Early Enteral Nutrition (within 48 h) for Patients with Sepsis or Septic Shock: A Systematic Review and Meta-Analysis.

OBJECTIVE: Medical nutrition therapy provides the opportunity to compensate for muscle wasting and immune response activation during stress and trauma. The objective of this systematic review is to assess the safety and effectiveness of early enteral nutrition (EEN) in adults with sepsis or septic shock. METHODS: The MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, and ICTRP tools were searched from inception until July 2023. Conference proceedings, the reference lists of included studies, and expert content were queried to identify additional publications. Two review authors completed the study selection, data extraction, and risk of bias assessment; disagreements were resolved through discussion. Inclusion criteria were randomized controlled trials (RCTs) and non-randomized studies (NRSs) comparing the administration of EEN with no or delayed enteral nutrition (DEE) in adult populations with sepsis or septic shock. RESULTS: Five RCTs (n = 442 participants) and ten NRSs (n = 3724 participants) were included. Low-certainty evidence from RCTs and NRSs suggests that patients receiving EEN could require fewer days of mechanical ventilation (MD -2.65; 95% CI, -4.44-0.86; and MD -2.94; 95% CI, -3.64--2.23, respectively) and may show lower SOFA scores during follow-up (MD -1.64 points; 95% CI, -2.60--0.68; and MD -1.08 points; 95% CI, -1.90--0.26, respectively), albeit with an increased frequency of diarrhea episodes (OR 2.23, 95% CI 1.115-4.34). Even though the patients with EEN show a lower in-hospital mortality rate both in RCTs (OR 0.69; 95% CI, 0.39-1.23) and NRSs (OR 0.89; 95% CI, 0.69-1.13), this difference does not achieve statistical significance. There were no apparent differences for other outcomes. CONCLUSIONS: Low-quality evidence suggests that EEN may be a safe and effective intervention for the management of critically ill patients with sepsis or septic shock.

Management and Clinical Outcomes of Breast Cancer in Women Diagnosed with Hereditary Cancer Syndromes in a Clinic-Based Sample from Colombia.

This study aimed to investigate prognosis and survival differences in 82 breast cancer patients with germline pathogenic/likely pathogenic variants (PVs) treated and followed at the Breast Unit of the Instituto Nacional de Cancerología, Colombia (INC-C) between 2018 and 2021. Median age at diagnosis was 46 years, with 62.2% presenting locally advanced tumors, 47.6% histological grade 3, and 35.4% with triple-negative breast cancer (TNBC) subtype. Most carriers, 74.4% (61/82), had PVs in known breast cancer susceptibility genes (i.e., "associated gene carriers" group, considered inherited breast cancer cases): BRCA2 (30), BRCA1 (14), BARD1 (4), RAD51D (3), TP53 (2), PALB2 (2), ATM (2), CHEK2 (1), RAD51C (1), NF1 (1), and PTEN (1). BRCA1-2 represented 53.7%, and homologous recombination DNA damage repair (HR-DDR) genes associated with breast cancer risk accounted for 15.9%. Patients with PVs in non-breast-cancer risk genes were combined in a different category (21/82; 25.6%) (i.e., "non-associated gene carriers" group, considered other breast cancer cases). Median follow-up was 38.1 months, and 24% experienced recurrence, with 90% being distant. The 5-year Disease-Free Survival (DFS) for inherited breast cancer cases was 66.5%, and for other breast cancer cases it was 88.2%. In particular, for carriers of PVs in the BRCA2 gene, it was 37.6%. The 5-year Overall Survival (OS) rates ranged from 68.8% for those with PVs in BRCA2 to 100% for those with PVs in other HR-DDR genes. Further studies are crucial for understanding tumor behavior and therapy response differences among Colombian breast cancer patients with germline PVs.

Acute presentation of Wunderlich syndrome in a pregnant woman treated with supra-selective cannulation of renal segmental arteries and nephrectomy: A case report.

Wunderlich syndrome is characterized by the presence of abdominal pain, hematuria, and hypovolemic shock. We report a rare case of a 25-year-old pregnant woman, who came to the emergency department due to the sudden onset of low back pain and diaphoresis. The patient, during medical evaluation, experienced an altered state of consciousness. Diagnosed with hypovolemic shock, she was admitted to the operating room, where examination of the abdominal cavity revealed a left retroperitoneal hematoma. Damage control surgery was performed, but given the postoperative clinical deterioration, computerized tomography angiography of the abdomen was performed, showing a mass-like lesion arising from the upper pole of the left kidney, consistent with Wunderlich syndrome. Left nephrectomy was the definitive treatment for the 10-cm renal angiomyolipoma. Since Wunderlich syndrome is a potentially lethal entity, CT is usually the preferred diagnostic approach, and supra-selective vascular embolization is the first-line treatment.

Definitive pelvic radiotherapy for patients with newly diagnosed stage IVB cervical cancer: a systematic review.

OBJECTIVE: The objective of this systematic review was to assess the oncologic outcomes of patients with International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IVB cervical cancer receiving definitive pelvic radiotherapy compared with systemic chemotherapy (with or without palliative pelvic radiotherapy). METHODS: This study was registered in PROSPERO (registration number CRD42022333433). A systematic literature review was conducted following the MOOSE checklist. MEDLINE (through Ovid), Embase, and Cochrane Central Register of Controlled Trials were searched from inception until August 2022. The inclusion criteria were patients with metastatic FIGO 2018 stage IVB cervical cancer, a histologic subtype of squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma that received definitive pelvic radiotherapy (≥45 Gy) as part of management compared with systemic chemotherapy with or without palliative (30 Gy) pelvic radiotherapy. Randomized controlled trials and observational studies with two arms of comparison were considered. RESULTS: The search identified 4653 articles; 26 studies were considered potentially eligible after removing duplicates, and 8 met the selection criteria. In total, 2424 patients were included. There were 1357 and 1067 patients in the definitive radiotherapy and chemotherapy groups, respectively. All included studies were retrospective cohort studies, and two were database population studies. The median overall survival reported in seven studies for the definitive radiotherapy arm versus systemic chemotherapy groups were 63.7 months versus 18.4 months (p<0.01), 14 months versus 16 months (p value not reported), 17.6 months versus 10.6 months (p<0.01), 32 months versus 24 months (p<0.01), 17.3 months versus 10 months (p<0.01), and 41.6 months versus 17.6 months (p<0.01), and not reached versus 19 months (p=0.13) respectively, favoring the groups that received definitive pelvic radiotherapy. The high clinical heterogeneity precluded the performance of meta-analysis, and all studies were at serious risk of bias. CONCLUSIONS: Definitive pelvic radiotherapy as part of treatment in patients with stage IVB cervical cancer may improve oncologic outcomes compared with systemic chemotherapy (with or without palliative radiotherapy); however, this is based on low-quality data. Prospective evaluation would be ideal before the adoption of this intervention in standard clinical practice.

Consensus for the treatment of upper urinary tract infections during pregnancy / Consenso para el tratamiento de la infección de vías urinarias altas durante la gestación

Objectives: To generate evidence-based recommendations through formal consensus regarding the treatment of upper urinary tract infections during gestation. Materials and methods: Experts in microbiology, public health, internal medicine, infectious diseases, obstetrics, maternal fetal medicine and obstetric and gynecological infections participated in the consensus development group. The group also included professionals with training in clinical epidemiology, systematic data search, and representatives from the Health Secretariat and the Bogota Obstetrics and Gynecology Association. The participants disclosed their conflicts of interest. Starting with a clinical question, outcomes were graded and a systematic search was conducted in the Medline via PubMed, Embase, Lilacs, and Bireme databases. The search was expanded to include institutional repositories and antimicrobial resistance surveillance systems, with no language or date restrictions. The search was updated on October 1, 2022. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to assess the quality of the evidence and determine the strength of the recommendations. Finally, the RAND/UCLA (Research and Development/University of California Los Angeles) methodology was applied for the formal consensus. This document was reviewed by academic peers before publication. Results: The following are the consensus recommendations. Recommendation 1. The initial management of pregnant women with upper urinary tract infections (UTIs) should be approached in a hospital setting. Recommendation 2. The use of second generation cephalosporins is the suggested first option for empirical antimicrobial management in pregnant women with upper UTI in order to improve the rates of clinical and microbiological cure. Recommendation 3. Because of the risk-benefit balance, the use of aminoglycosides is suggested as a second option for empirical antimicrobial treatment in pregnant women presenting with upper UTIs in the second and third trimester. Recommendation 4. The use of third-generation cephalosporins is suggested as the third option for empirical antimicrobial treatment in pregnant women with upper UTIs given that the risk of inducing microbial resistance is high with this group of antibiotics. Recommendation 5. The use of carbapenems is suggested as a first option in pregnant women with upper UTIs and a history of infections caused by microorganisms with resistance to third or fourth-generation cephalosporins. Recommendation 6. The use of aminoglycosides or fourth-generation cephalosporins is suggested as a second option in pregnant women with upper UTIs and a history of infection caused by microorganisms with resistance to third-generation cephalosporins, taking risk-benefit into account. Recommendation 7. The use of piperacillin/tazobactam is suggested as a third option in pregnant women with upper UTIs and a history of infection caused by microorganisms with resistance to third or fourthgeneration cephalosporins. Recommendation 8. Getting a urine culture is recommended in pregnant women with upper UTIs before initiating empirical antimicrobial treatment. Recommendation 9. In pregnant women with upper UTIs, it is suggested to modify therapy in accordance with the results of the sensitivity test when the culture report shows resistance to the antimicrobial agent initiated empirically. Recommendation 10. In pregnant women hospitalized due to upper UTIs, it is suggested to switch to oral antimicrobial therapy after at least 48 hours of modulation of the systemic inflammatory response and the clinical signs of infection, and when tolerance to oral intake is adequate. Recommendation 11. In pregnant women with upper UTIs with no complications secondary to the primary infection, it is recommended to administer antibiotic therapy for a period of 7 to 10 days. Conclusions: It is expected that with this Colombian upper UTI consensus variability in clinical practice will be reduced. It is recommended that groups doing research in maternal fetal medicine assess the implementation and effectiveness of these recommendations.

Objetivos: generar recomendaciones informadas en la evidencia, a través de un consenso formal, orientadas al tratamiento de la infección de vías urinarias altas durante la gestación. Materiales y métodos: en el grupo desarrollador participaron expertos temáticos en microbiología, salud pública, medicina interna, infectología, obstetricia, medicina materno-fetal e infectología ginecobstétrica. También hicieron parte profesionales con entrenamiento en epidemiología clínica, búsqueda sistemática de la información, representantes de la Secretaría de Salud y la Asociación Bogotana de Obstetricia y Ginecología. Los participantes presentaron sus conflictos de interés. A partir de una pregunta clínica se realizó la graduación de los desenlaces y una búsqueda sistemática que abarcó las bases de datos Medline vía PubMed, Embase, Lilacs, Bireme. La pesquisa se amplió a repositorios institucionales y reportes de vigilancia de resistencia antimicrobiana, sin restricción de idioma o fecha, la búsqueda se actualizó el 1 de octubre de 2022. Se utilizó la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation) para valorar la calidad de la evidencia y establecer la fuerza de las recomendaciones.Finalmente, se utilizó la metodología RAND/ UCLA (Research and Development/University of California Los Angeles) para el consenso formal. Este documento fue revisado por pares académicos previo a su publicación. Resultados: el consenso formuló las siguientes recomendaciones. Recomendación 1. Se sugiere que el manejo inicial de la gestante con infección de vías urinarias (IVU) altas se realice de forma intrahospitalaria. Recomendación 2. Como primera opción, se sugiere que el tratamiento antimicrobiano empírico de la gestante con IVU altas se realice con el uso de cefalosporinas de segunda generación con el fin de mejorar la tasa de cura clínica y microbiológica. Recomendación 3. Como segunda opción, se sugiere que el tratamiento antimicrobiano empírico de la gestante con IVU altas en el segundo y tercer trimestre se realice con aminoglucósidos dado su balance riesgo-beneficio. Recomendación 4. Como tercera opción, se sugiere que el tratamiento antimicrobiano empírico de la gestante con IVU altas se realice con el uso de cefalosporinas de tercera generación, debido a que el riesgo de inducción de resistencia microbiana es alto con este grupo de antibióticos. Recomendación 5. Como primera opción, en mujeres gestantes con IVU altas y antecedente de infección por microorganismos con resistencia a cefalosporinas de tercera o cuarta generación se sugiere el uso de carbapenémicos. Recomendación 6. Como segunda opción, en gestantes con IVU altas y antecedente de infección por microorganismos con resistencia a cefalosporinas de tercera generación se sugiere el uso de aminoglucósidos o cefalosporinas de cuarta generación teniendo en cuenta el riesgo-beneficio. Recomendación 7. Como tercera opción, en gestantes con IVU altas y antecedente de infección por microorganismos con resistencia a cefalosporinas de tercera o cuarta generación se sugiere el uso de piperacilina/tazobactam. Recomendación 8. En gestantes con IVU altas se recomienda realizar urocultivo previo al inicio de tratamiento antimicrobiano empírico. Recomendación 9. En gestantes con IVU altas, cuando el urocultivo reporte resistencia al antimicrobiano iniciado de forma empírica, se sugiere modificar la terapia guiada por los resultados del antibiograma. Recomendación 10. En la gestante hospitalizada por IVU altas se sugiere realizar el cambio de terapia antimicrobiana a vía oral cuando la paciente tenga, al menos, 48 horas de modulación de respuesta inflamatoria sistémica y de los signos clínicos de infección, así como adecuada tolerancia a vía oral. Recomendación 11. En gestantes con IVU altas, sin complicaciones secundarias a la infección primaria, se recomienda que la terapia antibiótica se administre de 7 a 10 días. Conclusiones: se espera que este consenso colombiano de IVU altas reduzca la variabilidad en la práctica clínica. Se recomienda a los grupos de investigación en medicina materno fetal e infectología evaluar la implementación y efectividad de las recomendaciones emitidas.

Consenso para el tratamiento de la infección de vías urinarias altas durante la gestación / Consensus for the treatment of upper urinary tract infections during pregnancy

Objetivos: Generar recomendaciones informadas en la evidencia, a través de un consenso formal, orientadas al tratamiento de la infección de vías urinarias altas durante la gestación. Materiales y métodos: En el grupo desarrollador participaron expertos temáticos en microbiología, salud pública, medicina interna, infectología, obstetricia, medicina materno-fetal e infectología ginecobstétrica. También hicieron parte profesionales con entrenamiento en epidemiología clínica, búsqueda sistemática de la información, representantes de la Secretaría de Salud y la Asociación Bogotana de Obstetricia y Ginecología. Los participantes presentaron sus conflictos de interés. A partir de una pregunta clínica se realizó la graduación de los desenlaces y una búsqueda sistemática que abarcó las bases de datos Medline vía PubMed, Embase, Lilacs, Bireme. La pesquisa se amplió a repositorios institucionales y reportes de vigilancia de resistencia antimicrobiana, sin restricción de idioma o fecha, la búsqueda se actualizó el 1 de octubre de 2022. Se utilizó la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation) para valorar la calidad de la evidencia y establecer la fuerza de las recomendaciones. Finalmente, se utilizó la metodología RAND/ UCLA (Research and Development/University of California Los Angeles) para el consenso formal. Este documento fue revisado por pares académicos previo a su publicación. Resultados: El consenso formuló las siguientes recomendaciones. Recomendación 1. Se sugiere que el manejo inicial de la gestante con infección de vías urinarias (IVU) altas se realice de forma intrahospitalaria. Recomendación 2. Como primera opción, se sugiere que el tratamiento antimicrobiano empírico de la gestante con IVU altas se realice con el uso de cefalosporinas de segunda generación con el fin de mejorar la tasa de cura clínica y microbiológica. Recomendación 3. Como segunda opción, se sugiere que el tratamiento antimicrobiano empírico de la gestante con IVU altas en el segundo y tercer trimestre se realice con aminoglucósidos dado su balance riesgo-beneficio. Recomendación 4. Como tercera opción, se sugiere que el tratamiento antimicrobiano empírico de la gestante con IVU altas se realice con el uso de cefalosporinas de tercera generación, debido a que el riesgo de inducción de resistencia microbiana es alto con este grupo de antibióticos. Recomendación 5. Como primera opción, en mujeres gestantes con IVU altas y antecedente de infección por microorganismos con resistencia a cefalosporinas de tercera o cuarta generación se sugiere el uso de carbapenémicos. Recomendación 6. Como segunda opción, en gestantes con IVU altas y antecedente de infección por microorganismos con resistencia a cefalosporinas de tercera generación se sugiere el uso de aminoglucósidos o cefalosporinas de cuarta generación teniendo en cuenta el riesgo-beneficio. Recomendación 7. Como tercera opción, en gestantes con IVU altas y antecedente de infección por microorganismos con resistencia a cefalosporinas de tercera o cuarta generación se sugiere el uso de piperacilina/tazobactam. Recomendación 8. En gestantes con IVU altas se recomienda realizar urocultivo previo al inicio de tratamiento antimicrobiano empírico. Recomendación 9. En gestantes con IVU altas, cuando el urocultivo reporte resistencia al antimicrobiano iniciado de forma empírica, se sugiere modificar la terapia guiada por los resultados del antibiograma. Recomendación 10. En la gestante hospitalizada por IVU altas se sugiere realizar el cambio de terapia antimicrobiana a vía oral cuando la paciente tenga, al menos, 48 horas de modulación de respuesta inflamatoria sistémica y de los signos clínicos de infección, así como adecuada tolerancia a vía oral. Recomendación 11. En gestantes con IVU altas, sin complicaciones secundarias a la infección primaria, se recomienda que la terapia antibiótica se administre de 7 a 10 días. Conclusiones: se espera que este consenso colombiano de IVU altas reduzca la variabilidad en la práctica clínica. Se recomienda a los grupos de investigación en medicina materno fetal e infectología evaluar la implementación y efectividad de las recomendaciones emitidas.

Objectives: To generate evidence-based recommendations through formal consensus regarding the treatment of upper urinary tract infections during gestation. Materials and methods: Experts in microbiology, public health, internal medicine, infectious diseases, obstetrics, maternal fetal medicine and obstetric and gynecological infections participated in the consensus development group. The group also included professionals with training in clinical epidemiology, systematic data search, and representatives from the Health Secretariat and the Bogota Obstetrics and Gynecology Association. The participants disclosed their conf licts of interest. Starting with a clinical question, outcomes were graded and a systematic search was conducted in the Medline via PubMed, Embase, Lilacs, and Bireme databases. The search was expanded to include institutional repositories and antimicrobial resistance surveillance systems, with no language or date restrictions. The search was updated on October 1, 2022. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to assess the quality of the evidence and determine the strength of the recommendations. Finally, the RAND/UCLA (Research and Development/University of California Los Angeles) methodology was applied for the formal consensus. This document was reviewed by academic peers before publication. Results: The following are the consensus recommendations. Recommendation 1. The initial management of pregnant women with upper urinary tract infections (UTIs) should be approached in a hospital setting. Recommendation 2. The use of second generation cephalosporins is the suggested first option for empirical antimicrobial management in pregnant women with upper UTI in order to improve the rates of clinical and microbiological cure. Recommendation 3. Because of the risk-benefit balance, the use of aminoglycosides is suggested as a second option for empirical antimicrobial treatment in pregnant women presenting with upper UTIs in the second and third trimester. Recommendation 4. The use of third-generation cephalosporins is suggested as the third option for empirical antimicrobial treatment in pregnant women with upper UTIs given that the risk of inducing microbial resistance is high with this group of antibiotics. Recommendation 5. The use of carbapenems is suggested as a first option in pregnant women with upper UTIs and a history of infections caused by microorganisms with resistance to third or fourth-generation cephalosporins. Recommendation 6. The use of aminoglycosides or fourth-generation cephalosporins is suggested as a second option in pregnant women with upper UTIs and a history of infection caused by microorganisms with resistance to third-generation cephalosporins, taking risk-benefit into account. Recommendation 7. The use of piperacillin/tazobactam is suggested as a third option in pregnant women with upper UTIs and a history of infection caused by microorganisms with resistance to third or fourth-generation cephalosporins. Recommendation 8. Getting a urine culture is recommended in pregnant women with upper UTIs before initiating empirical antimicrobial treatment. Recommendation 9. In pregnant women with upper UTIs, it is suggested to modify therapy in accordance with the results of the sensitivity test when the culture report shows resistance to the antimicrobial agent initiated empirically. Recommendation 10. In pregnant women hospitalized due to upper UTIs, it is suggested to switch to oral antimicrobial therapy after at least 48 hours of modulation of the systemic inflammatory response and the clinical signs of infection, and when tolerance to oral intake is adequate. Recommendation 11. In pregnant women with upper UTIs with no complications secondary to the primary infection, it is recommended to administer antibiotic therapy for a period of 7 to 10 days. Conclusions: It is expected that with this Colombian upper UTI consensus variability in clinical practice will be reduced. It is recommended that groups doing research in maternal fetal medicine assess the implementation and effectiveness of these recommendations.

Primary HPV-DNA screening in women under 30 years of age: health technology assessment / Tamización primaria con prueba ADN-VPH en mujeres menores de 30 años: evaluación de tecnología sanitaria

Background: Primary screening with Human Papilloma Virus (HPV) testing was introduced in Colombia in 2014 for individuals between 30 and 65 years of age. When the result is positive, cytology triage is performed for colposcopy referral. The convenience of initiating HPV-DNA testing for screening at 25 years of age is currently a subject of discussion. Therefore, the objective of this health technology assessment (HTA) is to analyze the available evidence regarding safety, efficacy, cost-effectiveness, values and preferences, ethical dilemmas and considerations pertaining to the implementation of the HPV-DNA test as a cervical screening strategy in women under 30 years of age in the Colombian context. Domains to be assessed: Clinical efficacy and safety 1. Cumulative rate of cervical intraepithelial neoplasia (CIN) grade 2 or high-er after 2 screening rounds. 2. Cumulative rates of invasive cancer of the uterine cervix after 2 screening rounds. 3. Safety: referral to colposcopy. Cost-effectiveness Cost-effectiveness for Colombia. Other domains considered Ethical considerations associated with cervical screening in women under 30 years of age. Organizational and individual considerations. Barriers and facilitators pertaining to the implementation of cervical screening in women under 30 years of age in the Colombian context. Methods: Clinical efficacy and safety assessment A systematic literature search of systematic reviews and clinical trials was conducted in MEDLINE, Embase and CENTRAL. The body of evidence was rated using the GRADE approach. An interdisciplinary team was then convened to create a working group to review the retrieved evidence. This led to the discussion and construction of the conclusions following the guidelines of a formal consensus in accordance with the RAND/UCLA methodology. Economic study Systematic literature research of studies that had assessed cost-effectiveness for Colombia. Results: Clinical outcomes An integrative analysis of 5 randomized clinical trials that met the inclusion critera was performed. Compared with cytology, primary HPV-DNA testing in women under 30 years of age could be associated with a lower frequency of CIN+2 lesions during the first screening round (RR: 1.57; CI: 1.20 to 2.04; low evidence certainty), and a lower incidence of CIN+2 (RR: 0.67; CI: 0.48 to 0.92; low evidence certainty). Moreover, it is associated with a lower frequency of invasive carcinoma at the end of follow-up (RR: 0.19; CI: 0.07 to 0.53; high evidence certainty). Economic results From the financial point of view, the use of HPVDNA testing plus cytology-based triage starting at 25 years of age is perhaps the most cost-effective option for Colombia (incremental cost-effectiveness ratio, COP 8,820,980 in 2013). Other implications Two studies suggest that barriers to implementation attributable to intermediation, public unrest and geographic considerations could be overcome with the use of new screening technologies or strategies. It is important to consider administration and service provision alternatives in order to overcome some acceptability and access barriers. Any cervical screening program must take into consideration ethical principles of nonmaleficence, beneficence, autonomy and equity. Future studies should focus on analyzing new screening techniques with emphasis on the population under 30 years of age. Conclusions: The use of HPV-DNA testing as a screening strategy in women under 30 years of age is a potentially efficacious and cost-effective intervention for Colombia. Future studies should focus on analyzing new screening technologies, with emphasis on the population under 30 years of age.

Antecedentes: A partir del 2014 en Colombia se incorporó la Tamización primaria con prueba de Virus del Papiloma Humano (VPH) desde los 30 hasta los 65 años, cuando la prueba es positiva se hace triage con citología para remisión a colposcopia. Actualmente se discute la conveniencia de iniciar la tamización con prueba de ADN de VPH a partir de los 25 años. De esta manera, el objetivo de esta evaluación de tecnologías sanitarias es analizar la evidencia disponible en torno a la seguridad, efectividad, costoefectividad, valores y preferencias, dilemas éticos y aspectos relacionados con la implementación para el contexto colombiano de la prueba ADN-VPH como estrategia de tamización cervical en mujeres menores de 30 años. Dominios a evaluar: Eficacia clínica y seguridad 1. Tasa acumulada de neoplasia intraepitelial cervical (NIC) grado 2 o más avanzado luego de 2 rondas de tamización. 2. Tasas acumuladas de cáncer invasor de cérvix luego de 2 rondas de tamización. 3. Seguridad: remisión a colposcopia. Costo-efectividad Costo efectividad para Colombia. Otros dominios considerados Aspectos éticos asociados a la tamización cervical en mujeres menores de 30 años. Aspectos organizacionales y del individuo. Barreras y facilitadores relacionados con la implementación en el contexto colombiano de la tamización cervical en mujeres menores de 30 años. Métodos: Evaluación de efectividad y seguridad clínicas Se realizó una búsqueda sistemática de la literatura en MEDLINE, Embase y CENTRAL de revisiones sistemáticas y ensayos clínicos. Se calificó el cuerpo de la evidencia con la aproximación GRADE. Posteriormente, se convocó a un grupo interdisciplinario a una mesa de trabajo en donde se presentó la evidencia recuperada, dando paso a la discusión y a la construcción de las conclusiones, siguiendo los lineamientos de un consenso formal acorde a la metodología RAND/UCLA. Estudio económico Se hizo una búsqueda sistemática de la literatura de estudios que hubieran evaluado el costo-efectividad para Colombia. Resultados: De 7.659 referencias recuperadas se incluyeron 8 estudios. Resultados clínicos Se realizó un análisis integrativo de 5 ensayos clínicos aleatorizados que cumplieron con los criterios de inclusión. Cuando se compara frente a la citología, la tamización primaria con ADN-VPH en mujeres menores de 30 años, podría asociarse con una mayor frecuencia de detección de lesiones NIC2+ durante la primera ronda de cribado (RR: 1.57; IC: 1,20 a 2,04; certeza en la evidencia baja), con una menor incidencia de NIC2+ (RR:0,67; IC: 0,48 a 0,92; certeza en la evidencia baja) y se asocia con una menor frecuencia de carcinoma invasor al término del seguimiento (RR: 0,19; IC: 0,07 a 0,53; certeza en la evidencia alta). Resultados económicos Desde el punto de vista económico, la alternativa de ADN-VPH y triage con citología desde los 25 años quizás representa la alternativa más costo-efectiva para Colombia (razón costo-efectividad incremental $8.820.980 COP año 2013). Otras implicaciones Dos estudios sugieren que las barreras de implementación, atribuibles a circunstancias de intermediación, de orden público y de carácter geográfico, podrían ser solventadas por nuevas tecnologías o estrategias de cribado. Es importante considerar alternativas de forma de administración y de prestación de servicios para solventar algunas barreras de aceptabilidad y acceso. Todo programa de tamización cervical debe contemplar los principios éticos de no maleficencia, beneficencia, autonomía y equidad. Futuros estudios deben enfocarse en analizar nuevas tecnologías de cribado con énfasis en población menor de 30 años. Conclusiones: El uso de la prueba ADN-VPH como estrategia de tamización en mujeres menores de 30 años es una intervención probablemente efectiva y costoefectiva para Colombia. Futuros estudios deben enfocarse en analizar nuevas tecnologías de cribado con énfasis en población menor de 30 años.

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

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

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

Spatulas for operative vaginal birth: A systematic review and meta-analysis.

BACKGROUND: Operative vaginal birth represents an alternative to address problems during the second stage of labor. Obstetricians have access to three different instruments: forceps, vacuum, and spatulas. OBJECTIVE: To evaluate the safety and effectiveness of the use of spatulas for operative vaginal birth. SEARCH STRATEGY: MEDLINE/PubMed, Embase, CENTRAL, LILACS, SciELO, ClinicalTrials.gov, and OpenGrey. SELECTION CRITERIA: Randomized controlled studies and non-randomized controlled studies (NRS) were included. DATA COLLECTION AND ANALYSIS: Studies were independently assessed for inclusion, data extraction, and risk of bias. MAIN RESULTS: Nine NRS (n = 16  497 women) compared the use of spatulas versus forceps. Low-certainty evidence suggests that spatulas were not different in terms of failed operative vaginal delivery rate (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.53-1.52), but may decrease the incidence of birth canal trauma (OR 0.70, 95% CI 0.54-0.91), birth canal laceration (OR 0.50, 95% CI 0.28-0.91), and neonatal soft-tissue injury (OR 0.19, 95% CI 0.13-0.29). Six NRS (n = 2992 women) compared the use of spatulas versus vacuum. Low-quality evidence suggests that spatulas may decrease failed operative vaginal delivery rate (OR 0.10, 95% CI 0.04-0.26). There were no apparent differences in other maternal and neonatal outcomes. CONCLUSION: Low-certainty evidence suggests that spatulas could be a safe and effective alternative for operative vaginal birth.

Exposure to armed conflict as a factor associated with very low birth weight: Case-control population study.

OBJECTIVE: To determine the association between armed conflict and very low birth wright (VLBW), which is a multifactorial etiology public health problem that includes aspects of poverty and violence. METHODS: Case-control population study matched by year of delivery conducted in Cauca, Colombia, between 2010 and 2016. Cases of VLBW, with weights between 500 and 1499 g and controls weighing between 2500 and 3999 g. Cases and controls were identified through the vital statistics registry, and exposure was determined using a multidimensional index designed by the Colombian State. Multiple gestations were excluded. Conditional logistic regression for matched data was used, adjusting for confounding variables. RESULTS: Overall, 7068 matched participants (1767 cases and 5301 controls) were included. Cases and controls had similar baseline characteristics. Participants were predominantly women in the second and third decades of life, 3222 (46%) were exposed to armed conflict, and 1902 (27%) were of African-Colombian or indigenous ethnicity. Maternal exposure to armed conflict significantly increased the odds of VLBW among women with rural birth (adjusted odds ratio [aOR] 3.86, 95% confidence interval [CI] 2.74-5.45) and inadequate prenatal care (aOR 10.38, 95% CI 8.20-13.12). CONCLUSION: Exposure to armed conflict increases the odds of VLBW neonates. This factor needs to be considered in prenatal care.

Expectant Versus Interventionist Care in the Management of Severe Preeclampsia Remote from Term: A Systematic Review.

OBJECTIVE: To compare the effects of expectant versus interventionist care in the management of pregnant women with severe preeclampsia remote from term. DATA SOURCES: An electronic search was conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS, for its Spanish acronym), World Health Organization's International Clinical Trials Registry Platform (WHO-ICTRP), and OpenGrey databases. The International Federation of Gynecology and Obstetrics (FIGO, for its French acronym), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and Colombian Journal of Obstetrics and Gynecology (CJOG) websites were searched for conference proceedings, without language restrictions, up to March 25, 2020. SELECTION OF STUDIES: Randomized clinical trials (RCTs), and non-randomized controlled studies (NRSs) were included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of the evidence. DATA COLLECTION: Studies were independently assessed for inclusion criteria, data extraction, and risk of bias. Disagreements were resolved by consensus. DATA SYNTHESIS: Four RCTs and six NRS were included. Low-quality evidence from the RCTs showed that expectant care may result in a lower incidence of appearance, pulse, grimace, activity, and respiration (Apgar) scores < 7 at 5 minutes (risk ratio [RR]: 0.48; 95% confidence interval [95%CI]: 0.23%to 0.99) and a higher average birth weight (mean difference [MD]: 254.7 g; 95%CI: 98.5 g to 410.9 g). Very low quality evidence from the NRSs suggested that expectant care might decrease the rates of neonatal death (RR: 0.42; 95%CI 0.22 to 0.80), hyaline membrane disease (RR: 0.59; 95%CI: 0.40 to 0.87), and admission to neonatal care (RR: 0.73; 95%CI: 0.54 to 0.99). No maternal or fetal differences were found for other perinatal outcomes. CONCLUSION: Compared with interventionist management, expectant care may improve neonatal outcomes without increasing maternal morbidity and mortality.

OBJETIVO: Comparar os efeitos dos cuidados expectantes versus intervencionistas no manejo de gestantes com pré-eclâmpsia grave distante do termo. FONTES DE DADOS: Foi realizada uma busca eletrônica no Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS, para o espanhol) acrônimo), Plataforma Internacional de Registro de Ensaios Clínicos da Organização Mundial da Saúde (OMS-ICTRP) e bancos de dados OpenGrey. Foram pesquisados os sites da Federação Internacional de Ginecologia e Obstetrícia (FIGO, por sua sigla em francês), do Royal College of Obstetricians e Ginecologistas (RCOG), do American College of Obstetricians e Ginecologistas (ACOG) e do Colombian Journal of Obstetrics and Gynecology (CJOG) procedimentos da conferência, sem restrições de idioma, até 25 de março de 2020. SELEçãO DE ESTUDOS: Ensaios clínicos randomizados (RCTs) e estudos controlados não randomizados (NRSs) foram incluídos. A abordagem de Classificação de Recomendações, Avaliação, Desenvolvimento e Avaliação (GRADE) foi usada para avaliar a qualidade da evidência. COLETA DE DADOS: Os estudos foram avaliados de forma independente quanto aos critérios de inclusão, extração de dados e risco de viés. As discordâncias foram resolvidas por consenso. SíNTESE DE DADOS: Quatro RCTs e seis NRS foram incluídos. Evidências de baixa qualidade dos ECRs mostraram que o cuidado expectante pode resultar em uma incidência menor de pontuações de aparência, pulso, careta, atividade e respiração (Apgar) <7 em 5 minutos (razão de risco [RR]: 0,48; intervalo de confiança de 95% [IC 95%]: 0,23% a 0,99) e um peso médio ao nascer superior (diferença média [MD]: 254,7 g; IC 95%: 98,5 ga 410,9 g). Evidências de qualidade muito baixa dos NRSs sugeriram que os cuidados expectantes podem diminuir as taxas de morte neonatal (RR: 0,42; IC de 95% 0,22 a 0,80), doença da membrana hialina (RR: 0,59; IC de 95%: 0,40 a 0,87) e admissão à assistência neonatal (RR: 0,73; IC 95%: 0,54 a 0,99). Nenhuma diferença materna ou fetal foi encontrada para outros resultados perinatais. CONCLUSãO: Em comparação com o manejo intervencionista, o cuidado expectante pode melhorar os resultados neonatais sem aumentar a morbidade e mortalidade materna.

Consenso de tromboprofilaxis en cirugía ginecológica / Consensus on thromboprophylaxis in gynecological surgery

RESUMEN Objetivo: sintetizar la evidencia disponible en torno a las intervenciones para la prevención de eventos tromboembólicos venosos durante el cuidado perioperatorio de las mujeres con patología ginecológica benigna, buscando reducir la morbi-mortalidad asociada a esta condición. Materiales y métodos: el grupo desarrollador estuvo integrado por profesionales de la salud, tomadores decisiones y un representante de las pacientes. Todos los participantes declararon sus conflictos de interés. Se construyeron preguntas clínicas contestables y se realizó la graduación de los desenlaces. Se elaboró la pesquisa de la información en Medline/PubMed, Embase, Epistemonikos y LILACS. La búsqueda también abarcó fuentes de literatura gris y se actualizó el 22 de septiembre de 2020 sin restricciones por fecha o idioma. Se implementó la aproximación GRADE (Grading of Recommendations Assessment, Development and Evaluation) para establecer la calidad de la evidencia y la fuerza de las recomendaciones, se realizó consenso formal acorde con la metodología RAND/UCLA. Previo a la publicación, el documento fue objeto de revisión por pares. Resultados: se presenta la versión corta del consenso "para la prevención de eventos tromboembólicos venosos durante el cuidado perioperatorio de las mujeres con patología ginecológica benigna", junto a su evidencia de soporte y respectivas recomendaciones. Conclusiones: como recomendaciones claves para la implementación, se proponen el uso de la escala de Caprini y el uso de intervenciones acorde con el nivel de riesgo perioperatorio de las pacientes.

ABSTRACT Objective: To draw a synthesis of the available evidence regarding interventions for the prevention of venous thromboembolic events during the peri-operative care of women with benign gynecological pathology, with the aim of reducing the associated morbidity and mortality. Materials and methods: The development group included healthcare professionals, decision-makers and one patient representative. All the participants stated their disclosures. Answerable clinical questions were built and outcomes were graded. The search for information was conducted in Medline, Embase, Epistemonikos and LILACS, but it also included grey literature and was updated on September 22, 2020, with no date or language restrictions. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to determine the quality of the evidence and the strength of the recommendations. Formal consensus was developed in accordance with the RAND/UCLA methodology. The document was submitted to peer review before publication. Results: The abbreviated version of the "consensus on the prevention of venous thromboembolic events during the perioperative care of women with benign gynecological pathology" is presented together with the supporting evidence and respective recommendations. Conclusions: The key recommendations for implementation include the use of the Caprini scale and of interventions consistent with the individual peri-operative risk level.

Expectant Versus Interventionist Care in the Management of Severe Preeclampsia Remote from Term: A Systematic Review / Cuidado expectante versus cuidado intervencionista no tratamento da pré-eclâmpsia grave a distância: uma revisão sistemática

Abstract Objective To compare the effects of expectant versus interventionist care in the management of pregnant women with severe preeclampsia remote from term. Data sources An electronic search was conducted in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Latin American and Caribbean Health Sciences Literature (LILACS, for its Spanish acronym), World Health Organization's International Clinical Trials Registry Platform (WHO-ICTRP), and Open- Grey databases. The International Federation of Gynecology and Obstetrics (FIGO, for its French acronym), Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and Colombian Journal of Obstetrics and Gynecology (CJOG) websites were searched for conference proceedings, without language restrictions, up to March 25, 2020. Selection of studies Randomized clinical trials (RCTs), and non-randomized controlled studies (NRSs) were included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of the evidence. Data collection Studies were independently assessed for inclusion criteria, data extraction, and risk of bias. Disagreements were resolved by consensus. Data synthesis Four RCTs and six NRS were included. Low-quality evidence from the RCTs showed that expectant care may result in a lower incidence of appearance, pulse, grimace, activity, and respiration (Apgar) scores<7 at 5 minutes (risk ratio [RR]: 0.48; 95% confidence interval [95%CI]: 0.23%to 0.99) and a higher average birth weight (mean difference [MD]: 254.7 g; 95%CI: 98.5 g to 410.9 g). Very low quality evidence from the NRSs suggested that expectant care might decrease the rates of neonatal death (RR: 0.42; 95%CI 0.22 to 0.80), hyalinemembrane disease (RR: 0.59; 95%CI: 0.40 to 0.87), and admission to neonatal care (RR: 0.73; 95%CI: 0.54 to 0.99). Nomaternal or fetal differences were found for other perinatal outcomes. Conclusion Compared with interventionist management, expectant care may improve neonatal outcomes without increasing maternal morbidity and mortality.

Resumo Objetivo Comparar os efeitos dos cuidados expectantes versus intervencionistas no manejo de gestantes com pré-eclâmpsia grave distante do termo. Fontes de dados Foi realizada uma busca eletrônica no Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS, para o espanhol) acrônimo), Plataforma Internacional de Registro de Ensaios Clínicos da Organização Mundial da Saúde (OMS-ICTRP) e bancos de dados OpenGrey. Foram pesquisados os sites da Federação Internacional de Ginecologia e Obstetrícia (FIGO, por sua sigla em francês), do Royal College of Obstetricians e Ginecologistas (RCOG), do American College of Obstetricians e Ginecologistas (ACOG) e do Colombian Journal of Obstetrics and Gynecology (CJOG) procedimentos da conferência, sem restrições de idioma, até 25 de março de 2020. Seleção de estudos Ensaios clínicos randomizados (RCTs) e estudos controlados não randomizados (NRSs) foram incluídos. A abordagem de Classificação de Recomendações, Avaliação, Desenvolvimento e Avaliação (GRADE) foi usada para avaliar a qualidade da evidência. Coleta de dados Os estudos foram avaliados de forma independente quanto aos critérios de inclusão, extração de dados e risco de viés. As discordâncias foram resolvidas por consenso. Síntese de dados Quatro RCTs e seis NRS foram incluídos. Evidências de baixa qualidade dos ECRs mostraram que o cuidado expectante pode resultar em uma incidência menor de pontuações de aparência, pulso, careta, atividade e respiração (Apgar) <7 em 5 minutos (razão de risco [RR]: 0,48; intervalo de confiança de 95% [IC 95%]: 0,23% a 0,99) e um peso médio ao nascer superior (diferença média [MD]: 254,7 g; IC 95%: 98,5 ga 410,9 g). Evidências de qualidade muito baixa dos NRSs sugeriram que os cuidados expectantes podem diminuir as taxas de morte neonatal (RR: 0,42; IC de 95% 0,22 a 0,80), doença da membrana hialina (RR: 0,59; IC de 95%: 0,40 a 0,87) e admissão à assistência neonatal (RR: 0,73; IC 95%: 0,54 a 0,99). Nenhuma diferença materna ou fetal foi encontrada para outros resultados perinatais. Conclusão Em comparação com o manejo intervencionista, o cuidado expectante pode melhorar os resultados neonatais sem aumentar a morbidade e mortalidade materna.

Prehypertension as a risk factor for the development of perinatal complications: Retrospective cohort study.

OBJECTIVE: To explore the association between prehypertension and the development of perinatal complications. METHODS: Retrospective cohort study (n = 293) that included pregnant women over 18 years of age carrying a single fetus of a gestational age of less than 20 weeks. Participants with chronic disease, assisted reproduction, fetal anomalies, early gestational loss, multiple pregnancy or who were delivered in a different institution were excluded. Pregnant women with and without prehypertension were compared. Multiple logistic regression was carried out. RESULTS: Prehypertension increased the incidence of hypertensive disorders (aOR 3.54, 95% CI 1.83-6.83) and hospitalization (aOR 2.41, 95% CI 1.17-4.95). No differences were found for other perinatal complications. CONCLUSIONS: Prehypertension increases the incidence of hypertensive disorders and hospitalization during pregnancy.