The inability to belch: a neglected disease in the era of high-resolution esophageal manometry.

Retrograde upper esophageal sphincter dysfunction (R-UESD) is characterized by the inability to belch. Evidence of using high-resolution manometry (HRM) in diagnosing R-UESD has emerged in recent years. We describe the clinical picture and HRM patterns of two patients with R-UESD. Case 1: A 23-year-old female presented with a two-year complaint of inability to belch. We performed HRM with a belch provocation test for which the patient drank 500 ml of carbonated water. The study revealed increased esophageal pressure, an absence of UES relaxation and secondary peristalsis once the patient mentioned the need to belch. Case 2: A 21-year-old male presented to our medical office with a history of an incapacity to belch during the last three years. We performed HRM with a belch provocation test. During the study, he reported an incapacity to belch and his symptoms coincided with increased esophageal pressure, an absence of UES relaxation, and secondary peristalsis. Retrograde upper esophageal sphincter dysfunction is a rare condition characterized by a lack of UES relaxation during esophageal distension. The incapacity to belch is the hallmark of the disease. We encourage the use of HRM, looking for an increase in esophageal pressure to the level of gastric pressure, failure of UES relaxation with consequently no venting of air across the UES, and secondary peristalsis. In conclusion, diverse R-UESD clinical presentations represent a diagnostic challenge for physicians. This case series highlights the need to actively search for typical HRM findings when encountering patients referring an incapacity to belch.

High-Resolution Esophageal Manometry in Myasthenia Gravis.

Myasthenia gravis (MG) is an autoimmune disease that affects the postsynaptic membrane at the neuromuscular junction. In MG, antibodies bind to acetylcholine receptors inducing muscle weakness. The weakness typically increases with exercise and repetitive muscle use. Improvement of muscular weakness after rest and/or administration of anticholinesterase drugs (edrophonium) are characteristic of MG. We report a patient with unexplained dysphagia, dysphonia, and dysarthria, whose diagnosis was suggested by high-resolution esophageal motility and edrophonium infusion. We highlight the importance of dysphagia as presenting or dominant symptom in MG and review the esophageal motility findings in this rare, but treatable disorder.

El uso del portafolio para el pregrado en Ciencias Médicas / The Usage of the Portfolio for the Undergraduate Level in Medical Sciences

En los últimos años ha surgido la utilización del portafolio o carpeta como herramienta en los procesos formativos, al adoptarse una nueva y renovada visión sobre la enseñanza, el aprendizaje desarrollador y la evaluación educativa. El objetivo de este artículo es evaluar la competencia del uso del portafolio en el pregrado de Ciencias Médicas. Se demostró que en las universidades donde se utilizaba el portafolio, este favorecía el desarrollo profesional de los estudiantes, lo que propiciaba el dominio de competencias clínicas, y el desarrollo de actitudes como la responsabilidad y la sistematicidad; implicaba la documentación del aprendizaje y la recopilación de evidencias; y permitía la retroalimentación del desempeño del alumno. Aunque en los escenarios cubanos no se encontraron evidencias del empleo del portafolio, ya existen experiencias en varias latitudes que dan cuenta de los beneficios potenciales que esta herramienta está generando en el ámbito universitario, por lo que puede ser una buena opción o alternativa de evaluación(AU)

In recent years, the usage of the portfolio or folder as a tool in training processes has emerged as a new and renewed vision has been adopted regarding teaching, developing learning and educational evaluation. The objective of this article is to assess the competence associated to the usage of the portfolio in the undergraduate level of medical sciences. It was shown that, in the universities where the portfolio was used, it favored the students' professional development, which led to the mastery of clinical skills and the development of attitudes such as responsibility and systematicity; it involved the documentation of learning and the collection of evidence; and allowed feedback on student performance. Although there was no evidence of the usage of the portfolio in Cuban settings, there are already experiences in several sites that account for the potential benefits that this tool is generating in the university context, so it can be a good option or alternative for evaluation(AU)

Totally endoscopic implant to effect a gastric bypass: 12-month safety and efficacy outcomes.

BACKGROUND: Only a small percentage of candidates for bariatric surgery ever undergo a procedure for weight loss. Devices duplicating key effects of bariatric surgeries with removable, fully trans-oral implants could extend their benefits to patients unwilling to undergo anatomy-altering abdominal surgeries. METHODS: Thirty-two obese subjects (mean BMI: 42.3) were enrolled in a prospective, multicenter, single-arm, feasibility trial of the first fully trans-oral endoscopic gastrointestinal bypass device. The device is a cuff attached to the distal esophagus by transmural anchors and connected to a 120-cm sleeve diverting undigested nutrients to the jejunum. Bodyweight, vital signs, adverse events, medications, HbA1c, fasting glucose, and lipids were collected at baseline and follow-up visits. Device status was endoscopically assessed every 6 months. RESULTS: The fully trans-oral procedure was successful in all subjects without intraoperative adverse events or postoperative infections. Twenty-eight of 32 subjects (88%) remained implanted with continuing follow-up beyond their 12-month visit. At 12 months, the 32 subjects had lost an average of 44.8% of excess body weight, 17.6% of total body weight, 20.8 kg, and 7.5 BMI points. Weight loss depended on capture of ingesta by the esophageal cuff, with 18 of 32 subjects without visible gaps around their cuffs at the 6 month endoscopy having significantly greater EWL (53.6 vs. 33.4% in the remaining subjects, p < 0.002). Mean HbA1c and fasting glucose declined by 1.1% points and 29 mg/dL in type 2 diabetic subjects, 80% of whom had remission of their diabetes at 12 months. CONCLUSION: This study demonstrates the feasibility, safety, and efficacy of a fully trans-oral gastrointestinal bypass implant. This purely endoscopic device may provide a valuable addition to the armamentarium of treatment available for the management of morbid obesity.

Cooperative Behavior of Fluoroquinolone Combinations against Escherichia coli and Staphylococcus aureus.

The effects of different combinations of ciprofloxacin (CIP) and norfloxacin (NOR) against Escherichia coli and Staphylococcus aureus were studied using checkerboard, fractional inhibitory concentration (FIC) and time-kill analysis methods. Results obtained by the checkerboard method showed that the more effectives combinations against Escherichia coli were 0.0009 µg/mL CIP+0.0312 µg/mL NOR and 0.0037 µg/mL CIP+0.0075 µg/mL NOR with a FIC index of 0.62. For Staphylococcus aureus, the combination of 0.0625 µg/mL CIP+0.2500 µg/mL NOR showed a synergistic effect, with a FIC index of 0.50. The results of the time-kill method demonstrated either indifference or additivity of the combinations 0.0009 µg/mL CIP+0.0312 µg/mL NOR, 0.0018 µg/mL CIP+0.0312 µg/mL NOR, 0.0037 µg/mL CIP+0.0075 µg/mL NOR and 0.0037 µg/mL CIP+0.0156 µg/mL NOR at 24 h against E. coli. The combination 0.0037 µg/mL CIP+0.0312 µg/mL NOR showed synergistic activity. All the analyzed combinations evidenced bactericidal effects at 4 h. The combinations 0.0625 µg/mL CIP+0.2500 µg/mL NOR and 0.0625 µg/mL CIP+0.0625 µg/mL NOR showed indifference or additivity against S. aureus. None of them generated bactericidal effect at 4 h. Moreover, this last equimolecular combination (equivalent to 1/4 minimum inhibitory concentration (MIC) CIP+1/16 MIC NOR) generated higher reduction of nitro blue tetrazolium than drugs alone. By another way, combinations not equimolecular of CIP and NOR assayed, generated less levels of reactive oxygen species (ROS) than the components alone.

Hybrid technique for removal of eroded adjustable gastric band.

BACKGROUND: Intragastric migration is a late and rare postsurgical complication in patients with gastric band placement. Gastric band erosion rate has previously been described to be 1.46%. In this report, we present the case of a 43-y-old male with gastric band erosion undergoing a laparoendoscopic retrieval of the gastric band, due to intragastric migration. METHOD: A hybrid procedure was performed to retrieve the gastric band. A laparoscopic approach was initially used to extract the connecting tube. Endoscopy was then performed to cut the gastric band with a specific cutter system and was subsequently extracted transorally. RESULTS: The postoperative course was uneventful. Clear liquids were started on day 1, and the patient was discharged on day 2. DISCUSSION: The purpose of this study was to describe a hybrid technique for the removal of an eroded gastric band, as a safe and feasible option in patients with band erosions. CONCLUSION: The laparoscopic approach enables safe extraction of the connecting tube, while endoscopy allows extraction of the band without creating a large incision in the stomach.

Dose and side effects of sublingual misoprostol for treatment of postpartum hemorrhage: what difference do they make?

BACKGROUND: Shivering and fever are common side effects of misoprostol. An unexpectedly high rate of fever above 40°C was documented among Ecuadorian women given treatment with 800mcg of sublingual misoprostol to manage postpartum hemorrhage (PPH) (36%). Much lower rates have been reported elsewhere (0-9%). METHODS: From February to July 2010, an open-label pilot study was conducted in Quito, Ecuador to determine whether a lower dose--600mcg sublingual misoprostol--would result in a lower incidence of high fever (≥40°C). Rates of shivering and fever with 600mcg sublingual regimen were compared to previously documented rates in Ecuador following PPH treatment with 800mcg sublingual misoprostol. RESULTS: The 600mcg dose resulted in a 55% lower rate of high fever compared with the 800mcg regimen (8/50; 16% vs. 58/163; 36%; relative risk 0.45 95% CI 0.23-0.88). Only one woman had severe shivering following the 600mcg dose compared with 19 women in the 800mcg cohort (2% vs. 12%; relative risk 0.17 (0.02-1.25)). No cases of delirium/altered sensorium were reported with the 600mcg dose and women's assessment of severity/tolerability of shivering and fever was better with the lower dose. CONCLUSIONS: 600mcg sublingual misoprostol was found to decrease the occurrence of high fever among Ecuadorian women when given to treat PPH. This study however was not powered to examine the efficacy of this treatment regimen and cannot be recommended at this time. Future research is needed to confirm whether other populations, outside of Quito, Ecuador, experience unusually high rates of elevated body temperature following sublingual administration of misoprostol for treatment of PPH. If indeed similar trends are found elsewhere, larger trials to confirm the efficacy of lower dosages may be justified. TRIAL REGISTRATION: Clinical trials.gov, Registry No. NCT01080846.

Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial.

BACKGROUND: Oxytocin, the standard of care for treatment of post-partum haemorrhage, is not available in all settings because of refrigeration requirements and the need for intravenous administration. Misoprostol, an effective uterotonic agent with several advantages for resource-poor settings, has been investigated as an alternative. This trial established whether sublingual misoprostol was similarly efficacious to intravenous oxytocin for treatment of post-partum haemorrhage in women not exposed to oxytocin during labour. METHODS: In this double-blind, non-inferiority trial, 9348 women not exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at four hospitals in Ecuador, Egypt, and Vietnam (one secondary-level and three tertiary-level facilities). 978 (10%) women were diagnosed with primary post-partum haemorrhage and were randomly assigned to receive 800 microg misoprostol (n=488) or 40 IU intravenous oxytocin (n=490). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97.5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. FINDINGS: All randomly assigned participants were analysed. Active bleeding was controlled within 20 min with study treatment alone for 440 (90%) women given misoprostol and 468 (96%) given oxytocin (relative risk [RR] 0.94, 95% CI 0.91-0.98; crude difference 5.3%, 95% CI 2.6-8.6). Additional blood loss of 300 mL or greater after treatment occurred for 147 (30%) of women receiving misoprostol and 83 (17%) receiving oxytocin (RR 1.78, 95% CI 1.40-2.26). Shivering (229 [47%] vs 82 [17%]; RR 2.80, 95% CI 2.25-3.49) and fever (217 [44%] vs 27 [6%]; 8.07, 5.52-11.8) were significantly more common with misoprostol than with oxytocin. No women had hysterectomies or died. INTERPRETATION: In settings in which use of oxytocin is not feasible, misoprostol might be a suitable first-line treatment alternative for post-partum haemorrhage.

New biosensing platforms based on the layer-by-layer self-assembling of polyelectrolytes on Nafion/carbon nanotubes-coated glassy carbon electrodes.

We are proposing for the first time the use of a Nafion/multi-walled carbon nanotubes dispersion deposited on glassy carbon electrodes (GCE) as a new platform for developing enzymatic biosensors based on the self-assembling of a chitosan derivative and different oxidases. The electrodes are obtained by deposition of a layer of Nafion/multi-wall carbon nanotubes dispersion on glassy carbon electrodes, followed by the adsorption of a chitosan derivative as polycation and glucose oxidase, l-aminoacid oxidase or polyphenol oxidase, as polyanions and biorecognition elements. The optimum configuration for glucose biosensors has allowed a highly sensitive (sensitivity=(0.28+/-0.02)muAmM(-1), r=0.997), fast (4s in reaching the maximum response), and highly selective (0% interference of ascorbic acid and uric acid at maximum physiological levels) glucose quantification at 0.700V with detection and quantification limits of 0.035 and 0.107mM, respectively. The repetitivity for 10 measurements was 5.5%, while the reproducibility was 8.4% for eight electrodes. The potentiality of the new platform was clearly demonstrated by using the carbon nanotubes/Nafion layer as a platform for the self-assembling of l-aminoacid oxidase and polyphenol oxidase. Therefore, the platform we are proposing here, that combines the advantages of nanostructured materials with those of the layer-by-layer self-assembling of polyelectrolytes, opens the doors to new and exciting possibilities for the development of enzymatic and affinity biosensors using different transdution modes.

Glucose biosensor based on the layer-by-layer self-assembling of glucose oxidase and chitosan derivatives on a thiolated gold surface.

The work proposed here deals with the design and characterization of biorecognition layers for the amperometric glucose determination based on the self-assembling of new chitosan derivatives, Nafion and glucose oxidase onto thiolated gold electrodes. The supramolecular multistructure is obtained by deposition of a layer of chitosan derivative (quaternized or hydrophobic) onto the gold surface modified with the sodium salt of 3-mercapto-1-propansulfonic acid, followed by the deposition of a layer of Nafion (as anti-interference barrier) and by the alternate deposition of the chitosan derivative and glucose oxidase (as biocatalytic layer). The influence of the deposition time and concentration of polyelectrolytes, organization and number of layers, and nature of the chitosan derivative on the sensitivity and selectivity of the bioelectrode is examined and optimized in order to obtain a rational design of the biosensor. The system is studied electrochemically from the oxidation at 0.700 V of the hydrogen peroxide enzymatically generated using gold as substrate, and spectrophotometrically from the protein absorption at 277 nm using quartz as substrate. The selected biosensor containing five quaternized chitosan/glucose oxidase bilayers exhibits very good analytical performance with a sensitive ((4.9+/-0.2) x 10(2) nA mM(-1)) and highly selective response (0% interference for maximum physiological levels of ascorbic acid and uric acid), demonstrating that the alternate electrostatic adsorption of conveniently selected polyelectrolytes allows noticeable improvements in the selectivity and sensitivity of a biosensor.

[Utility of rabeprazole as a diagnostic test in non-erosive gastroesophageal reflux disease]. / Utilidad del rabeprazol como prueba diagnóstica en la enfermedad por reflujo gastroesofágico no erosiva.

BACKGROUND: Proton pump inhibitor test (PPIt) has been shown adequate diagnostic usefulness and cost-effectiveness in the evaluation of patients with gastroesophageal reflux disease (GERD). However, comparative studies of PPIt with 24 hr esophageal pH-metry (24-pH) in non erosive GERD (NERD) are scarce and the utility of rabeprazole as a PPIt has not been evaluated. OBJECTIVE: To investigate the diagnostic utility of rabeprazole test in patients with NERD. MATERIAL AND METHODS: An open label trial was performed, and NERD patients with heartburn at least 3 times per week were included. Symptomatic evaluation before, during and after rabeprazole 20 mg bid for 7 days was performed. All patients underwent 24-pH before treatment with rabeprazole. Patients were classified in three groups: 1) abnormal pH, 2) normal pH and symptom index (SI) positive, and 3) normal pH and SI negative. A positive rabrepazole test was considered when symptoms improvement was higher than 50% at the end of the test. Sensitivity, specificity, negative predictive value, positive predictive value and positive likelihood ratio were calculated considering the 24-pH as gold standard. RESULTS: Sixty four patients, 47 (72%) female were studied. Forty four percent of the patients had normal pH, 29% with SI positive and 71% with SI negative. Sensitivity, specificity, positive predictive value, negative predictive value and positive likelihood ratio were 82%, 47%, 78%, 52% and 1.406 respectively. No adverse events were reported. CONCLUSION: PPI test with rabeprazole 20 mg bid for 7 days is a simple and useful test in the diagnostic approach of patients with NERD.

Trastornos motores del músculo liso del esófago / Motor disorders of the smooth muscle of the esophagus

Los trastornos motores del esófago, son problemas que se manifiestan predominantemente con disfagia y/o dolor torácico; llegan a se incapacitaciones y graves. Se clasifican en dos grandes grupos: primarios cuando se presentan sin relación a alguna otra enfermedad y secundarios, cuando son consecuancia de la efección del esófago por una enfermedad sistémica. El diagnóstico y caracterización de los trastornos motores se realizan mediante manometría. En el presente trabajo se exponen algunos aspectos clínicos relevantes y los criterios de diagnóstico manométricos actuales, se hace referencia a algunas variedades de tratamiento