Clinical and manometric results of peroral endoscopic myotomy in patients with achalasia: experience in a latin american reference center. / Resultados clínicos y manométricos de la miotomía endoscópica peroral en pacientes con acalasia: experiencia en un centro de referencia latinoamericano.

INTRODUCTION: Currently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM). PRIMARY OUTCOME: Evaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia. METHODS: Observational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables. RESULTS: 29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238). CONCLUSION: Peroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Are the Chicago 3.0 manometric diagnostics consistent with Chicago 4.0?

There is little information on the degree of concordance between the results obtained using the Chicago 3.0 (CCv3.0) and Chicago 4.0 (CCv4.0) protocols to interpret high-resolution manometry (HRM) seeking to determine the value provided by the new swallowing maneuvers included in the last protocol. This is a study of diagnostic tests, evaluating concordance by consistency between the results obtained by the CCv3.0 and CCv4.0 protocols, in patients undergoing HRM. Concordance was assessed with the kappa test. Bland-Altman scatter plots, and Lin's correlation-concordance coefficient (CCC) were used to assess the agreement between IRP measured with swallows in the supine and seated position or with solid swallows. One hundred thirty-two patients were included (65% women, age 53 ± 17 years). The most frequent HRM indication was dysphagia (46.1%). Type I was the most common type of gastroesophageal junction. The most frequent CCv4.0 diagnoses were normal esophageal motility (68.9%), achalasia (15.5%), and ineffective esophageal motility (IEM; 5.3%). The agreement between the results was substantial (Kappa 0.77 ± 0.05), with a total agreement of 87.9%. Diagnostic reclassification occurred in 12.1%, from IEM in CCv3.0 to normal esophageal motility in CCv4.0. Similarly, there was a high level of agreement between the IRP measured in the supine compared to the seated position (CCC0.92) and with solid swallows (CCC0.96). In conclusion, the CCv4.0 protocol presents a high concordance compared to CCv3.0. In the majority of manometric diagnoses there is no reclassification of patients with provocation tests. However, the more restrictive criteria of CCv4.0 achieve a better reclassification of patients with IEM.

Lower Digestive Tract Bleeding in a Patient with Behçet's Disease: A Case Report

Behçet's disease is a chronic, multisystemic, and relapsing inflammatory pathology that frequently manifests with oral and genital ulcers and ocular and skin lesions. It rarely exhibits gastrointestinal involvement, which varies depending on the affected gastrointestinal segment; these have in common the predominance of ulcerated lesions and, consequently, a greater risk of bleeding from the digestive tract. A clinical case of a 28-year-old female patient who consulted for a clinical picture of melenic stools and oral ulcers is described. As a crucial clinical history, she had been diagnosed with Behçet's disease since adolescence, associated with severe gastrointestinal complications. An esophagogastroduodenoscopy was performed with findings of antral erythematous gastropathy and a colonoscopy with a report of ulcerated ileitis. Treatment with azathioprine and corticosteroids was indicated, significantly improving the clinical picture.

La enfermedad de Behçet es una patología inflamatoria crónica, multisistémica y recidivante que se manifiesta frecuentemente con úlceras orales y genitales, y lesiones oculares y cutáneas. En raras ocasiones presenta compromiso gastrointestinal y este varía dependiendo del segmento gastrointestinal afectado; estas enfermedades tienen en común el predominio de lesiones ulceradas y, consecuentemente, un mayor riesgo de sangrado de las vías digestivas. Se describe un caso clínico de una paciente femenina de 28 años que consultó por un cuadro clínico de deposiciones melénicas y úlceras orales. Como antecedente clínico de importancia presentó diagnóstico de enfermedad de Behçet desde la adolescencia asociado a complicaciones gastrointestinales graves. Se realizó una esofagogastroduodenoscopia con hallazgos de gastropatía eritematosa antral y una colonoscopia con reporte de ileítis ulcerada. Se indicó el tratamiento con azatioprina y corticoides con una mejoría significativa del cuadro clínico.

Sedación administrada por médicos generales para procedimientos endoscópicos de baja complejidad: experiencia en una unidad de endoscopia de una clínica de alta complejidad en Cali / Sedation Administered by General Practitioners for Low Complexity Endoscopic Procedures: Experience in an Endoscopy Unit of a Tertiary Referral Hospital in Cali

Resumen Objetivos: en Colombia se ha venido implementando la sedación por médicos no anestesiólogos para procedimientos endoscópicos fuera del quirófano. Se describió la experiencia en la unidad de gastroenterología de una clínica de alto nivel de atención en Cali, Colombia. Materiales y métodos: estudio observacional, de tipo cohorte analítica para describir la frecuencia y el tipo de eventos adversos asociados a los procedimientos de sedación por médicos generales, y evaluar los factores asociados a su ocurrencia en pacientes que acudieron a la unidad de endoscopia de la Fundación Valle del Lili para la realización de estudios endoscópicos bajo sedación intravenosa que, por ser de bajo riesgo, fue aplicada por un médico no anestesiólogo entre noviembre de 2018 y junio de 2019. Se realizó análisis descriptivo, se calcularon mediana y rango intercuartílico para las variables numéricas, y frecuencias para las variables cualitativas. Resultados: se incluyeron 1506 participantes, 59,4 % ASA I y 40,6 % ASA II. En promedio, la dosis inicial de propofol fue de 60 mg y la dosis total, de 140 mg. Se registraron eventos adversos no serios en 46 pacientes (3,05 %) y el más común fue la desaturación transitoria (80,4 %). Ningún paciente presentó eventos adversos serios. El puntaje inicial promedio de la escala de Aldrete fue 8, mientras que al alta el puntaje promedio fue de 10. Conclusiones: la sedación para procedimientos endoscópicos dada por médicos no anestesiólogos es segura, siempre y cuando sea realizado por personal entrenado que realice una adecuada valoración de los antecedentes (cardiovasculares, gastrointestinales y neurológicos) y factores de riesgo del paciente dentro del marco de los lineamientos institucionales vigentes.

Abstract Objectives: in Colombia, sedation by non-anesthesiologists for endoscopic procedures outside the operating room has been implemented. A description of an experience in the gastroenterology unit of a tertiary referral hospital in Cali, Colombia, was conducted. Materials and methods: an analytical cohort observational study to describe the frequency and type of adverse events associated with sedation procedures performed by general practitioners and evaluate the factors related to their occurrence in patients who attended the endoscopy unit of Fundación Valle del Lili for endoscopic studies under intravenous sedation. Between November 2018 and June 2019, non-anesthesiologist physicians performed this procedure due to the minimal risk implied. A descriptive analysis was completed, and the median and interquartile range were calculated for numerical variables and frequencies for qualitative variables. Results: There were 1506 participants, 59.4% ASA I and 40.6% ASA II in this study. On average, the starting dose of propofol was 60 mg, and the total dose was 140 mg. Forty-six patients (3.05%) reported non-severe adverse events; the most common occurrence was transient desaturation (80.4%). No patients experienced severe adverse events. The average initial Aldrete scale score was 8, while at discharge, the average score was 10. Conclusions: sedation for endoscopic procedures performed by non-anesthesiologists is safe provided that it is performed by trained personnel conducting a correct assessment of the patient's (cardiovascular, gastrointestinal, and neurological) history and risk factors within the framework of the current institutional guidelines.

Imatinib: a new chemopreventive option in adenomatous polyposis?

Patients with adenomatous polyposis, usually defined as patients with >10 adenomatous polyps in the colorectum, are at increased risk for colorectal cancer (CRC). Since surgical and endoscopic treatment do not completely eliminate the potential for future polyps or extraintestinal neoplasms, there is an unmet medical need to identify pharmacological agents to delay major surgical interventions. We present two cases of patients with adenomatous polyposis who developed chronic myelogenous leukaemia and were treated with imatinib as part of their chemotherapy. A sustained regression of the colonic polyps documented in both cases was observed after the initiation of the tyrosine kinase inhibitor. Despite the presence of potential confounders, we hypothesise the potential role of imatinib as a chemopreventive agent in patients with familial adenomatous polyposis.

Pathologic features and clinical course of a non-functioning primary pulmonary paraganglioma: A case report.

INTRODUCTION: Paragangliomas (PGGL) are rare neuroendocrine tumors arising from non-epithelial extra-adrenal chromaffin cells. They have been described in different sites: abdomen, pelvis, head, neck and thorax. Incidence is very low, occurring in less than 2-8/million per year. PGGL's of the lung are extremely rare, they have a slow growth and present as painless lesions. Biopsy is the method of choice for diagnosis and prognosis. PRESENTATION OF CASE: This is a 70-year-old woman with chronic cough, with a CT-scan showing a 3.3-cm mass in the left lower lobe. After video-assisted thoracic surgery, histologic findings confirmed a non-functioning pulmonary paraganglioma. We present the clinical, radiological, pathological findings and clinical course. DISCUSSION: Primary pulmonary PGGL's are extremely rare neuroendocrine tumors with low-grade malignancy, difficult to distinguish from other pulmonary tumors relying only on imaging techniques. In this case, PGGL presented as an incidentaloma during the evaluation of chronic cough. After histological diagnosis, genetic testing are ideally performed to identify somatic or germline mutations that may condition a higher risk of malignancy and metastasis. CONCLUSION: PGGL's must be considered when other diagnoses are unlikely due to immunohistochemistry findings. Larger studies in this field are needed to determine the risk factors for its development and to determine which populations have the greatest potential for malignant transformation.

Ossifying Lipoma in Costal Arches That Suggest Extensive Pulmonary Involvement: Case Report.

BACKGROUND: Lipomas are the most common benign soft tissue tumors in the general population. These lesions can appear on any part of the body and usually develop in the subcutaneous superficial tissue. Lipomas that show ossifying changes are very rare, representing less than 1% of the reported lipomas. They usually manifest as hard nodular lesions in the head and neck, the extremities, the sternoclavicular region, and the subcutaneous tissue in general; they are rare in the costal arches. CASE PRESENTATION: We report the case of a patient with a history of multiple diseases and 2 tumor-like lesions with internal lytic areas detected in the fourth right costal arch and in the eighth left costal arc; we describe his clinical manifestations, radiological and laboratory findings as well as the pathological results and outcome. CONCLUSIONS: Ossifying lipomas are rare benign tumors with asymptomatic clinical presentation. It is important to perform an adequate radiological differentiation from other more aggressive lesions such as liposarcomas.

Descripción clínico-epidemiológica de pacientes con enfermedad inflamatoria intestinal en una clínica de cuarto nivel en Cali / Clinical-epidemiological description of patients with inflammatory bowel disease in a fourth level clinic in Cali

Resumen Introducción: en América Latina, la enfermedad inflamatoria intestinal (EII) es poco frecuente y la información, limitada. Se describieron características de los pacientes con EII en una unidad de gastroenterología de una clínica de alto nivel de atención en Cali, Colombia. Materiales y métodos: estudio descriptivo de pacientes que consultaron con diagnóstico de enfermedad de Crohn (EC) o colitis ulcerativa (CU) a la Clínica Fundación Valle del Lili entre enero de 2011 y diciembre de 2015. Se realizó un análisis con Statistical Package for the Social Sciences de IBM (SPSS) versión 19, se calcularon la mediana y el rango intercuartílico para las variables numéricas, y frecuencias para las variables cualitativas. Resultados: se incluyeron 416 participantes, 115 con EC y 301 con CU. El 41 % se clasificó como enfermedad leve, 23,5 % moderada y 35,3 % grave. Se realizó cirugía a 24 pacientes (9,0 %) con CU y 53 (46,1 %) con EC. En esta última, el manejo más frecuente fue los medicamentos biológicos (32,2 %), seguidos de inmunomoduladores (27,8 %), esteroides (20 %) y ácido 5-aminosalicílico (5-ASA) (11,3 %). El tratamiento más frecuente de CU fue 5-ASA (84,8 %), seguido de esteroides (32,19 %), azatioprina (24,6 %) y biológicos (15,9 %). Conclusiones: el diagnóstico precoz sigue siendo un reto. La gravedad de la CU en los pacientes estudiados fue menor a la reportada en el mundo, lo cual no ocurrió con los pacientes con EC y podría estar en relación con el retraso diagnóstico. El uso de medicamentos biológicos se acercó a lo reportado en el primer mundo. Es difícil determinar si las menores tasas de cirugía se deben a una mejor respuesta clínica o a un difícil acceso a estas intervenciones.

Abstract Objectives: In Latin America, inflammatory bowel disease (IBD) is rare, and information about it is limited. This article describes characteristics of IBD patients in a gastroenterology unit at a high-level clinic in Cali, Colombia. Materials and methods: This is a descriptive study of patients diagnosed with Crohn's disease (CD) or ulcerative colitis (UC) at the Clínica Fundación Valle de Lili between January 2011 and December 2015. Statistical analysis was performed with SPSS version 19. Medians and interquartile ranges were calculated for numerical variables. Frequencies were calculated for qualitative variables. Results: The 416 participants included 115 with CD and 301 with UC. Of the total cases, 41% were classified as mild, 23.5% as moderate and 35.3% as severe. Surgery was performed in 24 patients (9.0%) with UC and 53 (46.1%) with CD. CD was most frequently managed with biologicals (32.2%), followed by immunomodulators (27.8%), steroids (20%) and 5-ASA (11.3%). The most frequent treatment for UC was 5-ASA (84.8%), but 32.19% received steroids, 24.6% received azathioprine and 15.9% received biologicals. Conclusions: Early diagnosis remains a challenge. The severity of UC but not CD in the patients studied was less than that reported elsewhere in the world. The difference could be related to diagnostic delay. The use of biologicals was close to that reported in the first world. It is difficult to determine if lower surgery rates are due to better clinical response or to difficult access to these interventions.

Hepatitis C: una aproximación clínica y epidemiológica en Cali, Colombia / Clinical and epidemiological approach to Hepatitis C in Cali, Colombia

Resumen Introducción: en Colombia, la infección por el virus de la hepatitis C (VHC) representa alta morbilidad y elevados costos. Con la llegada de nuevos tratamientos más efectivos, se hace necesario conocer las características propias de esta población para su adecuado uso. Objetivos: describir las características epidemiológicas y clínicas de los pacientes con VHC manejados en un centro de referencia en enfermedades hepáticas. Materiales y métodos: se realizó un estudio descriptivo de corte transversal en una población de adultos con diagnóstico serológico de VHC entre el 2011 y el 2016. Resultados: se evaluaron 214 historias clínicas de pacientes con diagnóstico serológico confirmado de VHC. La mediana de edad fue de 59 años y el 62 % fue de sexo femenino. El genotipo se reportó en 114 pacientes, el 75 % presentó genotipo 1B. El 36,9 % de los pacientes había recibido algún hemoderivado y el 5 % tenía tatuajes. La prevalencia de cirrosis fue del 29,4 % y de hepatocarcinoma fue del 3,3 %. El 1,8 % y el 5,1 % de los pacientes presentó coinfección con el virus de la hepatitis B (VHB) y virus de la inmunodeficiencia humana (VIH), respectivamente. Conclusión: los factores determinantes de la infección por el VHC en Cali presentan un comportamiento clínico similar al que reporta la literatura científica a nivel mundial, lo que obliga a enfatizar en la prevención de la población en riesgo. El genotipo 1B continúa siendo el más frecuente en nuestro medio, lo que hace a esta población susceptible a los nuevos tratamientos.

Abstract Introduction: In Colombia, Hepatitis C virus infections have high rates of morbidity and high costs. The advent of new more effective treatments has produced a need for better knowledge of this population's characteristics to allow their proper use. Objectives: The objective of this study is to describe the epidemiological and clinical characteristics of patients with hepatitis C at a referral center for liver diseases. Materials and methods: We conducted a cross-sectional descriptive study of a population of adults with serological diagnoses of hepatitis C between 2011 and 2016. Results: We evaluated 214 clinical records of patients with confirmed serological diagnoses of hepatitis C. Their median age was 59 years, and 62 % were women. The HCV genotypes of 114 patients were reported: 75 % had genotype 1B. Transfusions of one or another type of blood product had been administered to 36.9 % of the patients, and 5% had tattoos. The prevalence of cirrhosis was 29.4 % while that of hepatocellular carcinoma was 3.3 %. Hepatitis B virus coinfections were found in 1.8 % of these patients, and 5.1 % of the patients had human immunodeficiency virus coinfections. Conclusion: The determinants of hepatitis C virus infection in Cali are similar to those reported in scientific literature worldwide and requires emphasis on prevention in the at-risk population. Genotype 1b continues to be the most frequent in our environment which makes this population susceptible to new treatments.

Flagellar biosynthesis exerts temporal regulation of secretion of specific Campylobacter jejuni colonization and virulence determinants.

The Campylobacter jejuni flagellum exports both proteins that form the flagellar organelle for swimming motility and colonization and virulence factors that promote commensal colonization of the avian intestinal tract or invasion of human intestinal cells respectively. We explored how the C. jejuni flagellum is a versatile secretory organelle by examining molecular determinants that allow colonization and virulence factors to exploit the flagellum for their own secretion. Flagellar biogenesis was observed to exert temporal control of secretion of these proteins, indicating that a bolus of secretion of colonization and virulence factors occurs during hook biogenesis with filament polymerization itself reducing secretion of these factors. Furthermore, we found that intramolecular and intermolecular requirements for flagellar-dependent secretion of these proteins were most reminiscent to those for flagellin secretion. Importantly, we discovered that secretion of one colonization and virulence factor, CiaI, was not required for invasion of human colonic cells, which counters previous hypotheses for how this protein functions during invasion. Instead, secretion of CiaI was essential for C. jejuni to facilitate commensal colonization of the natural avian host. Our work provides insight into the versatility of the bacterial flagellum as a secretory machine that can export proteins promoting diverse biological processes.

Hemerythrins in the microaerophilic bacterium Campylobacter jejuni help protect key iron-sulphur cluster enzymes from oxidative damage.

Microaerophilic bacteria are adapted to low oxygen environments, but the mechanisms by which their growth in air is inhibited are not well understood. The citric acid cycle in the microaerophilic pathogen Campylobacter jejuni is potentially vulnerable, as it employs pyruvate and 2-oxoglutarate:acceptor oxidoreductases (Por and Oor), which contain labile (4Fe-4S) centres. Here, we show that both enzymes are rapidly inactivated after exposure of cells to a fully aerobic environment. We investigated the mechanisms that might protect enzyme activity and identify a role for the hemerythrin HerA (Cj0241). A herA mutant exhibits an aerobic growth defect and reduced Por and Oor activities after exposure to 21% (v/v) oxygen. Slow anaerobic recovery of these activities after oxygen damage was observed, but at similar rates in both wild-type and herA strains, suggesting the role of HerA is to prevent Fe-S cluster damage, rather than promote repair. Another hemerythrin (HerB; Cj1224) also plays a protective role. Purified HerA and HerB exhibited optical absorption, ligand binding and resonance Raman spectra typical of µ-oxo-bridged di-iron containing hemerythrins. We conclude that oxygen lability and poor repair of Por and Oor are major contributors to microaerophily in C. jejuni; hemerythrins help prevent enzyme damage microaerobically or during oxygen transients.

Identification and analysis of flagellar coexpressed determinants (Feds) of Campylobacter jejuni involved in colonization.

The flagellum of Campylobacter jejuni provides motility essential for commensal colonization of the intestinal tract of avian species and infection of humans resulting in diarrhoeal disease. Additionally, the flagellar type III secretion system has been reported to secrete proteins such as CiaI that influence invasion of human intestinal cells and possibly pathogenesis. The flagellar regulatory system ultimately influences σ(28) activity required for expression of the FlaA major flagellin and other flagellar filament proteins. In this work, we discovered that transcription of ciaI and four genes we propose annotating as feds (for flagellar coexpressed determinants) is dependent upon σ(28) , but these genes are not required for motility. Instead, the Feds and CiaI are involved in commensal colonization of chicks, with FedA additionally involved in promoting invasion of human intestinal cells. We also discovered that the major flagellin influences production, stability or secretion of σ(28) -dependent proteins. Specific transcriptional and translational mechanisms affecting CiaI were identified and domains of CiaI were analysed for importance in commensalism or invasion. Our work broadens the genes controlled by the flagellar regulatory system and implicates this system in co-ordinating production of colonization and virulence determinants with flagella, which together are required for optimal interactions with diverse hosts.

Identification of Plasmodium falciparum family of SNAREs.

SNARE proteins function as specificity determinants in all eukaryotic vesicle-mediated transport pathways. Although the intra-erythrocytic parasite Plasmodium falciparum is known to target nuclear-encoded proteins via transport vesicles to several destinations within and beyond its plasma membrane, little is known about the role of SNARE proteins in these unusual trafficking pathways. In this study, we identified and compared the subunit structure of P. falciparum homologues of SNAREs (PfSNAREs) with their complements in mammals, and determined the subcellular localizations of some family members. A comprehensive bioinformatics analysis of the P. falciparum genome revealed 18 SNARE-like proteins that could be classified into five main phylogenetic groups: membrin-like, Bet1-like, VAMP-like, syntaxin5-like, and a P. falciparum-specific syntaxin-like subfamily. Unique to some PfSNARE proteins were presence of atypical amino acid residues at the "0" layer position, presence of up to two transmembrane segments, and frequent occurrence of low-complexity regions. Subcellular distribution of green fluorescence protein (GFP)-tagged P. falciparum SNARE orthologues indicates that PfSyn5p and PfSec22p are partly associated to ER and Golgi compartments, and to other punctuated structures within the parasite plasma membrane. Our data confirms of a conserved SNARE-mediated anterograde transport system in the parasite and argues against any involvement of these two SNAREs in vesicular trafficking within the host cell compartment.