Josué Barahona-Garrido

Association of GIST and somatostatinoma in a patient with type-1 neurofibromatosis: is there a common pathway?

Association of GIST and Somatostatinoma in a Patient With Type-1 Neurofibromatosis: Is There a Common Pathway?

Antinuclear Antibodies: A Marker Associated with Steroid Dependence in Patients with Ulcerative Colitis

Background: The autoimmune phenomena and the autoantibody profile have acquired great importance in ulcerative colitis (UC). Few studies have explored antinuclear antibodies (ANAs) prevalence, but not its association with steroid dependence. We hypothesized that ANAs could be a factor associated to steroid dependence. Methods: Ninety‐seven consecutive patients with UC were included. ANA titers and staining patterns were determined by indirect immunofluorescence. Gender, age, follow‐up time, C‐reactive protein (CRP), disease extent, Mayo Score Activity Index, extraintestinal manifestations, and steroid dependence were analyzed in univariate and multivariate models. Results: Ninety‐seven patients were included and 49 (50.5%) were females; mean age was 41.7 ± 22.2 years. Positivity for ANAs was encountered in 52 (53.5%) patients, and none for anti‐dsDNA. The prevalence of ANAs was higher in steroid‐dependent than in nonsteroid‐dependent patients (77.8% versus 48.1%, P = 0.020; odds ratio [OR] = 3.8, 95% confidence interval [CI] 1.1–12.5), and in those with uveitis (100% versus 51.1%; P = 0.040) or pyoderma gangrenosum (100% versus 51.6%; P = 0.078). No association was observed with gender, age, CRP, disease extent, and Mayo Score Activity Index. The multiple regression analysis model showed an association between steroid dependence and ANAs (P = 0.033, OR = 3.9, 95% CI 1.4–14.9). Conclusions: ANAs are associated with steroid dependence in UC patients. Further studies are required to determine the role of ANAs as serological markers for prediction of steroid dependence in order to perform early therapeutic interventions with biological agents.

Distinguishing between anti-neutrophil cytoplasmic antibody patterns in inflammatory bowel disease: is the "atypical pattern" adding more information?

Distinguishing Between Anti-Neutrophil Cytoplasmic Antibody Patterns in Inflammatory Bowel Disease: Is the “Atypical Pattern” Adding More Information?

New treatment options in the management of IBD - focus on colony stimulating factors

Inflammatory bowel disease (IBD) is characterized by inflammation of the gastrointestinal tract, typically with a relapsing and remitting clinical course. The intestinal inflammation in IBD is controlled by a complex interplay of innate and adaptive immune mechanisms. Innate immunity comprises a set of distinct elements, which includes circulating cells such as neutrophils, monocytes, and resident intestinal immune cells (dendritic and Paneth cells), as well as intestinal epithelium and cellular products, including antimicrobial peptides such as defensins and cathelicidins. Different components of innate immunity in IBD have been suggested to be defective or impaired. The human granulocyte-macrophage colony-stimulating factor (GM-CSF) and the human granulocyte colony-stimulating factor (G-CSF) have emerged as potential tools for the modulation of intestinal inflammation and repair. The greatest evidence supporting the use of colony-stimulating factors in intestinal inflammation comes from studies conducted in active Crohn’s disease (CD) patients treated with sargramostim and filgrastim, but evidence for its recommendation as treatment remains weak, as the majority of studies are open label, nonrandomized, and with a small number of patients.

Bacterial meningitis in cirrhotic patients: case series and description of the prognostic role of acute renal failure.

Aim To analyze the mortality risk factors in cirrhotic patients with bacterial meningitis (BM). Background Cirrhotic patients are susceptible to infections. Despite its high mortality rate, BM has not been extensively studied in this group of patients. Study BM patients diagnosed with cirrhosis, between 1987 and 2008, were studied. BM was defined as the presence of signs or symptoms of meningitis and a cerebrospinal fluid (CSF) leukocyte count >100/mm3 or the presence of bacteria in CSF. Results We identified 4955 infections among 7591 cirrhotic patients; 12 (0.2%) had BM. The mean age at diagnosis was 60±16 years. Abnormal mental status (83%), fever (67%), and neck stiffness (67%) were the most frequent clinical presentations. The sensitivity of CSF culture was 75% (Streptococcus pneumoniae, 2; Staphylococcus aureus, 2; Listeria monocytogenes, 1; Group B Streptococcus, 1; Streptococcus agalactiae, 1; Streptococcus bovis, 1; and Escherichia coli, 1), and its correlation with blood culture was 78%. Five patients died. On admission, the serum creatinine level was 1.63±0.93 mg/dL. A serum creatinine level ≥1.3 mg/dL was associated with increased mortality (P=0.028). The model for end-stage liver disease score, gastrointestinal bleeding, bilirubin level >3.5 mg/dL, hepatic encephalopathy, diabetes mellitus, and results of cytology and biochemistry tests of CSF were not associated with mortality. Conclusions BM in cirrhotic patients is associated with a high mortality rate. The clinical and microbiologic features of BM in cirrhotic patients differ from those in the general population. A serum creatinine level ≥1.3 mg/dL on admission is associated with a higher risk of mortality.

Diagnostic yield and therapeutic impact of rectal retroflexion: a prospective, single-blind study conducted in three centers.

Background/Aims No clear data have been established and validated regarding whether rectal retroflexion has an important and therapeutic impact. The aim of the present study was to evaluate the diagnostic yield and therapeutic impact of rectal retroflexion compared with straight view examination. Methods A prospective single-blind study was conducted. Consecutive patients evaluated between October 2011 and April 2012 were included. Results A total of 934 patients (542 women, 58%) were included. The mean age was 57.4±14.8 years. Retroflexion was successful in 917 patients (98.2%). Distinct lesions in the anorectal area were detected in 32 patients (3.4%), of which 10 (1%) were identified only on retroflex view and 22 (2.4%) on both straight and retroflex views. Of the 32 identified lesions, 16 (50%) were polyps, nine (28.1%) were angiodysplasias, six (18.8%) were ulcers, and one (3.1%) was a flat lesion. All 10 patients (1%) in whom lesions were detected only by rectal retroflexion showed a therapeutic impact. Conclusions Rectal retroflexion has minimal diagnostic yield and therapeutic impact. However, its low rate of major complications and the possibility of detecting lesions undetectable by straight viewing justify its use.

Growth Factors as Treatment for Inflammatory Bowel Disease: A Concise Review of the Evidence Toward Their Potential Clinical Utility

In the process of inflammation and repair of the intestinal mucosa in inflammatory bowel disease (IBD), there occurs a complex and an unknown interplay of innate and adaptive immune mechanisms. This interaction of factors may explain why IBD is characterized by a relapsing and remitting clinical course. Different components of innate immunity, hormones and interleukins in IBD have been suggested to be impaired. The growth hormone, epidermal growth factor, keratinocyte growth factor and colony-stimulating factors have emerged as potential tools for the modulation of intestinal inflammation and repair. Despite promising results of initial studies, the evidence that justify treatment of patients in clinical practice is not enough as some of the trials are nonrandomized or included a small number of patients. In this concise review, we provide a summary of the most recent and relevant evidence regarding the potential therapeutic effects of growth factors in IBD.

Fosfomycin-Containing Second-Line Treatment For Helicobacter pylori Infection

elevation was successfully managed with a dose reduction to 7.5 mg of weekly oral methotrexate. Th e patient began to notice some improvement in her symptoms and was able to begin tapering her prednisone at week 4 of infl iximab treatment. Repeat colon biopsies at week 5 of infl iximab therapy revealed persistent collagenous colitis. Th e patient discontinued prednisone at 8 weeks without recurrence of diarrhea, and gradually returned to her baseline weight. Following induction therapy, infl iximab maintenance therapy (5 mg / kg intravenously every 8 weeks) was administered. At ~ 6 months following infl iximab initiation, the patient remained asymptomatic and free of corticosteroids. Repeat colon biopsies revealed a normal appearing colon with no evidence of collagenous colitis ( Figure 1b ). Relapse and steroid dependence is not uncommon in microscopic colitis. Anti-tumor necrosis factor use has been reported as successful in 5 / 7 patients with refractory microscopic colitis ( 1,2 ). We demonstrate the successful use of infl iximab in a patient with severe refractory collagenous colitis resulting in symptomatic and histologic remission. Anti-tumor necrosis factor therapies can be considered in patients with refractory or cortico steroid dependent collagenous colitis.

Wallenberg's Syndrome: An Unusual Case of Dysphagia.

A 56-year-old man presented with sudden-onset oropharyngeal dysphagia and vomiting of central etiology. Neurological evaluation showed uvula deviation to the left, paresis of the mid-right portion of the soft palate, lateralization of gaze to the right side, and dysphonia. Magnetic resonance imaging (MRI) showed an infarction in the left lateral medullary region, therefore the diagnosis of Wallenberg’s syndrome was established. The neurological issues along with the dysphagia gradually improved and the patient was discharged.

Carta al DirectorMarcadores serológicos en enfermedad inflamatoria intestinal: diferencias poblacionales y limitaciones de su aplicaciónSerological markers in inflammatory bowel disease: Differences among populations and limitations of their application

Las pruebas de la asociación de marcadores serológicos (MS) con el comportamiento y fenotipo de la enfermedad inflamatoria intestinal (EII) han crecido de forma importante en los últimos años, pero es notable que haya diferencias entre las distintas poblaciones, especialmente cuando se trata de Latinoamérica. Hasta este momento, los anticuerpos anti-Saccharomyces cerevisiae (ASCA) y los anticuerpos anti-citoplasma del neutrófilo de patrón perinuclear (p-ANCA) son los MS mejor estudiados en EII. La certeza diagnóstica del estudio independiente de estos MS ha sido superada por la combinación de sus resultados, permitiendo una mejor diferenciación entre la enfermedad de Crohn (EC) y la colitis ulcerosa (CU). El fenotipo ASCA+/p-ANCA– es caracterı́stico de la EC, mientras que el fenotipo ASCA–/p-ANCA+ es caracterı́stico de CU. Recientemente, y desde que se reconoce el patrón atı́pico de los p-ANCA (x-ANCA), su interés está aumentando, ya que puede ser una herramienta útil para la distinción entre las formas de EII. Con la mejor distinción de los patrones de ANCA la prevalencia de pANCA, y probablemente su utilidad, es menor que la de xANCA. Antes de que se iniciara la distinción entre p-ANCA y x-ANCA se conocı́a que la prevalencia de los p-ANCA en pacientes mexicanos con CU era del 51%. Recientemente analizamos y queremos reportar que, como parte de un proyecto piloto, se estudió a un grupo de 60 pacientes con CU en el que observamos que la prevalencia de p-ANCA y de x-ANCA fue del 32 y del 40%, respectivamente. Parece haber diferencias entre poblaciones porque Desplat-Jégo et al recientemente reportaron en un estudio multicéntrico francés que la prevalencia de x-ANCA en pacientes con CU es del 71,8%. Estos resultados han motivado a que iniciemos el estudio de una cohorte de pacientes más grande para determinar su utilidad clı́nica, la que aún no es bien conocida. Ahora se tienen a disposición marcadores derivados de componentes de varias especies microbianas del intestino (anticuerpos contra la porina tipo C de la membrana externa de la Escherichia coli, anticuerpos contra la secuencia I2 asociada a Pseudomonas fluorescens, anticuerpos contra flagelina, anticuerpos contra los hidratos de carbono chitobioside, laminaribioside y mannobioside) que permiten nuevas formas de estratificar a los pacientes con EII. Estos marcadores pueden actuar como indicadores pronósticos y de comportamiento de la enfermedad; además, como en los ASCA y en los ANCA, al combinar sus resultados se obtiene una mejor certeza diagnóstica. A pesar del descubrimiento de estos nuevos MS, aún estamos lejos de disponer de un MS perfecto. El clı́nico debe conocer la utilidad de los MS e interpretarlos con cautela, brindando mayor importancia al juicio clı́nico porque no hay mejor herramienta que el análisis detallado de cada caso. Si bien los MS apoyan el diagnóstico de un fenotipo de EII, su sensibilidad y especificidad no son suficientes para ser útiles como pruebas de escrutinio o de uso habitual. Por último, el uso indiscriminado de los MS puede llevar a que se trate erróneamente a pacientes que no tienen EII o a que se retrase el diagnóstico en aquellos con pruebas negativas, especialmente cuando no se conoce la prevalencia de los MS en las distintas poblaciones.