Compromising between European and US allergen immunotherapy schools: Discussions from GUIMIT, the Mexican immunotherapy guidelines

Background: Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools. Methods: Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, see Supplementary data) concluded the following: Results: Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50–200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico. Conclusions: Countries where European and American AIT extracts are available should adjust AIT according to which school is followed

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Vitamina D como adyuvante a la inmunoterapia específica subcutánea en pacientes con rinitis alérgica

Ciencias Médica

Factores asociados a enfermedad pulmonar obstructiva crónica, hospitales José Carrasco Arteaga y Vicente Corral Moscoso, 2011-2012

Objetivo: Determinar los factores asociados a enfermedad pulmonar obstructiva crónica en pacientes entre 40 y 85 años en los departamentos de Medicina Interna y Neumología de los hospitales José Carrasco Arteaga y Vicente Corral Moscoso entre el 2011 y 2012. Materiales y Métodos: Se realizó un estudio de casos y controles. La muestra se calculó sobre la base del 95% de nivel de confianza, 80% de poder estadístico, OR de 3 y 10% del factor de exposición con más baja frecuencia; se pareó por edad y sexo e ingresaron al estudio de manera secuencial. Los datos se obtuvieron por entrevista directa y se analizaron con el programa SPSS.-Resultados: Se evaluó a 318 sujetos, 106 casos y 212 controles. Los grupos fueron similares en promedio de edad y sexo (p> 0.05). El 72.3% fueron hombres; el promedio de edad fue 62.4 años (±13.1D.E.). El índice paquetes/años superior a 20 resultó ser factor de riesgo para EPOC (OR de 9.03, IC95%, 3.76 21.72; valor de p = 0.000), al igual que la exposición al humo de leña en horas/años mayor a 100 (OR de 9.65, IC 95% 4.87 19.32; valor de p = 0.000). La exposición al polvo, contaminación ambiental y antecedente familiar de EPOC en los padres, no resultaron ser factores de riesgo. Conclusiones:Main objective: Our main objective is to determine risk factors which are associated to chronic pulmonary disease, among patients who are 40-85 years old, who were attended to the external consultation wards or admitted to the Internal Medicine and Pneumology Departments of the Jose Carrasco Arteaga and Vicente Corral Moscoso hospitals from 2011 to 2012. Materials and methods: This is a case-control research. Our sample was calculated taking in account a 95% confidence interval, 80% ratio of statiscal power, odds ratio of 3 and a 10% of exposition factor with its lowest frequency; a couple procedure was applied according to sex and age and were interned in a sequential manner. All data was obtained by a direct interview and was analyzed with the SPSS analytics software. Results: 318 patients were evaluated, of whom, 106 were cases and 212 controls. Both groups were similar in relation to age and sex (p>0.05). 72.3% were male, with an average of 62.4 years old (±13.1D.E.). The pack/year index superior to 20 was a risk factor for COPD (OR de 9.03, CI95%, 3.76 – 21.72; p = 0.000), equally biomass fumes exposure in years/hours index greater than a 100 (OR 9.65, CI 95% 4.87-19.32, p=0.000). Dust exposure, air pollution and family antecedents of COPD in patients’ parents were not risk factors for COPD. Conclusions: The risk factors for COPD are attributable to smoking and biomass fumes exposure.Especialista en Medicina InternaCuenc

DRESS syndrome or reaction to drugs with eosinophilia and systemic symptoms associated to anti-tuberculosis drugs

Tuberculosis has increased all over the world. This paper reports the case of a male patient with tuberculous meningitis, spinal tuberculosis (Pott’s disease) and severe adverse reactions to antituberculosis drugs. He had skin rash, hepatitis, eosinophilia and fever; all these signs make the diagnosis of DRESS syndrome. This syndrome is caused by a severe hypersensitivity reaction to different drugs. It is usually caused by anticonvulsants, sulfonamides and some antiviral drugs, among other drugs. Anti-tuberculosis drugs can also cause this potentially fatal syndrome. The importance of surveillance for early detection and treatment of adverse drug reactions is emphasized

Allergic Bronchopulmonary Aspergillosis

Allergic bronchopulmonary aspergillosis is a slowly progressive disease, caused by the fungus Aspergillus fumigatus hypersensitivity when it is found in the airway. It usually affects asthmatics and patients with cystic brosis. We report the case of a 20-year-old male patient, student, farmer and rancher with chronic respiratory disease. The diagnosis of allergic bronchopulmonary aspergillosis was made on the basis of the clinical symptoms and complementary studies

Aeroallergen immunotherapy associated with reduced risk of severe COVID-19 in 1095 allergic patients

Introduction: Allergen immunotherapy (AIT) brings along changes in the immune system, restoring dendritic cell function, reducing T2 inflammation and augmenting the regulatory cell activation. Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, interferes with the immune system causing immune suppression during the first phase and over-activation in more advanced disease. We decided to explore the interaction of both in a real-world observational trial. Methods: We registered COVID-19 outcomes in patients with allergic disorders in Latin America, treated with and without AIT. The registry was conducted during the first 1.3 years of the pandemic, with most of the data collected before COVID-19 vaccination was concluded in most countries. Data collection was anonymous via a web-based instrument. Ten countries participated. Results: 630/1095 (57.6%) of the included patients received AIT. Compared to patients without AIT, those treated with AIT had a reduced risk ratio (RR) for COVID-19 lower respiratory symptoms (RR 0.78, 95% CI: 0.6703–0.9024; p = 0.001662) and need for oxygen therapy (RR 0.65, 95% CI: 0.4217–0.9992; p = 0.048). In adherent patients on maintenance sublingual immunotherapy/subcutaneous immunotherapy (SLIT/SCIT) the RR reduction was larger [RR = 0.6136 (95% CI 0.4623–0.8143; p < 0.001) and RR: 0.3495 (95% CI 0.1822–0.6701; p < 0.005), respectively]. SLIT was slightly more effective (NS). We excluded age, comorbidities, level of health care attendance, and type of allergic disorder as confounders, although asthma was related to a higher frequency of severe disease. When analyzing patients with allergic asthma (n = 503) the RR reduction favoring AIT was more pronounced with 30% for lower respiratory symptoms or worse (RR 0.6914, 95% CI 0.5264 to 0.9081, p = 0.0087) and 51% for need of oxygen therapy or worse (RR 0.4868, 95% CI 0.2829–0.8376, p = 0.0082). Among severe allergic patients treated with biologics (n = 24) only 2/24 needed oxygen therapy. There were no critical cases among them. Conclusion: In our registry AIT was associated with reduced COVID-19 severity

Guía metodológica para la implantación de desarrollos curriculares virtuales accesibles

La Formación Virtual tiene un crecimiento cada vez mayor no solo en las instituciones de educación superior, sino también en el aprendizaje en el trabajo, en la escuela, etc. En el ámbito de las instituciones de educación superior, se identifican sus tres funciones principales para lograr la meta de la institución de educación superior contemporánea: la enseñanza, la investigación y la extensión. En relación a la función de enseñanza, las plataformas educativas digitales y los nuevos espacios virtuales se encuentran presentes en la actualidad en muchas instituciones de educación superior en Iberoamérica. Sin embargo, al igual que las limitaciones físicas que puedan existir en los campus, tanto las plataformas como los desarrollos curriculares virtuales, presentan limitaciones hacia las personas con discapacidad. En general este obstáculo se presenta en general a cualquier persona que tenga una limitación temporal dependiente del medio con el que utiliza las plataformas virtuales. En el punto de vista de la función de extensión, se interpreta tanto como el objeto de llevar fuera de los muros de las instituciones el conocimiento al ámbito laboral, así como la proyección que responda a las demandas sociales. En el marco de la XXII Cumbre Iberoamericana de Jefes de Estado celebrada en Cádiz, España (2012), fue declarado el año 2013 como el Año Iberoamericano para la inclusión laboral de las Personas con Discapacidad. Esta declaración debe incentivar a las instituciones de educación superior a brindar a las personas con discapacidad, la oportunidad de obtener las competencias que le permitan ser incluidos en el ámbito laboral, tomando en cuenta que la formación virtual accesible aporta un gran valor inclusivo. Es por ello que debemos de buscar un diseño universal de nuestras propuestas de educación virtual. Adicionalmente los avances tecnológicos y culturales alrededor de Internet están produciendo diversos cambios rápidamente. Y es está rapidez la que exige a las instituciones de educación superior ejercer su función de investigación para adaptarse a las necesidades de la Sociedad de la Información, y de cierta forma perseguir el objetivo de liderar a través de la innovación en la educación esta evolución de la sociedad. Para ello las instituciones de educación superior deben de buscar la excelencia a través de procesos que aseguren la calidad en la formación virtual accesible desde una perspectiva holística, que involucre todos los procesos y fases de la formación virtual, y que a su vez la haga incluyente para todas las personas, es por esto último, el énfasis en la accesibilidad. Enfocar estos objetivos en Iberoamérica a través de actuaciones como algunas de la financiadas por la Comisión Europea a través del programa ALFA, provee una plataforma ideal promover el avance en la región. Uno de los proyectos financiado a través del programa ALFA III, es el proyecto “ESVI-AL (Educación Superior Virtual Inclusiva – América Latina): Mejora de la Accesibilidad en la Educación Superior Virtual en América Latina”. Como parte del proyecto ESVI-AL se ha elaborado esta guía metodológica para la implantación de los desarrollos curriculares virtuales accesibles. El objetivo de la guía es establecer un modelo de trabajo para el cumplimiento de requisitos y estándares de accesibilidad en el contexto de la formación virtual, especialmente a través de la Web. El modelo propuesto facilitará la elaboración de auditorías que permitan el diagnóstico de cumplimiento de normas de accesibilidad, y la mejora de la capacidad de madurez, respecto a la accesibilidad, de las instituciones de educación superior y en general para organizaciones de educación. Esta guía ha sido concebida como un instrumento de apoyo para todos los involucrados en proyectos educativos virtuales accesibles, principalmente para los docentes, pero también para el personal de gestión, administración y técnico de las instituciones que pretendan implantar actividades formativas virtuales inclusivas, en las que puedan participar en igualdad de condiciones estudiantes sin o con discapacidad. Lo que el lector va a encontrar en este libro es una propuesta de los procesos que debería implantarse en una institución de educación superior, pero también en cualquier organización o empresa de formación virtual, que esté comprometida con una educación inclusiva de calidad. En la guía se detallan las actividades y tareas que deberían llevarse a cabo e cada uno de los procesos definidos, así como los productos, técnicas, métodos, criterios de calidad y perfiles de participantes que deben tenerse en cuenta en cada fase de un proyecto educativo virtual que se llevará a cabo en un campus virtual accesible, es decir utilizable y practicables por todas las personas. Asegurar sistemas de educación inclusivos a todos los niveles debe ser un compromiso de todos los implicados en la educación. Los participantes en el proyecto ESVI-AL así lo entendemos, y esperamos y deseamos que esta modesta aportación del proyecto en forma de guía metodológica, contribuya a avanzar hacia el objetivo de conseguir una educación inclusiva. Este trabajo ha sido una realidad gracias a la estrecha colaboración en su organización entre los socios y colaboradores del proyecto del Programa ESVI-AL. Agradecer el trabajo llevado a cabo por los socios, colaboradores y, en especial, a los revisores externos, cuyas aportaciones y sugerencias han enriquecido la guía.No data (2013)UE