Clinical Practice Guidelines for Diagnosis and Management of Hypersensitivity Reactions to Quinolones.

The consumption of quinolones as first-line treatment has increased in recent years, leading to an increase in the incidence of hypersensitivity reactions (HSRs) to this antibiotic group. Both diagnosis and management of HSRs to quinolones are complex and controversial. These practical guidelines aim to provide recommendations for effective clinical practice. The recommendations were drafted by an expert panel that reviewed the literature regarding HSRs to quinolones and analyzed controversies in this area. Most HSRs to quinolones are immediate and severe. The risk for HSRs is higher in patients who report allergy to ß-lactams, moxifloxacininduced anaphylaxis, and immediate reactions than in patients who report reactions to quinolones inducing other symptoms. The usefulness of skin tests in diagnosing HSRs to quinolones is controversial, with sensitivity and specificity varying between studies. Most in vitro tests are produced in-house, with no validated commercial options. The basophil activation test has proven useful for diagnosing immediate reactions, albeit with diverse results regarding sensitivity. Drug provocation testing is currently the gold standard for confirming or excluding the diagnosis and for finding safe alternatives, although it is contraindicated in patients with severe reactions. Cross-reactivity between quinolones has proven controversial in several studies, with the lowest cross-reactivity reported for levofloxacin. Desensitization may be considered in allergy to quinolones when no other alternatives are available.

Clinical Practice Guidelines for Diagnosis and Management of Hypersensitivity Reactions to Quinolones

The consumption of quinolones as first-line treatment has increased in recent years, leading to an increase in the incidence of hypersensitivity reactions (HSRs) to this antibiotic group. Both diagnosis and management of HSRs to quinolones are complex and controversial. These practical guidelines aim to provide recommendations for effective clinical practice. The recommendations were drafted by an expert panel that reviewed the literature regarding HSRs to quinolones and analyzed controversies in this area. Most HSRs to quinolones are immediate and severe. The risk for HSRs is higher in patients who report allergy to ß-lactams, moxifloxacininduced anaphylaxis, and immediate reactions than in patients who report reactions to quinolones inducing other symptoms. The usefulness of skin tests in diagnosing HSRs to quinolones is controversial, with sensitivity and specificity varying between studies. Most in vitro tests are produced in-house, with no validated commercial options. The basophil activation test has proven useful for diagnosing immediate reactions, albeit with diverse results regarding sensitivity. Drug provocation testing is currently the gold standard for confirming or excluding the diagnosis and for finding safe alternatives, although it is contraindicated in patients with severe reactions. Cross-reactivity between quinolones has proven controversial in several studies, with the lowest cross-reactivity reported for levofloxacin. Desensitization may be considered in allergy to quinolones when no other alternatives are available (AU)

Organización y métodos didácticos de una asignatura que integra asignaturas y competencias transversales en el Grado en Medicina. Experiencia con «Talleres integrados II» de la Universidad Miguel Hernández de Elche / Organisation and didactic methods of a subject that integrates subjects and transversal skills into the Medical Degree. Experience with the Integrated Workshops of the Miguel Hernández University of Elche, Spain

Los estudiantes de medicina necesitan adquirir una serie de conocimientos, habilidades y actitudes que les capaciten para el desempeño de la medicina. La facultad de Medicina de la Universidad Miguel Hernández de Elche incluyó en su plan de estudios del Grado en Medicina 4 asignaturas denominadas «talleres integrados» en las que se desarrollan diversas actividades docentes para integrar conocimientos y habilidades clínicas de varias disciplinas y fomentar la adquisición de competencias transversales. En este artículo describimos la organización y métodos didácticos empleados en la asignatura «Talleres integrados II» como un elemento de reflexión para compartir la experiencia con la comunidad educativa en medicina. Esta asignatura integra las siguientes materias: bases generales de la cirugía, farmacología clínica, patología general, inmunología y alergia, dermatología, epidemiología y demografía sanitaria, microbiología, obstetricia y oftalmología. Es una asignatura con 4,5 créditos prácticos y utiliza elementos docentes como práctica hospitalaria guiada por objetivos, participación de alumnos y talleres prácticos, simulación, prueba evaluación de competencias objetiva estructurada, y presentación clínica en formato Pecha Kucha, lo que potencia la integración de conocimientos y el aprendizaje activo con adquisición de competencias y habilidades prácticas muy pertinentes para el futuro médico

Medical students need to acquire a range of knowledge, skills, and attitudes that will prepare them for medical clinical practice. The School of Medicine of Miguel Hernández University (Elche, Spain) includes, in its Medical Degree curriculum, 4 subjects called "Talleres integrados" (Integrated Workshops-II). Diverse teaching activities are developed to integrate knowledge and clinical skills of several disciplines, and to promote the acquisition of transversal skills. A description is presented of the organisation and didactic methods used in the Integrated Workshops-II subject as an element for reflection and to share the experience with the educational community in medicine. This subject integrates the following: general bases of surgery, clinical pharmacology, general pathology, immunology and allergy, dermatology, epidemiology and health demography, microbiology, obstetrics and ophthalmology. It is a subject with 4.5 practical credits and uses teaching elements such as hospital practice guided by objectives, student participation and practical workshops, simulation, objective structured clinical examination (OSCE), and presentation of cases in Pecha Kucha format, all of which enhances the integration of knowledge and active learning with acquisition of skills and practical skills very pertinent for the future doctor

Results of an early intervention programme for patients with bacteraemia: analysis of prognostic factors and mortality.

BACKGROUND: Bacteraemia is a common cause of morbidity and mortality in patients admitted to hospital. The aim of this study is to analyse the results of a two-year programme for the early optimisation of antibiotic treatment in patients admitted to the Costa del Sol Hospital (Marbella. Spain). METHODS: A prospective two-year cohort study was conducted, evaluating all episodes of bacteraemia at the Costa del Sol Hospital. Epidemiological and microbiological characteristics, any modification of the initial antibiotic treatment, prognostic risk stratification, early mortality related to the episode of bacteraemia, and mortality after the seventh day, were included in the analysis. RESULTS: Seven hundred seventy-three episodes of bacteraemia were treated, 61.6% males and 38.4% females. The mean age was 65.2 years. The condition was most commonly acquired in the community (41.4%). The bacteraemia was most frequently urological in nature (30.5%), and E coli was the microorganism most frequently isolated (31.6%). In 51.1% of the episodes, a modification was made to optimise the treatment. In the first week, 8.2% died from bacteraemia, and 4.5% had died when they were located. The highest rates of death were associated with older patients, nosocomial acquisition, no source, McCabe score rapidly fatal, Charlson index ≥3, Pitt index ≥3 and treatment remained unmodified. CONCLUSION: The existence of bacteraemia control programmes and teams composed of clinicians who are experienced in the treatment of infectious diseases, can improve the disease outcome by enabling more severe episodes of bacteraemia to be recognised and their empirical treatment optimised.

[The presence of anti-Chlamydia pneumoniae antibodies in peripheral vascular and neurological disorders]. / Presencia de anticuerpos anti-Chlamydia pneumoniae en procesos vasculares periféricos y neurológicos.

OBJECTIVES: To make a retrospective analysis of the synthesis of antibodies to the MOMPS and LPS antigens of Chlamydia pneumoniae in patients with occlusive disease of the peripheral arteries (ODPA) and multiple sclerosis (MS). PATIENTS AND METHODS: We studied 190 samples of plasma from patients included in the following groups: group 1:66 samples from 66 patients with ODPA; group 2:74 samples from 31 patients with MS (20 remittent-relapsing and 11 secondarily progressive), followed over time; and group 3:50 samples from persons acting as controls. In all cases determinations were made using ELISA, of the IgG anti-MOMP and the IgG and IgA anti-LPS. Comparison of the continuous variables was made using the Mann-Whitney U Test. Discrete variables were analysed using the exact bilateral Fisher Test. The Wilcoxon Test over ranges was used to compare the evolution of antibodies in the patients with MS. RESULTS: The percentage of positive results in groups 1 to 3 for anti-LPS IgG were: 24.6%, 18.9% and 20.8%, respectively, with no differences between patients and controls; nor were there any differences with IgA (29%, 29.7% and 25%, respectively). However differences were seen in the anti-MOMP IgG between patients and controls (group 1:80.3%, group 2:37.8% and group 3: 33.3%). In patients with MS the results of the evolution of the antibodies did not reflect a uniform tendency of the levels of the different antibodies. CONCLUSION: A higher level of IgG anti-MOMP was seen in ODPA and MS, although this did not occur with anti-LPS or IgA.

Presencia de anticuerpos anti-Chlamydia pneumoniaeen procesos vasculares periféricos y neurológicos / The presence of anti-chlamydia pneumonia antibodies in peripheral vascular and neurological disorders

Objetivos. Analizar, retrospectivamente, la síntesis de anticuerpos frente a los antígenos MOMP y LPS de Chlamydia pneumoniae en pacientes con enfermedad oclusiva de las arterias periféricas (EOAP) y esclerosis múltiple (EM). Pacientes y métodos. Se estudiaron 190 muestras de suero procedentes de enfermos que se incluyeron en los siguientes grupos: grupo 1: 66 muestras de otros tantos enfermos con EOAP; grupo 2: 74 muestras de 31 pacientes con EM (20 remitente-recidivante y 11 secundariamente progresiva) seguidos en el tiempo, y grupo 3: 50 muestras de sujetos controles. En todas se determinaron, mediante ELISA, la IgG anti-MOMP y la IgG e IgA anti-LPS. La comparación de las variables continuas se realizó con la prueba U de Mann-Whitney. Las variables discretas se analizaron con la prueba de Fischer bilateral exacta. Para comparar la evolución de los anticuerpos en los enfermos con EM se utilizó la prueba de rangos con signo de Wilcoxon. Resultados. Los porcentajes de positividad, en los grupos 1 a 3, para la IgG anti-LPS fueron: 24,6 por ciento, 18,9 por ciento y 20,8 por ciento, respectivamente, sin que existieran diferencias entre enfermos y controles. Tampoco hubo diferencias para la IgA (29 por ciento, 29,7 por ciento y 25 por ciento, respectivamente). Sí se hallaron diferencias en la IgG anti-MOMP entre enfermos y controles (grupo 1: 80,3 por ciento, grupo 2: 37,8 por ciento y grupo 3: 33,3 por ciento). En los enfermos con EM, los resultados de la evolución de los anticuerpos no reflejaron una tendencia uniforme de las tasas de los diferentes anticuerpos. Conclusión. Se encontró una mayor tasa de IgG anti-MOMP en la EOAP y la EM; sin embargo, esto no ocurrió para la IgG e IgA anti-LPS (AU)

Characteristics of thoracic duct lymph in multiple organ dysfunction syndrome.

OBJECTIVE: To investigate the presence of endotoxin, bacteria, and potential humoral and cellular mediators in thoracic duct lymph and peripheral blood in patients with severe refractory multiple organ dysfunction. DESIGN: Convenience sample. SETTING: General intensive care unit of a university hospital. PATIENTS: Two men and 2 women were studied after a mean of 7.25 days (range, 6-9 days) of multiple organ dysfunction syndrome. The primary injury was thoracic in 1 patient and abdominal in 3 patients. INTERVENTION: The thoracic duct was cannulated with a 7F catheter and samples of lymph and peripheral blood were obtained. MAIN OUTCOME MEASURES: Simultaneous lymph and serum levels of lipopolysaccharide, tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6, and activation markers on T lymphocytes. RESULTS: Lipopolysaccharide and cytokine levels were low in lymph and serum, except for a mean lymph-to-serum ratio of 53.4 for interleukin-1 beta. There was phenotypical evidence of intense polyclonal T-lymphocyte activation in both lymph and peripheral blood with increased lymph-to-peripheral blood ratios. Increased percentages in lymph of CD45RA + CD45RO + lymphocytes were observed. In 1 patient, Proteus mirabilis grew simultaneously in lymph, pancreatic necrosis fluid, and a central venous catheter tip. All simultaneous blood cultures were negative. CONCLUSIONS: Our results provide evidence of the participation of the gut-associated lymphatic tissue in the pathogenesis of the multiple organ dysfunction syndrome, suggesting that T-cell activation and cytokine production occur at the gut level. Future studies are needed to confirm and extend our findings.

[A sickness called unemployment: a long-term unemployment. Association of Community Development (ACD)]. / Una enfermedad llamada paro: la trastienda del desempleo del larga duración. Asociación para el Desarrollo Comunitario (ADC).

OBJECTIVES: The general objective of this investigation is to know the possible consequences of long-term unemployment on the family and social environment, as well as the mechanisms which lead to the appearance of health problems among long-term unemployed people. METHODS: The subjects of this study were long-term unemployed people of 35 to 55 years of age of the municipal term of Madrid, with families depending on them. This is a qualitative-intensive investigation, with special emphasis on the individual, social, sanitary and economical aspects. The instrument of common measurement was the combination of the discussion group integrated by five people, during approximately 120 minutes, with focused and individual interviews (48) over a semistructured script, during approximately 60 minutes, using recording instruments (audio tape). RESULTS: During the development of the discussion group a worsening of the psychological health and family situation was observed as a consequence of remaining unemployed. In the more thorough interviews we could detect clear differences according to the impact of unemployment on health depending on the low socioeconomical area, women and older unemployed people. CONCLUSIONS: The effects of unemployment on health cannot be isolated from other underlying bad social and economical conditions, that is to say, from social, economical, educative inequalities, etc., previous to the unemployment situation.