Anafilaxia en niños y adultos: prevención, diagnóstico y tratamiento

La anafilaxia es una condición que requiere asistencia inmediata para su resolución, se puede presentar en diferentes entornos: consultorio, hospital, escuela, hogar o en algún otro espacio público. La información aquí contenida forma parte de lineamientos conocidos sobre prevención, diagnóstico y tratamiento. Se abordan aspectos epidemiológicos, desencadenantes, factores de riesgo y cofactores; se explican de una manera didáctica los mecanismos fisiopatológicos que se traducen en fenotipos de presentación. Se enfatiza el diagnóstico clínico con base en criterios ya establecidos, se mencionan clasificaciones para evaluar la gravedad de la reacción, así como el rol de las pruebas clínicas o de laboratorio. Como aspectos de relevancia, se abordan el tratamiento de primera elección con adrenalina, instrucciones sobre autoinyectores y diferentes elementos para el tratamiento complementario y de segunda elección. También se refieren aspectos a considerar al dar de alta a un paciente y medidas de seguimiento, con un énfasis preventivo en la comunidad. Finalmente, se menciona el abordaje en el consultorio de alergia para decidir sobre opciones de inmunomodulación. ABSTRACT Anaphylaxis is a condition that requires immediate assistance for its resolution, it can occur in different settings: office, hospital, school, home or some other public space. The information contained herein forms part of known guidelines on prevention, diagnosis and treatment. Epidemiological aspects, triggers, risk factors and co-factors are addressed; physiopathological mechanisms that are translated into presentation phenotypes are explained in a didactic way. Clinical diagnosis is emphasized based on established criteria, classifications are mentioned to evaluate the severity of the reaction, as well as the role of clinical or laboratory tests. As relevant aspects, the first choice treatment with adrenaline, instructions on auto-injectors and different elements for the complementary and second choice treatment are dealt with. They also refer to aspects to consider when discharging a patient and followup measures, with a preventive emphasis on the community. Finally, the allergy clinic approach to deciding on immunomodulation options is mentione

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Canagliflozin and Cardiovascular and Renal Outcomes in Type 2 Diabetes Mellitus and Chronic Kidney Disease in Primary and Secondary Cardiovascular Prevention Groups

Background: Canagliflozin reduces the risk of kidney failure in patients with type 2 diabetes mellitus and chronic kidney disease, but effects on specific cardiovascular outcomes are uncertain, as are effects in people without previous cardiovascular disease (primary prevention). Methods: In CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation), 4401 participants with type 2 diabetes mellitus and chronic kidney disease were randomly assigned to canagliflozin or placebo on a background of optimized standard of care. Results: Primary prevention participants (n=2181, 49.6%) were younger (61 versus 65 years), were more often female (37% versus 31%), and had shorter duration of diabetes mellitus (15 years versus 16 years) compared with secondary prevention participants (n=2220, 50.4%). Canagliflozin reduced the risk of major cardiovascular events overall (hazard ratio [HR], 0.80 [95% CI, 0.67-0.95]; P=0.01), with consistent reductions in both the primary (HR, 0.68 [95% CI, 0.49-0.94]) and secondary (HR, 0.85 [95% CI, 0.69-1.06]) prevention groups (P for interaction=0.25). Effects were also similar for the components of the composite including cardiovascular death (HR, 0.78 [95% CI, 0.61-1.00]), nonfatal myocardial infarction (HR, 0.81 [95% CI, 0.59-1.10]), and nonfatal stroke (HR, 0.80 [95% CI, 0.56-1.15]). The risk of the primary composite renal outcome and the composite of cardiovascular death or hospitalization for heart failure were also consistently reduced in both the primary and secondary prevention groups (P for interaction >0.5 for each outcome). Conclusions: Canagliflozin significantly reduced major cardiovascular events and kidney failure in patients with type 2 diabetes mellitus and chronic kidney disease, including in participants who did not have previous cardiovascular disease

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Effect of SGLT2 inhibitors on stroke and atrial fibrillation in diabetic kidney disease: Results from the CREDENCE trial and meta-analysis

BACKGROUND AND PURPOSE: Chronic kidney disease with reduced estimated glomerular filtration rate or elevated albuminuria increases risk for ischemic and hemorrhagic stroke. This study assessed the effects of sodium glucose cotransporter 2 inhibitors (SGLT2i) on stroke and atrial fibrillation/flutter (AF/AFL) from CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) and a meta-Analysis of large cardiovascular outcome trials (CVOTs) of SGLT2i in type 2 diabetes mellitus. METHODS: CREDENCE randomized 4401 participants with type 2 diabetes mellitus and chronic kidney disease to canagliflozin or placebo. Post hoc, we estimated effects on fatal or nonfatal stroke, stroke subtypes, and intermediate markers of stroke risk including AF/AFL. Stroke and AF/AFL data from 3 other completed large CVOTs and CREDENCE were pooled using random-effects meta-Analysis. RESULTS: In CREDENCE, 142 participants experienced a stroke during follow-up (10.9/1000 patient-years with canagliflozin, 14.2/1000 patient-years with placebo; hazard ratio [HR], 0.77 [95% CI, 0.55-1.08]). Effects by stroke subtypes were: ischemic (HR, 0.88 [95% CI, 0.61-1.28]; n=111), hemorrhagic (HR, 0.50 [95% CI, 0.19-1.32]; n=18), and undetermined (HR, 0.54 [95% CI, 0.20-1.46]; n=17). There was no clear effect on AF/AFL (HR, 0.76 [95% CI, 0.53-1.10]; n=115). The overall effects in the 4 CVOTs combined were: Total stroke (HRpooled, 0.96 [95% CI, 0.82-1.12]), ischemic stroke (HRpooled, 1.01 [95% CI, 0.89-1.14]), hemorrhagic stroke (HRpooled, 0.50 [95% CI, 0.30-0.83]), undetermined stroke (HRpooled, 0.86 [95% CI, 0.49-1.51]), and AF/AFL (HRpooled, 0.81 [95% CI, 0.71-0.93]). There was evidence that SGLT2i effects on total stroke varied by baseline estimated glomerular filtration rate (P=0.01), with protection in the lowest estimated glomerular filtration rate (45 mL/min/1.73 m2]) subgroup (HRpooled, 0.50 [95% CI, 0.31-0.79]). CONCLUSIONS: Although we found no clear effect of SGLT2i on total stroke in CREDENCE or across trials combined, there was some evidence of benefit in preventing hemorrhagic stroke and AF/AFL, as well as total stroke for those with lowest estimated glomerular filtration rate. Future research should focus on confirming these data and exploring potential mechanisms

The application of diffusion–reaction mixed model to assess the best experimental conditions for bark chemical activation to improve copper(II) ions adsorption

Artículo de publicación ISINatural sorbents have been thoroughly assessed to determine their adsorption capabilities to remove pollutants from industrial wastewaters. Among them, pine bark has demonstrated potential for carrying out the removal of contaminants, particularly heavy metals, at the level of traces present in dissolved state. Nevertheless, to move towards the wastewater treatment implementation at large scale, the handling and processing requirements of pine bark to optimise the adsorption of heavy metals must be fully assessed. This research study presents a new mathematical model to evaluate the impact of acid pretreatment of pine bark on heavy metals adsorption at different pine bark-aqueous solution pulp densities. A diffusion– reaction mixed model was developed and applied to the case study of copper(II) adsorption onto pine bark. The low binding energy inferred from analysing the adsorption isotherms suggested that a diffusive mechanism is governing the whole process. The mixed diffusion–reaction kinetic model indicated that the activation increases the rate at which metal ions are adsorbed, but it reduces the maximum achievable adsorption which in turn restricts its usefulness to relatively high pulp densities (above 10 g/L). The latter constitutes the first step towards optimising the use of bark pine for treating wastewater polluted with heavy metals and for establishing rules for scaling-up the process

Transport of molybdenum with Alamine 336 using supported liquid membrane

The appropriate experimental conditions of Mo(VI) ion transport across a supported liquid membrane containing Alamine 336 as the mobile carrier dissolved in kerosene solvent have been investigated. The molybdenum flux has been studied as a function of the extraction solution acidity, the sodium carbonate concentration in the stripping solution and the carrier concentration in the liquid membrane. Suitable conditions for both feed and stripping solutions were achieved from analysis of experimental results of molybdenum transport through the liquid membrane. The permeation experiments showed that, at pH 2 with sulfuric acid in the extraction solution and at pH 11.5 with Na2CO3 in the stripping solution, an efficient transfer of the metal ion can be obtained. Furthermore, a maximum molybdenum transport was achieved at around 0.02 M of Alamine carrier in the organic phase. From these results, the extraction-stripping interface reactions for Mo(VI) permeation are proposed. An equation describing the permeation rate, taking into account the aqueous stagnant layers and liquid organic resistance as simultaneous controlling factors, has been derived. The validity of this model is evaluated with experimental data of mass transfer coefficient measured at different stirring rates

Transport of Zn(II), Cu(II), and Ni(II) on hollow fibers-type solid supported liquid membranes

This study reports on the transport and separation of Zn(II), Cu(II), and Ni(II) ions via a hollow fiber-type solid supported liquid membrane extractor. Alamine 336, a long chain tertiary amine was used as carrier extractant. The results of liquid-liquid extraction equilibrium measurements of these metals indicate that separation of zinc from copper and nickel is favored at a feed phase of acid concentration below 3.0 mol/L HCl using bidistilled water as acceptor solution. Measurements of permeations of these metallic ions through the liquid membrane indicate that the transport of metals is strongly affected by: the content of carrier extractant in organic solvent; the HCl concentration in the feed solution; and the volumetric flow rate of the stripping solution. By decreasing HC concentration in the feed phase, the separation factor of Zn(II) from Cu(II) increases and the recovery of both metals decreases. Ni(II) ion was not transported during the entire experiment

Using an Interactive CD-ROM to Teach Pharmacy Students Unit Operations

This article describes the basis and development of the solid dosage form section of an educational CD-ROM, including both the theoretical and self-evaluation sections

Proyecto de creación de una empresa de investigación de comportamiento del consumidor en la escuela superíor politécnica del litoral

El actual proyecto consiste en la creación de una empresa de Investigación de Comportamiento del Consumidor fusionando las disciplinas de las Neurociencias y el Marketing, a lo que llamamos hoy en día Neuromarketing. Dicho proyecto se llevará a cabo en las instalaciones de la Escuela Superior Politécnica del Litoral. En nuestro Empresa se realizarán pruebas a productos y servicios para determinar los gustos y preferencias que pueden tener los consumidores al momento de compra, para lo cual utilizaremos mediciones biométricas tales como la actividad cerebral, el ritmo cardiaco, respuesta galvánica de la piel, y seguimiento ocular. De esta manera se podrán rediseñar las estrategias de las empresas ecuatorianas, y asistir las grandes corporaciones líderes en el mercado nacional. Ayudará además en la difusión de; servicios y/o productos, comerciales y páginas web de las diferentes firmas existentes en el medio. Siendo esto una mejora continua en la innovación de productos, marcas y posicionamiento de los mismos. Con la finalidad de ofrecer un servicio vanguardista de muy alta calidad a Corporaciones y Empresas; proporcionándoles información científicamente comprobada sobre las verdaderas razones que determinan la conducta de compra de sus clientes, lo cual será de gran interés, para alcanzar mayores beneficios