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Coenzyme Q9 (COQ9), a coenzyme Q (CoQ) precursor, is an essential component of the mitochondrial electron transport chain that drives adenosine triphosphate production. COQ9 polymorphism 18:25527339 is characterized by substitution of guanine (allele G) for adenine (allele A), which modifies the function of the protein encoded by the gene. In Holsteins, allele A has been associated with better reproductive performance in terms of the conception rate, number of services per conception (SPC) and days open (DO). The signal transducer and activator of transcription (STAT) protein is a transcription factor activated in the presence of cytokines and growth factors. STAT5A polymorphism 19:42407732 in exon 8 has been associated with higher fertility and embryonic survival rates. The objective of this study was to determine the relationship of COQ9 and STAT5A polymorphisms with reproductive parameters [calving to first heat interval (CFHI), DO and SPC]. Blood samples were taken from 112 lactating Holstein from a herd in México for allele genotyping by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). To estimate the association between reproductive parameters and genotypes, a linear mixed-effect model was performed. The COQ9 AG genotype was associated significantly with lower SPC (P<0.05) but not with DO or CFHI. No significant association with any reproductive parameter was found for STAT5A. Our findings suggest that the COQ9 18:25527339 polymorphism is a useful molecular marker for improvement of reproductive performance in dairy herds.

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The 'Gait keeper' mutation in the DMRT3 gene alters locomotion and gait patterns in horses. This mutation (C>A) has been found in all gaited breeds of horses analyzed but is absent in most non-gaited breeds. We developed a new mutagenically separated polymerase chain reaction (MS-PCR) based method for simple detection of horse DMRT3 genotype. Our method was applied in a preliminary study to determine DMRT3 allele frequencies in 78 Azteca horses (AZ) and 53 Costa Rican Saddle Horses (CRSH). We found a wild-type C allele frequency of 100% in the AZ horses. For the CRSH, the wild-type C frequency and mutant A allele frequency were 88.7% and 11.3%, respectively.

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ABSTRACT Objective. To determine egg production in laying hens treated with oligofructose from agave. Materials and methods. Eighteen weeks old Hy-line W-36 hens (n = 300) were distributed randomly into 3 treatment groups: no feed supplementation (control) or feed supplementation with 0.1% of 0.2% oligofructose from agave (OFA). Hens were monitored from development until 30 weeks of egg laying. Results. A significant (p<0.05) increase in the percent of egg-laying hens as well as increased in egg weight and egg quality occurred in hens from the OFA treatment groups relative to the control hens. Significantly lower levels (p<0.05) of fecal putrescine were observed in hens from the OFA treatment groups. Conclusions. The oligofructose from agave may be used as an alternative feed additive in laying hens.

RESUMEN Objetivo. Determinar la producción de huevos en gallinas tratadas con oligofructosa de agave (OFA). Materiales y métodos. Se utilizaron 300 gallinas de la línea genética Hy-line w-36, de 18 semanas de nacidas, distribuidas aleatoriamente en tres tratamientos con cuatro repeticiones de 25 gallinas cada uno. Los tratamientos consistieron en tres niveles de OFA, 0, 0.1 y 0.2% en alimento. La prueba duró desde las 18 hasta las 30 semanas de postura. Resultados. Se presentó un incremento significativo (p<0.05) en el porcentaje de postura y peso del huevo, así como en índices de calidad del huevo a favor de tratamientos con OFA. Se encontraron valores significativamente (p<0.05) más bajos de putrescina fecal en las gallinas tratadas con OFA. Conclusiones. El uso de la OFA en gallinas ponedoras puede ser una alternativa como aditivo en la alimentación.

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BACKGROUND: Laparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate. AIM: The aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores. METHODS: A randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires. RESULTS: Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months. CONCLUSION: There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

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Theileria equi infection prevalence was calculated from 1000 blood samples obtained from apparently healthy horses in western Mexico. Samples were sent to the Animal Biotechnology Laboratory of the University of Guadalajara (Mexico) for T. equi diagnosis. Nested polymerase chain reaction (nPCR) was used as a diagnostic method to detect pathogen DNA. Using primers for the merozoite antigen-1 (EMA-1) gene, 19.70±2.47% of the horses (95% CI, 17.23-22.17%) tested positive for T. equi. There was no significant association between gender and T. equi infection. However, prevalence was higher among stabled horses (25.81%) than that among grazing horses (15.02%). The positivity rate was also higher among Quarter Horse (24.70%), Lusitano (35.90%), and Costa Rican Saddle Horse (47.37%) breeds than that among the other seven breeds investigated in this study. The percentage of T. equi infection was higher among adult horses (≥ 4years old, 25.05%) than that among colts and fillies (2-4years old, 15.48%), yearlings (1-2years old, 10.49%), and foals (<1year old, 10.34%). This is the first study of T. equi infection prevalence among horses in Mexico by nPCR . The results indicate that the equine piroplasmosis (EP) caused by T. equi is enzootic in western Mexico.

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Hydrocephalus in Friesian horses is an autosomal recessive hereditary disease that can result in an abortion, a stillbirth, or euthanization of a newborn foal. Here, the hydrocephalus-associated c.1423C > T mutation in B3GALNT2 gene was detected with PCR-RFLP and PCR-PIRA methods for horse genotyping. A preliminary genotyping survey was performed on 83 randomly selected Friesian stallion horses to determine the current allele frequency in Mexico. The frequency of the mutant T allele was 9.6%.

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Idiopathic achalasia is an archetype esophageal motor disorder, causing significant impairment of eating ability and reducing quality of life. The pathophysiological underpinnings of this condition are loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter (LES). The clinical manifestations include dysphagia for both solids and liquids, regurgitation of esophageal contents, retrosternal chest pain, cough, aspiration, weight loss and heartburn. Even though idiopathic achalasia was first described more than 300 years ago, researchers are only now beginning to unravel its complex etiology and molecular pathology. The most recent findings indicate an autoimmune component, as suggested by the presence of circulating anti-myenteric plexus autoantibodies, and a genetic predisposition, as suggested by observed correlations with other well-defined genetic syndromes such as Allgrove syndrome and multiple endocrine neoplasia type 2 B syndrome. Viral agents (herpes, varicella zoster) have also been proposed as causative and promoting factors. Unfortunately, the therapeutic approaches available today do not resolve the causes of the disease, and only target the consequential changes to the involved tissues, such as destruction of the LES, rather than restoring or modifying the underlying pathology. New therapies should aim to stop the disease at early stages, thereby preventing the consequential changes from developing and inhibiting permanent damage. This review focuses on the known characteristics of idiopathic achalasia that will help promote understanding its pathogenesis and improve therapeutic management to positively impact the patient's quality of life.

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Lethal white foal syndrome (LWFS) is an autosomal recessive disease of neonatal foals characterized by a white hair coat and a functional intestinal obstruction. Traditional techniques for identifying the dinucleotide mutation (TC→AG) of the endothelin receptor B gene (EDNRB) associated with LWFS are time-consuming. We developed a new technique based on mutagenically separated polymerase chain reaction (MS-PCR) for simple detection of the EDNRB genotype in horses.

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BACKGROUND: The Nissen fundoplication procedure is the most widely used type of antireflux surgery. The results are not always as good as expected, and several modifications to the original technique have been proposed. Long-term effectiveness studies comparing different techniques of antireflux surgery are limited. Our group developed a new concept in antireflux surgery (complete fixed "nondeformable" fundoplication) in order to improve its outcome; we present the long-term comparative results of this novel concept/technique. METHODS: Overall, 512 patients were included in the study and assigned into 1 of 3 fundoplications groups: partial (131), Nissen (133), and fixed "nondeformable" (121). We compared the groups with each other and with a group who chose to receive medical treatment (MT) (127). All patients underwent clinical evaluation, upper gastrointestinal endoscopy, esophageal manometry, 24-hour esophageal pH monitoring, and the SF-36 health status survey prior to operation and at 1, 5, 10, and 15 years of follow-up. RESULTS: At the 15-year follow-up, we were able to complete the protocol in 319 patients: 103 patients from the partial group, 102 patients from the Nissen group, 97 patients from the fixed "nondeformable" group, and 17 patients from the medical treatment group. A lower prevalence of erosive gastroesophageal reflux disease (GERD) was observed in the fixed "nondeformable" group (7.20%) versus 21.56% for Nissen, 39.80% for partial, and 47.05% for MT (P < .01). Lower esophageal sphincter (LES) pressure and LES length were more constant in the fixed "nondeformable" group (14.7 mm Hg/2.2 cm) compared with the Nissen (9 mm Hg/0.7 cm), partial (7 mm Hg/2 cm), and MT (5.64 mm Hg/1.3 cm) groups (P < .01). Reflux recurrence was observed in 168 patients (13 in fixed "nondeformable," 41 in Nissen, and 98 in partial (P < .01). CONCLUSION: The complete fixed "nondeformable" fundoplication showed best results in studied parameters and had a lower long-term recurrence compared with Nissen and partial techniques.

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BACKGROUND: There are several indications for the use of proton pump inhibitors (PPIs) but little evidence to support their use in patients with chronic liver disease. Moreover, the pattern of clinical use is unknown. The aim of the present study was to analyze the use of PPIs in patients with chronic liver disease in an ambulatory setting. MATERIAL/METHODS: This was a retrospective study in a clinical setting. Clinical variables, severity indexes, and endoscopic findings were assessed. Management of PPIs was classified according to proven indication as: G1, proven indication and a prescription; G2, no proven indication and prescription; G3, proven indication and no prescription; and G4, no proven indication and no prescription. G1+G4 were considered proper use of PPIs. The classification was used to identify variables associated with proper use. RESULTS: The study included 243 patients (mean age: 55.82+/-12.9 years). The most common etiologies of chronic liver disease were hepatitis C virus infection and chronic alcoholic liver disease. PPIs were indicated in 46.1% patients. Multivariate analysis showed that a MELD score < or =8 points (OR: 2.6, 95% CI: 1.3-5.3), esophageal varices (OR: 0.38, 95% CI: 0.16-0.90), and previous in-hospital use of PPIs (OR: 0.78, 95% CI: 0.6-0.9) were associated with G1+G4. CONCLUSIONS: Clinical use of PPIs in chronic liver disease was inappropriate in nearly one half of all patients. A less severe disease was associated with proper use and previous in-hospital use was associated with inappropriate use. Future research into the clinical use of PPIs in cirrhotic patients is mandatory.

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Colorectal cancer is an important neoplasm in general population, about 90% of the cases are sporadical, but near of 5% are due to hereditary non polyposis colorectal cancer. Early detection is imperative due to genetic linkage and association to other neoplasms diagnosed an early age. This case report is about a young man diagnosed with colorectal cancer that presented multiple recurrences and had at least two affected generations. The most important aspects of diagnosis, management and genetic counseling are discussed.

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BACKGROUND: Although the ingestion of chilli has been associated with gastroesophageal reflux (GER) symptoms, there are no studies that have explored the effect of a chronic ingestion of different kinds of chilli with a variable content of capsaicin as a cause of GER. METHODS: The effect of chilli on esophageal 24-hour pH monitoring was studied in 12 healthy subjects without GER symptoms before and after of ingestion one of two kinds of chilli. Patients were randomized to ingest 3 g daily of cascabel chilli (Capsicum annum coraciforme containing 880 ppm of capsaicin) or ancho chilli (Capsicum annum grossum containing 488 ppm of capsaicin). RESULTS: After chilli ingestion, the Johnson De Meester Index (JDI) increased significantly [basal: 7 (1-14), after chilli: 13 (2-69), p = 0.0047]. When considering both kinds of chilli separately, the JDI varied, although nonsignificantly, with the ancho chilli [basal: 3 (1-8), after chilli: 10 (2-69), p = 0.11], and significantly with the cascabel chilli [basal: 10 (5-14), after chilli: 18 (2-44), p = 0.028]. CONCLUSION: Our results suggest that the chronic ingestion of chilli induces GER, and that the magnitude of the induced reflux seems to be related to the kind of chilli.

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UNLABELLED: Fecal incontinence (FI) is a devastating condition that affects quality of life. Age and gender are related with the prevalence of FI. In adults, prevalence varies from 2% to 7%. It is more frequent in women than in men (3:1) and is more prevalent in elderly patients. There are no studies in Mexico that evaluate the frequency of FI in adults older than 60 years. AIM: To investigate the FI frequency, severity and associated factors in patients > or = 60 years. PATIENTS AND METHODS: Three groups of patients were included: a) Group I: consecutive outpatients patients from the Gastroenterology and Geriatrics Clinics of the INCMNSZ; b) Group II: INCMNSZ inpatients admitted due to a non-related condition with FI; c) Group III: Reyna Sofia nursing home residents (NHR) in Mexico City. A structured questionnaire was used to obtain demographic data, comorbidity and associated factors with FI. Grade of FI was assessed with the Wexner scale. RESULTS: 159 patients were included, 89 (56%) were women. Mean age was 75 years (range 59-98). There were 54 patients in group I, 50 in group II and 55 in group III. Overall frequency of FI was 33% (n = 53). Frequency of FI was 26% in group 1, 20% in group II and 53% in group III. Sixty six percent (n = 35) of the FI cases were female. Neuropsychiatric disorders were associated to FI in 29 patients (54%) and diabetes mellitus in 17 (32%). Eighty percent of patients wore disposable pads for FI. Urinary incontinence was associated to FI in 31 (58%). Thirteen (24%) patients had mild FI, 20 (38%) moderate, and 20 (38%) severe FI. The severity score for FI was lower in groups I and II (8.1 y 9.7) than in group III (18, p = 0.001). Age in patients with mild FI was significantly lower (73 years) than in patients with severe FI (83y, p = 0.01). CONCLUSIONS: FI in patients older than 60 years old is a very common condition. FI was more frequent and severe in women, in NHR and in those with neuropsychiatric disorders. Urinary incontinence was associated in half of patients with FI.

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Patients with chest pain of presumed esophageal origin should be reassured and should undergo an esophageal manometry study. In patients with spastic esophageal disorders, a trial with calcium channel blockers or low-dose antidepressants used as visceral analgesics is the best approach. Inpatients with non GERD-related, nonspastic esophageal motility disorder, low-dose antidepressants seem reasonable. Anxiolytics are useful in patients with panic disorders, and psychological interventions (eg, cognitive-behavioral therapy) are also valuable, mainly in patients in whom reassurance is not sufficient to avoid the misinterpretation of their symptoms. In the future, visceral sensitivity modifying agents such as serotoninergic agonists or antagonists may become the cornerstone of therapy in patients with chest pain of presumed esophageal origin. Combinations of different approaches, such as proton pump inhibitors and psychotropic or antinociceptive agents, should also be evaluated in clinical trials.

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Fecal incontinence (FI) is a devastating condition that affects quality of life. Age and gender are related with the prevalence of FI. In adults, prevalence varies from 2% to 7%. It is more frequent in women than in men (3:1) and is more prevalent in elderly patients. There are no studies in Mexico that evaluate the frequency of FI in adults older than 60 years. Aim. To investigate the FI frequency, severity and associated factors in patients ≥ 60 years. Patients and methods. Three groups of patients were included: a) Group I: consecutive outpatients patients from the Gastroenterology and Geriatrics Clinics of the INCMNSZ; b) Group II: INCMNSZ inpatients admitted due to a non-related condition with FI; c) Group III: Reyna Sofia nursing home residents (NHR) in Mexico City. A structured questionnaire was used to obtain demographic data, comorbidity and associated factors with FI. Grade of FI was assessed with the Wexner scale. Results. 159 patients were included, 89 (56%) were women. Mean age was 75 years (range 59-98). There were 54 patients in group I, 50 in group II and 55 in group III. Overall frequency of FI was 33% (n = 53). Frequency of FI was 26% in group I, 20% in group II and 53% in group III. Sixty six percent (n = 35) of the FI cases were female. Neuropsychiatric disorders were associated to FI in 29 patients (54%) and diabetes mellitus in 17 (32%). Eighty percent of patients wore disposable pads for FI. Urinary incontinence was associated to FI in 31 (58%). Thirteen (24%) patients had mild FI, 20 (38%) moderate, and 20 (38%) severe FI. The severity score for FI was lower in groups I and II (8.1 y 9.7) than in group III (18, p = 0.001). Age in patients with mild FI was significantly lower (73 years) than in patients with severe FI (83y, p = 0.01). Conclusions. FI in patients older than 60 years old is a very common condition. FI was more frequent and severe in women, in NHR and in those with neuropsychiatric disorders. Urinary incontinence was associated in half of patients with FI.

La incontinencia fecal (IF) es una condición que afecta la calidad de vida del enfermo. La prevalencia está relacionada con la edad y el género. Afecta de 2 a 7% de los adultos y es tres veces más frecuente en mujeres que hombres. En personas mayores de 65 años la frecuencia de IF se incrementa y varía según la población estudiada. En México no existen estudios que evalúen la frecuencia de IF en los adultos mayores. Objetivo. Investigar la frecuencia, gravedad y factores asociados a la IF en tres poblaciones de pacientes adultos mayores de 60 años. Pacientes y métodos. Se realizó un estudio descriptivo en el cual se evaluaron tres poblaciones de pacientes adultos > de 60 años: a) Grupo I, pacientes consecutivos que acudieron a la consulta externa de Gastroenterología y Geriatría del INCMNSZ; b) Grupo II, pacientes hospitalizados en el INCMNSZ por motivos diferentes a la IF; y c) Grupo III, pacientes residentes del asilo Reina Sofía de la Ciudad de México. Mediante un cuestionario estructurado se investigaron datos demográficos, tiempo de evolución, comorbilidad y factores asociados a la IF. El grado de IF se evaluó mediante la escala de Wexner modificada por Kamm. Resultados. Se evaluaron 159 pacientes, 89 (56%) mujeres. La edad promedio fue de 75 años (rango 59-98). Hubo 54 pacientes en el grupo I, 50 en el grupo II y 55 en el grupo III. Cincuenta y tres pacientes (33%) presentaron IF. La frecuencia de IF fue de 26% en el grupo I, de 20% en el grupo II y de 53% en el grupo III. De los casos con IF, 66% (n = 35) fueron mujeres. Veintinueve pacientes (54%) tuvieron trastornos neuropsiquiátricos asociados y 17 (32%) diabetes mellitus. De los pacientes, 80% utilizaron pañal. La incontinencia urinaria estuvo presente en 31 (58%) pacientes. De acuerdo con la escala de gravedad, 13 (24%) pacientes tuvieron IF leve, 20 (38%) moderada y 20 (38%) tuvieron IF grave. Los pacientes de los grupos I y II tuvieron puntuaciones menores en la escala de gravedad (8.1 y 9.7) que los pacientes del grupo III (18, p = 0.001). Los pacientes con IF leve tuvieron un promedio de edad menor (73 años) que los pacientes con IF grave (83 años, p = 0.01). Conclusiones. La frecuencia de IF en pacientes adultos mayores es elevada y afecta a la mitad de los pacientes residentes de un asilo. El grado de IF es más grave en las mujeres, en los pacientes residentes de un asilo y con trastornos neuropsiquiátricos. La incontinencia urinaria se asoció a IF en más de la mitad de los pacientes.

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PURPOSE: In this prospective study we investigated the feasibility, safety, and efficacy of radio-frequency energy delivery deep to the mucosa of the anal canal for the treatment of fecal incontinence. METHODS: We studied ten patients with fecal incontinence of varying causes. All patients underwent anoscopy, anorectal manometry, endorectal ultrasound, and pudendal nerve terminal motor latency testing at baseline and six months. The Cleveland Clinic Florida scale for fecal incontinence (Wexner, 0-20), fecal incontinence-related quality of life score, and Short Form 36 were administered at baseline, 1, 2, 3, 6, and 12 months. Using conscious sedation and local anesthesia, we delivered temperature-controlled radio-frequency energy via an anoscopic device with multiple needle electrodes to create thermal lesions deep to the mucosa of the anal canal. RESULTS: Ten females (age, 55.9 +/- 9.2 years; range, 44-74) were enrolled and treated. Median discomfort by visual analog scale (0-10) was 3.8 during and 0.9 two hours after the procedure. Bleeding occurred in four patients (14-21 days after procedure), spontaneous resolution (n = 3) and anoscopic suture ligation (n = 1). At 12 months, the median Wexner score improved from 13.5 to 5 (P < 0.001), with 80 percent of patients considered responders. All parameters in the fecal incontinence-related quality of life were improved (lifestyle (from 2.3 to 3.4), coping (from 1.4 to 2.7), depression (from 2.2 to 3.5), and embarrassment (from 1.3 to 2.8); P < 0.05 for all parameters). Protective pad use was eliminated in five of the seven baseline users. At six months, there was a significant reduction in both initial and maximum tolerable rectal distention volumes. Anoscopy was normal at six months. CONCLUSION: Radio-frequency energy delivery to the anal canal for treatment of fecal incontinence is a new modality that, in this study group, safely improved Wexner and fecal incontinence-related quality of life scores, eliminated protective pad use in most patients, and improved patient quality of life.

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A través del análisis citogenético se diagnosticaron como freemartin cinco individuos seleccionados de un total de 10 bovinos (Bos taurus) que tenían el antecedente de proceder de partos múltiples heterosexuales; asimismo, se estudiaron anatomopatológicamente dos de estos individuos. La presencia de quimerismo cromosómico (60,XX/60,XY) caracterizó a los animales estudiados, excepcionalmente un individuo freemartin mostró tan sólo células 60,XY, en tanto que los hallazgos anatomopatológicos de dos freemartin estudiados hasta su sacrificio exhibieron masculinización del tracto reproductor con únicamente tejido testicular en las gónadas.

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La hemorragia es una complicación poco frecuente en pacientes con acalasia. La esofagitis por estasis es una causa rara de tal evento en la que las formas convencionales de tratamiento pueden asociarse con alto riesgo de complicaciones agudas. La toxina botulínica ha surgido como una alternativa terapéutica útil con muy pocos efectos secundarios. Presentamos un caso de hemorragia asociada a esofagitis por estasis en una paciente con acalasia y desnutrición grave que fue tratada en forma exitosa con toxina botulínica. Se discuten aspectos interesantes de la esofagitis por estasis y el papel de la toxina botulínica en el tratamiento de la acalasia.

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Objetivo. Determinar la prevalencia de manifestaciones atípicas (MA) de la enfermedad por reflujo gastroesofágico (ERGE) en pacientes con esofagitis péptica comparada con la de sujetos controles. Métodos. Se estudiaron pacientes consecutivos que acudieron a nuestro instituto de enero a agosto de 1997 para endoscopia de tubo digestivo proximal. Se clasificaron en dos grupos: a) casos, enfermos con diagnóstico endoscópico de esofagitis péptica; y b) controles, enfermos sin síntomas típicos de ERGE ni evidencia de esofagitis en la endoscopia. Se les aplicó un cuestionario para evaluar la presencia intergrupos significativas en género (p= 0.2), edad (p= 0.4=, antecedentes de tabaquismo (p = 0.7= ni antecedentes de atopia (p = 0.6=. Las MA de la ERGE fueron más frecuentes en los casos (66 por ciento) que en los controles (42 por ciento), con diferencia estadísticamante significativa (RM = 2.7, IC 1.2-6, p = 0.02). La MA con mayor frecuencia en los casos fueron disfonía (RM = 9.3, IC = 1.1-77), dolor torácico (4.9, 1.8-14) y globus (2.8, 0.9-9). El desarrollo de las MA no se asoció a grado de esofagitis (p= 0.7), presencia o intensidad de manifestaciones típicas (p= 0.2), género (p= 0.4) ni edad de los pacientes (p= 0.2). Conclusiones. Los enfermos con esofagitis por reflujo mostraron mayor riesgo de desarrollar manifestacione sextraesofágicas que involucraron farínge, larínge y pulmones

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