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

Skin reactivity frequency to aeroallergens in patients with clinical symptoms of allergic disease

Background: Allergic diseases diagnosis must be based on adequate allergological anamnesis and an immunological sensitization test; the most sensitive and specific is the skin prick test. Objective: To determine the frequency of skin reactivity to aeroallergens, by age groups, in patients of the Department of Allergy and Clinical Immunology of the Hospital Universitario de Puebla, in Mexico. Methods: A cross-sectional study was conducted that included patients aged 2 to 64 years with symptoms suggestive of allergic disease, in which skin prick tests with aeroallergens were performed; the diagnostic criteria were those of international guidelines. Frequencies, percentages and dispersion measures were calculated. Results: Of 173 patients, 63 % were females. Mean age was 22.3 years. The frequency of skin reactivity for Quercus sp. was 12.72 %, for Periplaneta americana, 9.83 %, for Dermatophagoides farinae, 9.25 %, for Cynodon dactylon, 8.09 %, for Blatella germanica, 8.09 %, for Holcus halepensis, 6.94 %, for Dermatophagoides pteronyssinus, 6.36 %, for Schinus molle, 5.78 %, for Fraxinus uhdei, 5.20 %, for Lolium perenne, 5.20 %, for Ambrosia eliator, 5.20 % and for Artemisa tridentata, 4.62 %. Conclusion: Although Dermatophagoides are the most frequently reported aeroallergens, the most common aeroallergen in this study was pollen, probably owing to geographical and environmental factors, although this was not observed in the analysis by age groups

Frequency of skin reactivity to food allergens in allergic patients

Background: Food allergy is deemed to have a worldwide prevalence ranging from 2 to 10 %. Objective: To determine the frequency of skin reactivity to food allergens by age groups. Methods: Cross-sectional, descriptive, prolective, observational study. Patients aged from 2 to 64 years with symptoms consistent with allergic disease were included. Skin prick tests were carried out with food allergens. Frequencies and percentages were estimated. Results: One-hundred and ninety-one patients were included, out of which 63.4% were females. Mean age was 22.5 years; 19.3 % showed positive skin reactivity to at least one food. Distribution by age group was as follows: preschool children 13.5 %, schoolchildren 24.3 %, adolescents 2.7 % and adults 59.5 %. Diagnoses included allergic rhinitis in 84.3 %, asthma in 19.4 %, urticaria in 14.1 % and atopic dermatitis in 8.4 %. Positive skin reactivity frequency distribution in descending order was: soybeans with 5.2 %, peach with 4.7 %, grapes, orange and apple with 3.6 %, nuts with 3.1 %, pineapple, avocado, tomato and tuna with 2.6 %. Conclusion: The frequency of skin reactivity to food allergens was similar to that reported in the national and Latin American literature, but sensitization to each specific allergen varied for each age group

Afro-reparaciones: memorias de la esclavitud y justicia reparativa para negros, afrocolombianos y raizales

En Colombia, los negros, afrocolombianos y raizales son sujetos de reparaciones no solo dentro del debate de la Ley de Justicia y Paz, debido a la embestida paramilitar y guerrillera en sus territorios colectivos, sino también porque la trata negra transatlántica, la que enmarcó la llegada masiva de esclavos a la Nueva Granada colonial, se ha considerado un crimen de lesa humanidad. La Conferencia de Durban (Sudáfrica, 2001) hizo sujetos de reparación a todos los integrantes de la diáspora africana en el mundo. Este doble entronque enciende y complejiza el debate sobre justicia reparativa en el país. La presente obra recoge ensayos de varios especialistas sobre el tema. Todos ellos buscan dar respuesta, desde diferentes perspectivas, a las siguientes preguntas: ¿Es posible la reconstrucción de una nación como la colombiana, que estableció un novedoso pacto de convivencia ética y política mediante la asunción constitucional de su carácter pluriétnico y multicultural? y, ¿Es posible alcanzar este loable ideal sin actos estatales de reparación de las múltiples injusticias heredadas del pasado, de los traumas sociales que se ocasionaron, que se expresan en las adversas condiciones de vida que llevan ciertos grupos poblacionales?. / Contenido. Preliminares; Capítulo 1 - Color, inferioridad y esclavización: La invención de la diferencia en los discursos de la colonialidad temprana; Capítulo 2 - Ciudadanía, racialización y memoria del cautiverio en la historia de Brasil; Capítulo 3 - Sin justicia étnico-racial no hay paz: Las afro-reparaciones en perspectiva histórico-mundial; Capítulo 4 - Afroecuatorianos: reparaciones y acciones afirmativas; Capítulo 5 - Reparaciones contemporáneas: De la memoria de la esclavitud al cuestionamiento de la exclusión social y el racismo; Capítulo 6 - Reparaciones para negros, afrocolombianos y raizales como rescatados de la Trata Negrera Trasatlántica y desterrados de la guerra en Colombia; Capítulo 7 - El Dorado Negro, o el verdadero peso del oro neogranadino en la colonia; Capítulo 8 - San Andrés Isla, memorias de la colombianización y reparaciones; Capítulo 9 - Mirar hacia adentro para reparar las memorias en Providencia y Santa Catalina; Capítulo 10 - Afrouresanos: la historia de un Palenque, el devenir de un pueblo; Capítulo 11 - Memorias palenqueras de la libertad; Capítulo 12 - Los afronortecaucanos: de la autonomía a la miseria ¿Un caso de doble reparación?; Capítulo 13 - Afro-reparaciones en tierras de comunidades negras: Vuelta de Candelilla, Tumaco; Capítulo 14 - Desde adentro: Una aproximación al tema de Verdad, Justicia y Repación a partir de la víctimas afrocolombianas; Capítulo 15 - Bojayá: Entre el miedo y los medios; Capítulo 16 - Conocimientos ancestrales amenazados y destierro prorrogado: La encrucijada de los afrocolombianos; Capítulo 17- Subvirtiendo la autoridad de lo sentencioso: "Cantadoras que se alaban de poetas"; Capítulo 18 - Los rostros de la memoria afrodescendiente: fiestas, bailes y fandangos; Capítulo 19 - Un rastro del África Central en el Pacífico Colombiano: tallas sagradas entre los indígenas de Chocó y su legado africano; Capítulo 20 - El cementerio africano en Nueva York: enseñanzas de un ejercicio de reconciliación; Capítulo 21 - La educación y el patrimonio cultural, nodos de los procesos de reparación de las comunidades adrocolombianas; Capítulo 22 - Andinocentrismo, salvajismo y afro-reparaciones; Capítulo 23 - La población afrodescendiente y su referencia como sujeto de ley en el desarrollo normativo de Colombia: punto de partida para definir niveles de reconocimiento y reparación, Capítulo 24 - "Aquí ellos también son iguales": una aproximación al racismo en el ámbito escolar; Capítulo 25 - Políticas étnicas afrocolombianas en educación superior: Dinámicas identitarias en la Universidad de Antioquia; Capítulo 26 - Las desigualdades raciales en Colombia: Un análisis sociodemográfico de condiciones de vida, pobreza e ingresos para la ciudad de Cali y el departamento del Valle del Cauca; Capítulo 27 - Memoria y reparación: ¿Y de ser mujeres negras qué?; Capítulo 28 - La encrucijada de los rescatados: entre la memoria doliente y el olvido; Capítulo 29 - Comunidad de la Boquilla: lo patrimonial local en el escenario global; Capítulo 30 - La justicia afrocolombiana se construye en el reconocimiento de la diversidad; Anexo 01 - Índice temático; Anexo 02 - Notas biográficas de autoras y autores; Anexo 03 - Presentación Grupo de Estudios Afrocolombianos GE

Clinical Presentation and Short- and Long-term Outcomes in Patients With Isolated Distal Deep Vein Thrombosis vs Proximal Deep Vein Thrombosis in the RIETE Registry

International audienceImportance: Insufficient data exist about the clinical presentation, short-term, and long-term outcomes of patients with isolated distal deep vein thrombosis (IDDVT), that is, thrombosis in infrapopliteal veins without proximal extension or pulmonary embolism (PE).Objective: To determine the clinical characteristics, short-term, and 1-year outcomes in patients with IDDVT and to compare the outcomes in unadjusted and multivariable adjusted analyses with patients who had proximal DVT.Design, setting, and participants: This was a multicenter, international cohort study in participating sites of the Registro Informatizado Enfermedad Tromboembólica (RIETE) registry conducted from March 1, 2001, through February 28, 2021. Patients included in this study had IDDVT. Patients with proximal DVT were identified for comparison. Patients were excluded if they had a history of asymptomatic DVT, upper-extremity DVT, coexisting PE, or COVID-19 infection.Main outcomes and measures: Primary outcomes were 90-day and 1-year mortality, 1-year major bleeding, and 1-year venous thromboembolism (VTE) deterioration, which was defined as subsequent development of proximal DVT or PE.Results: A total of 33 897 patients were identified with isolated DVT (without concomitant PE); 5938 (17.5%) had IDDVT (mean [SD] age, 61 [17] years; 2975 male patients [50.1%]), and 27 959 (82.5%) had proximal DVT (mean [SD] age, 65 [18] years; 14 315 male patients [51.2%]). Compared with individuals with proximal DVT, those with IDDVT had a lower comorbidity burden but were more likely to have had recent surgery or to have received hormonal therapy. Patients with IDDVT had lower risk of 90-day mortality compared with those with proximal DVT (odds ratio [OR], 0.47; 95% CI, 0.40-0.55). Findings were similar in 1-year unadjusted analyses (hazard ratio [HR], 0.52; 95% CI, 0.46-0.59) and adjusted analyses (HR, 0.72; 95% CI, 0.64-0.82). Patients with IDDVT had a lower 1-year hazard of VTE deterioration (HR, 0.83; 95% CI, 0.69-0.99). In 1-year adjusted analyses of patients without an adverse event within the first 3 months, IDDVT was associated with lower risk of VTE deterioration (adjusted HR, 0.48; 95% CI, 0.24-0.97). By 1-year follow-up, symptoms or signs of postthrombotic syndrome were less common in patients with IDDVT (47.6% vs 60.5%).Conclusions and relevance: Results of this cohort study suggest that patients with IDDVT had a less ominous prognosis compared with patients with proximal DVT. Such differences were likely multifactorial, including the differences in demographics, risk factors, comorbidities, particularly for all-cause mortality, and a potential association of thrombus location with VTE deterioration and postthrombotic syndrome. Randomized clinical trials are needed to assess the optimal long-term management of IDDVT

Patient-Level, Institutional, and Temporal Variations in Use of Imaging Modalities to Confirm Pulmonary Embolism

International audienceBackground: The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE. Methods: Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001–January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging. Results: Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6–78.7]); including pregnant patients (58.9% [99% CI, 47.7%–69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9–65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%, P <0.001). The use of computed tomography pulmonary angiography varied between 13.3% and 98.3% across the countries, and its use increased over time (46.5% in 2002 to 91.7% in 2018, P <0.001). Conclusions: In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation

Risk of recurrence after discontinuing anticoagulation in patients with COVID-19- associated venous thromboembolism: a prospective multicentre cohort studyResearch in context

Summary: Background: The clinical relevance of recurrent venous thromboembolism (VTE) after discontinuing anticoagulation in patients with COVID-19-associated VTE remains uncertain. We estimated the incidence rates and mortality of VTE recurrences developing after discontinuing anticoagulation in patients with COVID-19-associated VTE. Methods: A prospective, multicenter, non-interventional study was conducted between March 25, 2020, and July 26, 2023, including patients who had discontinued anticoagulation after at least 3 months of therapy. All patients from the registry were analyzed during the study period to verify inclusion criteria. Patients with superficial vein thrombosis, those who did not receive at least 3 months of anticoagulant therapy, and those who were followed for less than 15 days after discontinuing anticoagulation were excluded. Outcomes were: 1) Incidence rates of symptomatic VTE recurrences, and 2) fatal PE. The rate of VTE recurrences was defined as the number of patients with recurrent VTE divided by the patient-years at risk of recurrent VTE during the period when anticoagulation was discontinued. Findings: Among 1106 patients with COVID-19-associated VTE (age 62.3 ± 14.4 years; 62.9% male) followed-up for 12.5 months (p25-75, 6.3–20.1) after discontinuing anticoagulation, there were 38 VTE recurrences (3.5%, 95% confidence interval [CI]: 2.5–4.7%), with a rate of 3.1 per 100 patient-years (95% CI: 2.2–4.2). No patient died of recurrent PE (0%, 95% CI: 0–7.6%). Subgroup analyses showed that patients with diagnosis in 2021–2022 (vs. 2020) (Hazard ratio [HR] 2.86; 95% CI 1.45–5.68) or those with isolated deep vein thrombosis (vs. pulmonary embolism) (HR 2.31; 95% CI 1.19–4.49) had significantly higher rates of VTE recurrences. Interpretation: In patients with COVID-19-associated VTE who discontinued anticoagulation after at least 3 months of treatment, the incidence rate of recurrent VTE and the case-fatality rate was low. Therefore, it conceivable that long-term anticoagulation may not be required for many patients with COVID-19-associated VTE, although further research is needed to confirm these findings. Funding: Sanofi and Rovi, Sanofi Spain