in the placenta.

Real life study of three years omalizumab in patients with difficult-to-control asthma.

BACKGROUND: Even though there are multiple options for the treatment of asthma, there still exists a fair group of patients with difficult-to-control asthma. We describe for the first time the real-world effects of three-year omalizumab treatment on patients with difficult-to-control asthma, seen in a social security hospital in a Latin American country. METHODS: Difficult-to-control asthmatic patients from the out-patient clinic of a regional hospital were recruited to receive a three-year omalizumab course. Efficacy parameters were asthma control test (ACT) score; FEV1; daily beclomethasone maintenance dose; and unplanned visits for asthma exacerbations (emergency room (ER), hospitalisations, intensive care). RESULTS: 52 patients were recruited, 47 completed the three-year treatment (42 female, 15-67 years, mean age 43.5). Comparing efficacy parameters of the year before omalizumab with the 3rd year of omalizumab: mean ACT improved from 12.4 to 20.5, mean FEV1 from 66.3% (standard deviation (SD) 19.1%) to 88.4% (SD 16.2%) of predicted, while mean beclomethasone dose reduced from 1750 to 766 mcg/day and there was a significant reduction in patients experiencing ER visits (from 95% to 19%, p<0.0001), hospitalisation (38% to 2%, p<0.0001) and intensive care (4% to 0, NS). Five patients discontinued omalizumab, two because of an adverse event (anaphylaxis, severe headache, both resolved without sequelae). CONCLUSION: Omalizumab improved most clinical parameters of Mexican patients with difficult-to-control asthma. Especially the rates of ER visits and hospitalisation were significantly reduced, thus reducing costs. Omalizumab was generally well tolerated.

Fluorouracil, epirubicin, and cyclophosphamide (FEC-75) followed by paclitaxel plus trastuzumab versus paclitaxel plus trastuzumab followed by FEC-75 plus trastuzumab as neoadjuvant treatment for patients with HER2-positive breast cancer (Z1041): a randomised, controlled, phase 3 trial.

BACKGROUND: Neoadjuvant chemotherapy with trastuzumab for patients with HER2-positive breast cancer can produce a pathological complete response in the breast in 30-65% of patients. We investigated the effect of the timing of trastuzumab administration with anthracycline and taxane neoadjuvant chemotherapy. METHODS: This randomised trial was done at 36 centres in the USA and Puerto Rico. Women with operable HER2-positive invasive breast cancer were randomly assigned (1:1) with a biased coin minimisation algorithm, stratified for age, tumour size, and hormone receptor status. Neither patients nor investigators (except for a cardiac safety review panel) were masked to treatment assignment. Patients randomly assigned to sequential treatment received fluorouracil 500 mg/m(2), epirubicin 75 mg/m(2), and cyclophosphamide 500 mg/m(2) (FEC-75) on day 1 of a 21-day cycle for four cycles followed by paclitaxel 80 mg/m(2) and trastuzumab 2 mg/kg (after a 4 mg/kg loading dose) once per week for 12 weeks, while those randomly assigned to the concurrent treatment group received paclitaxel and trastuzumab once per week for 12 weeks followed by four cycles of FEC-75 (on day 1 of each 21-day cycle) and once-weekly trastuzumab, in the same doses as the sequential group. Surgery, including evaluation of the axilla, was done within 6 weeks of completion of neoadjuvant treatment. The primary outcome was the percentage of patients who had a pathological complete response in the intention-to-treat population. The study is registered with ClinicalTrials.gov, number NCT00513292. FINDINGS: From Sept 15, 2007, to Dec 15, 2011, 282 women were enrolled (140 in the sequential group, 142 in the concurrent group). Two patients in the sequential group withdrew consent before starting treatment. 78 of 138 (56·5%, 95% CI 47·8-64·9) patients who received sequential treatment had a pathological complete response in the breast versus 77 of 142 (54·2%, 95% CI 45·7-62·6) who received concurrent treatment (difference 2·3%, 95% CI -9·3 to 13·9). No treatment-related deaths occurred. The most common severe toxic effects were neutropenia (35 [25·3%] of 138 patients in the sequential group vs 45 [31·7%] of 142 patients in the concurrent group) and fatigue (six [4·3%] vs 12 [8·5%]). Left ventricular ejection fraction dropped below the institutional lower limit of normal at week 12 in one (0·8%) of 130 patients who received sequential treatment and four (2·9%) of 137 patients who received concurrent treatment; by week 24, it had dropped below this limit in nine (7·1%) of 126 patients and in six (4·6%) of 130 patients, respectively. INTERPRETATION: Concurrent administration of trastuzumab with anthracyclines offers no additional benefit and is not warranted. FUNDING: US National Cancer Institute.

New eastern Pacific Ocean records of Hydrolagus melanophasma, with annotations of a juvenile female.

Two new records of Hydrolagus melanophasma, one juvenile female from off the central Mexican coast and one adult male from off the coast of Ecuador, confirm the presence of this species throughout its known range in the eastern Pacific Ocean, from southern California, U.S.A., to Valdivia, Chile. This report gives a description and comparison of proportional measurements, head shape and colouration for juvenile and adult H. melanophasma. A taxonomic key to distinguish the eastern Pacific Ocean species of Hydrolagus is included.