Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología

INTRODUCTION

Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment.

AIM

The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD.

METHODS

The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires.

RESULTS

Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient.

CONCLUSIONS

An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.

Intra-individual variation of sperm DNA fragmentation in the Human ejaculate

This retrospective study assessed the biological intra-individual variability of the percentage of sperm with DNA damage (SDF) observed in subsequent ejaculates of the same individual. Variation in SDF was analyzed using the Mean Signed Difference (MSD) statistic based on 131 individuals, comprising 333 ejaculates. Either two, three or four ejaculates were collected from each individual. With this cohort of individuals two main questions were addressed; (1) does the number of ejaculates analyzed influence the variability in the level of SDF associated with each individual? and (2) is the variability observed in SDF similar when individuals are ranked according to their level of SDF? Results showed that the variation observed in mean SDF was not different when 2, 3 or 4 ejaculates were analyzed; consequently, we suggest that the assessment of SDF based on two ejaculates is likely to be representative of the mean SDF expected for the individual. In parallel, it was determined that the variation in SDF increased as SDF increased; in individuals presenting with an SDF value of lower than 30% (potentially fertile), only 5% possessed levels of MSD that could be considered as variable as that presented by individuals presenting with a recurrent high SDF. Finally, we showed that a single assessment of SDF in individuals with medium SDF (20-30%) was less likely to be predictive of the SDF value in the next ejaculate, and therefore, less informative of the patient's SDF status.

The efficacy of novel centrifugation-free sperm selection (Io-Lix) on sperm parameters and ICSI reproductive outcomes

RESEARCH QUESTION

What is the effect of a novel non-centrifugation method (Io-Lix) of sperm selection on sperm parameters and intracytoplasmic sperm injection (ICSI) reproductive outcomes?

DESIGN

This pilot study elevated the capacity of the Io-Lix sperm selection protocol to improve sperm parameters (concentration, motility and sperm DNA fragmentation) of the neat ejaculate. Once established, the reproductive outcomes of Io-Lix selected spermatozoa were used for autologous and donor oocyte ICSI programmes and their efficacy compared with those using conventional swim-up.

RESULTS

Io-Lix sperm selection resulted in lower sperm concentration yield (P < 0.001) and sperm DNA fragmentation (P < 0.001) but higher sperm motility (P < 0.001) when compared with spermatozoa in the neat ejaculate. When compared with swim-up sperm selection the Io-Lix protocol resulted in a 14.7% (P = 0.028) increase in pregnancy rate and 16.3% (P = 0.047) reduction in miscarriages in the autologous ICSI programme. A similar comparison of sperm selection procedures employed for a donor oocyte ICSI programme showed no difference in terms of their respective reproductive outcomes.

CONCLUSIONS

The Io-Lix sperm selection protocol resulted in improved pregnancy rate and reduction in miscarriage when applied to autologous ICSI, which was attributed to a reduction in the proportion of spermatozoa with DNA damage post-selection. A similar finding was not apparent in the donor oocyte programme, which may be associated with the capacity of the donor oocyte to repair sperm DNA post-syngamy.

Gastroesophageal reflux disease after peroral endoscopic myotomy: Short-term, medium-term, and long-term results

INTRODUCTION AND AIMS

Achalasia is characterized by incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. The efficacy of peroral endoscopic myotomy (POEM) is similar to that of the Heller myotomy, with an apparently greater prevalence of gastroesophageal reflux disease. Our aim was to determine the presence of GERD in a post-POEM cohort of Mexican patients with achalasia and follow-up of at least 12 months.

MATERIALS AND METHODS

A retrospective cohort study was conducted on post-POEM patients with a minimum of 12 months of follow-up, within the time frame of 2012 to 2017. Pregnant patients were excluded. Serial endoscopy, pH study, and GERDQ application were performed. Univariate and bivariate data analyses were carried out and statistical significance was set at a P<0.05.

RESULTS

Sixty-eight patients had post-POEM follow-up for 12 months. Of those patients, follow-up continued to 24 months for 58, 36 months for 47, 48 months for 39, and 60 months for 25. Mean patient age was 47.8±14.3 years, 57.3% of the patients were women, 77.9% were treatment-naïve, and 54.4% had type II achalasia. The pH study, endoscopy, and questionnaire were positive in 73, 28, and 18% at 3 months; 48, 35, and 13% at 6 months, and 55, 30, and 15% at 12 months, respectively. Once the proton pump inhibitor was begun, the percentages decreased to 5, 2, and 6% at 24 months; 6, 2, and 8% at 36 months; 4,1, and 6% at 48 months; and 3, 1, and 4% at 60 months, respectively. There was no relation between the efficacy of POEM and the presence or intensity of GERD. There were no secondary complications due to gastroesophageal reflux.

CONCLUSIONS

The post-POEM prevalence of GERD was 50% in the short term (12 months), with no evidence of complications at the medium term or long term (60 months). Gastroesophageal reflux was adequately controlled through proton pump inhibitors administration in over 95% of the cases.

Clinical assessment and health-related quality of life in patients with non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain (NCCP) is mainly related to oesophageal disease, and in spite of being a common condition in Mexico, information regarding it is scarce.

AIM

To assess the clinical characteristics and health-related quality of life of patients with NCCP of presumed oesophageal origin.

MATERIAL AND METHODS

Patients with NCCP of presumed oesophageal origin with no previous treatment were included in the study. Associated symptoms were assessed and upper gastrointestinal endoscopy and 24-hour oesophageal pH monitoring were performed to diagnose gastroesophageal reflux disease, while oesophageal manometry was used to determine oesophageal motility disorders. The SF-36 Health-Related Quality of Life (HR-QoL) questionnaire was completed and its results compared to a control group without oesophageal symptoms.

RESULTS

The study included 33 patients, of which 61% were women, and the mean age was 46.1 (±11.6) years. Causes of NCCP were gastroesophageal reflux disease in 48%, achalasia in 34%, and functional chest pain in 18%. The average progression time for chest pain was 24 (2-240) months, with ≤ 3 events/week in 52% of the patients. The most frequent accompanying symptoms were: regurgitation (81%), dysphagia (72%) and heartburn (66%). Patients with NCCP show deterioration in HR-QoL compared to the control group (P=.01), regardless of chest pain aetiology. The most affected areas were general perception of health, emotional issues, and mental health sub-scale (P>0.05).

CONCLUSIONS

In our population, patients with NCCP show deterioration in HR-QoL regardless of the aetiology, frequency, and accompanying symptoms.

Seminal quality in the first fraction of ejaculate

Semen samples from 40 patients were collected in consecutive fractions. The variability in semen quality of each fraction was then determined. The first ejaculated fraction (FEF) primarily contained prostatic secretions, while the second ejaculate fraction (SEF) held the majority of the spermatozoa suspended in the secretions from the seminal vesicle. Differences in sperm quality were observed when the FEF was compared to the SEF and the total ejaculate fraction (TEF). These included the seminal parameters (volume, sperm concentration, motility) and sperm DNA fragmentation (SDF). When compared to TEF and SEF, the FEF presented a lower volume, higher sperm concentration, higher motility rates, and lower SDF. The data suggest that the first fraction renders an improved subpopulation of spermatozoa, with lower SDF. Spermatozoa from this fraction and hence their use for ART may have a positive effect on fertilization and embryo development.

Shorter abstinence decreases sperm deoxyribonucleic acid fragmentation in ejaculate

OBJECTIVE

To evaluate the relationship between duration of sexual abstinence and sperm selection on sperm DNA fragmentation (SDF).

DESIGN

Prospective study based on normozoospermic individuals.

SETTING

Fertility and IVF unit and university unit for research.

PATIENT(S)

Two cohorts of normozoospermic individuals: 21 men (aged 25-35 years) attending a clinic and with clearly adverse female factors; and a group of 12 selected donors (aged 20-25 years).

INTERVENTION(S)

SDF assessment using the sperm chromatin the dispersión test (Halosperm) in two cohorts of normozoospermic men.

MAIN OUTCOME MEASURE(S)

SDF assessment after 24 hours of abstinence with recurrent ejaculation (one every 24 hours) using neat sperm samples; and SDF assessment before and after sperm selection with abstinence of 3 hours.

RESULT(S)

Lower baseline levels of SDF were observed after shorter periods of abstinence between ejaculations (24 hours and 3 hours) than those recommended. This effect is much more marked after quick repetitive ejaculation (3 hours of abstinence) and sperm selection.

CONCLUSION(S)

The present results challenge the role of abstinence in current male infertility treatments and suggest that SDF can be efficiently reduced by a biological practice consisting of short-term recurrent ejaculation coupled with effective sperm selection.

Clinical and manometric findings on elderly patients with achalasia

INTRODUCTION

Data regarding the age impact on the clinical presentation and esophageal motility in adults with idiopathic achalasia are scarce.

OBJECTIVE

To asses the clinical and manometric features of elderly patients with idiopathic achalasia.

METHODS

The medical charts of 159 patients diagnosed with achalasia were divided into two groups according to the patients' age: ?60 years (n = 123) and >60 years (n = 36). Clinical and manometric findings [esophageal body aperistalsis, basal lower esophageal sphincter (LES) pressure and abnormal LES relaxation] of both groups were compared upon diagnosis. Patients with previous esophageal interventions were excluded.

RESULTS

Only chest pain was more common in the ?60 year-old group (51.2% vs. 22.2%, p <0.003). This difference remained when comparing the group of men ≤60 years. Other presenting features (including sex, weight loss, and presence of dysphagia, regurgitation and heartburn) did not differ between the groups. The LES relaxation was incomplete in 70.4% of the cases. No differences on the basal LES pressure, residual LES pressure or the amplitude of the esophageal body contractions between both groups were found. Considering only the classic achalasia cases, symptomatic time before diagnosis was greater in ≤60 years compared with older patients: 24 vs. 12 months (p <0.05), respectively.

CONCLUSIONS

These results suggest that chest pain is more common in younger male achalasia patients and residual LES pressure decreases with age.

[Pharmacological treatment of the irritable bowel syndrome: a technical review]

INTRODUCTION

The goal of a comprehensive treatment in irritable bowel syndrome (IBS) patients should be the improvement of symptoms and improve the quality of life.

AIM

To review the drugs recommended in IBS, their mechanisms of action, side effects, risks and benefits, contraindications, availability in our country and the evidence supporting their use.

MATERIAL AND METHODS

A technical and narrative review which evaluated the articles published in national and world literature regarding the pharmacological treatment of IBS was performed. PubMed and IMBIOMED electronic databases were searched (until September 2009) using all descriptors regarding IBS and drug therapy.

RESULTS

There is enough clinical evidence to recommend the use of antispasmodics (alone orin combination) and tricyclic antidepressants for pain treatment in IBS. Laxatives are useful in the management of chronic constipation, but there is little evidence in the management of IBS. Although, antiflatulents and antidiarrheals are widely used there is little information supporting its use. The use of a nonabsorbable antibiotic (rifaximin) is effective in a subgroup of IBS patients. Serotoninergics drugs have proven effective in relieving symptoms of IBS; however, these drugs require caution in their use. There are studies have shown that probiotics improve some symptoms of IBS.

CONCLUSIONS

There are many effective treatment options in the symptomatic management of IBS. The choice of treatment should be based on the predominant symptoms of each patient.

Estrogenic effects of p-hydroxybenzoic acid in CD1 mice

Xenobiotic estrogens in the environment or diet have received much attention as a possible source of certain hormonal disease states in human and wildlife. Therefore, the detection of estrogenic activity of any substance, especially those related to the food industry, is important. The estrogenic activity of p-hydroxybenzoic acid (PHBA), a compound related to a commonly used group of preservatives in food, cosmetic, and pharmaceutical preparations, was evaluated with immature and adult ovariectomized female mice (CD1) using two well-known bioassays. Subcutaneous administrations (s.c.) of different doses of PHBA were compared with estradiol (E2), and their effects on vaginal cornification and uterotrophic activities were evaluated. Different groups of animals were treated s.c. daily for 3 days with vehicle (corn oil, 0.3 ml/100 g), E2 (1 microgram/100 g), and PHBA (0.5, 5, 50, and 500 micrograms/100 g). Four days after treatment, PHBA produced a dose-dependent response on vaginal cornification and uterotrophic activity in both immature and adult ovariectomized mice. The relative uterotrophic potency of PHBA (500 micrograms/100 g) to E2 (1 microgram/100 g) was 0.0011 in immature mice and 0.0018 in ovariectomized animals.

[Therapeutic effectiveness of anticoagulation in acute myocardial infarction: a case-control study]

The main aim was to assess the role of anticoagulant therapy (AT) in reducing the mortality for patients with acute myocardial infarction (AMI). A pair-matched case-control study was designed according to three confounding factors: gender, age (+/- 5 years), and hospitalization date (+/- 13 months). Cases were defined as patients with AMI who died during hospitalization and controls were those patients with AMI who survived. Excluded from the study were patients with strong indications or contraindications for use of AT, and also those with early death (less than 12 hr). The study undertaken at the National Institute of Cardiology "Ignacio Chávez" of Mexico City and all necessary information was obtained from clinical charts of patients discharged between the period from January 1, 1975 to December 31, 1985. Complete information was accomplished for 212 pairs of cases and controls. A protective odds ratio (favoring use of AT) = 12.1 (p less than 0.0001, 95% CI 4.2-34.9) was obtained by means of a multiple logistic regression analysis by conditional method. Other variables that entered into the logistic model were: antithrombotic therapy, severity measured by Killip scale and by Norris index. Such findings support the favorable therapeutic role of AT in patients with AMI.

A fast transient hyperpolarization occurs during the sea urchin sperm acrosome reaction induced by egg jelly

The egg jelly-induced sea urchin sperm depolarization, assayed with the membrane potential-sensitive dye diS-C3-(5), is preceded by a fast quenching, which was initially taken as an artifact. Here we show that part of this quenching results from a K+-dependent transient hyperpolarization (approximately 4 s). Seawater containing 25-35 mM KCl inhibits this hyperpolarization, the depolarization and the acrosome reaction induced by egg jelly, or by the acrosome reaction inducing factor purified therefrom. These results suggest that egg jelly induces a transient hyperpolarization mediated by an increase in K+ permeability, which may be involved in triggering the acrosome reaction.

Internal pH can regulate Ca2+ uptake and the acrosome reaction in sea urchin sperm

The egg jelly-induced acrosome reaction of sea urchin sperm is accompanied by intracellular alkalinization and Ca2+ entry. We have previously shown that in the absence of egg jelly, NH4Cl, which increases intracellular pH (pHi), induces Ca2+ uptake and the acrosome reaction in sperm of the sea urchin, Strongylocentrotus purpuratus. Here we show that at a constant concentration of NH4Cl (20 mM) in seawater, sperm react less as external pH is lowered from the normal 8 to 7.25. The pH dependence of the NH4Cl response is not very sensitive to temperatures between 12 and 17 degrees C. NH4Cl (15-50 mM) stimulates Ca2+ uptake and acrosome reactions in sperm suspended in Na+-free seawater, a condition known to inhibit the inductive effect of jelly. Jelly does not further stimulate Ca2+ uptake of sperm preincubated in NH4Cl, indicating that once the permeability to Ca2+ is increased by raising the pHi, the jelly has no further effect. We have used the membrane potential-sensitive dye 3,3'-dipropylthiadicarbocyanine iodide to follow the membrane potential change that occurs when NH4Cl is added. Depolarization (25 mV) is associated with the acrosome reaction when either the natural inducer, egg jelly, or NH4Cl is added to sperm. Response to both inducers is inhibited under conditions known to abolish the acrosome reaction, i.e., low-pH seawater and nisoldipine. These results indicate that the NH4Cl-induced depolarization that accompanies the reaction is probably due to the opening of channels that allow Ca2+ to enter the cell and not to the depolarization by NH4+ ions. High-K+ seawater, which depolarizes sperm, and tetraethylammonium, a K+ channel blocker, inhibit the jelly-induced depolarization and the acrosome reaction, but do not inhibit NH4Cl-induced changes. It has already been shown that nigericin promotes Ca2+ entry and the acrosome reaction in sea urchin sperm. We found that the action of this ionophore depends on the pH of normal seawater. In the absence of external Na+ (replaced by choline), nigericin does not induce the reaction and does not stimulate Ca2+ uptake.