Pulmonary Manifestation of Granulomatosis With Polyangiitis: A Challenging Case Presentation.

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a rare and potentially life-threatening autoimmune disease characterized by antineutrophil cytoplasmic antibody (ANCA)-associated vasculature inflammation. It presents as a systemic autoimmune disease with necrotizing granulomatous inflammation and pauci-immune small vessel vasculitis. This case initially posed a diagnostic challenge due to its atypical presentation and was misdiagnosed as hypersensitivity pneumonitis. The avian precipitin screening assay was positive in our patient, which may be consistent with bird breeder's lung disease or a non-specific reactivity of the chicken antigen test. However, the presence of positive c-ANCA was pivotal for the GPA diagnosis. Here, we describe in detail the clinical manifestations, diagnostic approach, and treatment of GPA in a 54-year-old female who presented with alveolar hemorrhage, but no renal involvement. Treatment involved the use of high-dose corticosteroids to suppress the autoimmune response. Finally, we discuss the striking response of this unique form of granulomatosis with polyangiitis to corticosteroid treatment and emphasize the importance of early initiation of treatment.

Etapa subaguda de pos-COVID-19 grave o crítico. Rehabilitación musculoesquelética, respiratoria y uso de corticoides. Experiencia de la Unidad de Rehabilitación del Hospital del Banco de Seguros del Estado (URHBSE)

está disponible en el texto completo

Introduction: In patients with severe or critical COVID-19, the use of prednisone and musculoskeletal and respiratory rehabilitation has been described. The role of these interventions and the optimal time for their initiation are not clearly established. This study presents the results of the Rehabilitation Unit of the Banco de Seguro del Estado Hospital, which implemented a comprehensive rehabilitation program and the use of corticosteroids in the subacute stage of patients with severe or critical post-COVID-19, with a systematic approach, working interdisciplinary and centered on the person being treated. Findings at admission, oxygen requirement, Barthel scale, tomographic patterns, use of corticosteroids, their response, and complications are reported. The results of this approach on clinical, respiratory, and functional variables are described. Method: Descriptive, retrospective study of post-COVID-19 patients who completed rehabilitation at the Rehabilitation Unit of the Banco de Seguros del Estado Hospital (URHBSE) in the period April-August 2021. Data obtained from review of medical records, statistical analysis with PRISM (v8.2.1). Results: Eighty-four patients completed the rehabilitation program. Upon admission to the URHBSE, 55% had total or severe dependence on the Barthel scale. Forty-eight percent were unable to walk. Eighty-nine-point two percent required oxygen, with a mean saturation of 90.3 ± 4.8. Twenty-five percent of patients were admitted requiring a reservoir mask. All patients who entered the program were in the subacute phase of the disease (4 to 12 weeks) and received a comprehensive and individualized rehabilitation plan. The objective was to achieve a functional situation similar to what they had before COVID-19. The length of stay at the URHBSE was 23.5 ± 13.8 days. A total of 76 patients (90.5%) underwent high-resolution chest tomography (HRCT), which was pathological in 96.1% of cases. The predominant findings were ground-glass opacity in 49.3% of cases, consolidation in 8.23%, and a fibrosis-like pattern in 30.13%. "Non-typical" post-COVID damage tomographic alterations were detected (pleural effusion, cavitary nodules, apical cavities, etc.) in 11.8% of the tomographies. In 2 patients (2.6%), pulmonary aspergillosis was found, and in 6.6%, pulmonary thromboembolism. Forty-four patients (52.3%) received prednisone. In 63.4% of cases, oxygen supplementation was discontinued within the first 15 days from the start of prednisone. We found an association between the ground-glass opacity tomographic pattern and early discontinuation of oxygen supplementation from the start of prednisone (p = 0.047). Despite the high degree of colonization, we did not observe infections by colonizing microorganisms, even in those who used prednisone. Comparing admission and discharge, statistically significant differences were found in the following parameters: degree of dyspnea, oxygen requirement (only one patient was discharged with oxygen), saturation, degree of instrumentation (tracheostomy, nasogastric tube, etc.), and the Barthel dependency scale. Regarding respiratory variables, we only have data on the presence of dyspnea in the first 35 patients. Of these, 83% had dyspnea at admission, while only 17% had it at discharge (p < 0.0001). There were also significant differences in the oxygen requirement between admission and discharge (p < 0.0001) and in the degree of dependency measured on the Barthel scale. Fifty-five percent of patients had total or severe dependence at admission, compared to only 3.4% at discharge. Conclusions: The interventions carried out in the subacute stage of the disease were associated with significant improvements in clinical variables of interest. More studies are needed to define the role and the exact timing of the initiation of corticosteroids and rehabilitation in this group of patients.

Introdução: O uso de prednisona e reabilitação musculoesquelética e respiratória foi descrito no tratamento de pacientes com COVID-19 grave ou crítico. O papel destas intervenções e o momento ideal para o seu início não estão claramente estabelecidos. Este trabalho mostra os resultados da Unidade de Reabilitação Hospitalar do Banco de Seguro del Estado que implementou um programa abrangente de reabilitação e uso de corticosteroides na fase subaguda de pacientes graves ou críticos pós-COVID-19, com uma abordagem sistematizada, trabalhando de forma interdisciplinar e centrada no paciente. São relatados os achados na admissão, a necessidade de oxigênio, a escala de Barthel, os padrões tomográficos, o uso de corticosteroides, a resposta ao tratamento e as complicações. Os resultados desta abordagem sobre variáveis clínicas, respiratórias e funcionais são descritos. Material e métodos: Estudo descritivo e retrospectivo de pacientes pós-COVID-19 que completaram reabilitação na Unidade de Reabilitação do Hospital Banco de Seguros del Estado (URHBSE) no período de abril a agosto de 2021. Os dados foram obtidos dos prontuários de pacientes com posterior análise estatísticas usando PRISM (v8.2.1). Resultados: 84 pacientes completaram o programa de reabilitação. No momento da admissão na URHBSE, 55% apresentavam dependência total ou grave da escala de Barthel. 48% não conseguiam se mover. 89,2% necessitaram oxigênio com saturação média de 90,3 ± 4,8. 25% dos pacientes foram internados necessitando máscara com reservatório. Todos os pacientes que ingressaram no programa estavam na fase subaguda da doença (4 a 12 semanas) e receberam um plano de reabilitação abrangente e individualizado. O objetivo era alcançar uma situação funcional semelhante à que apresentavam antes da COVID-19. O tempo de permanência na URHBSE foi de 23,5±13,8 dias. A tomografia de tórax de alta resolução (TCAR) foi realizada em 76 pacientes (90,5%); os resultados foram patológicos em 96,1%. O vidro fosco predominou em 49,3% deles, a consolidação em 8,23% e o padrão fibroso em 30,13%. Alterações tomográficas "atípicas" de danos pós-COVID (derrame pleural, nódulos cavitados, cavidades apicais, etc.) foram detectadas em 11,8% dos exames tomográficos. Aspergilose pulmonar foi encontrada em 2,6% dos pacientes e tromboembolismo pulmonar em 6,6%. 44 pacientes (52,3%) receberam prednisona. Em 63,4% a oferta de oxigênio foi suspensa nos primeiros 15 dias após o início da mesma. Encontramos associação entre o padrão tomográfico em vidro fosco e a suspensão precoce da oferta de oxigênio desde o início da administração da prednisona (p = 0,047). Apesar do alto grau de colonização, mesmo naqueles que usaram prednisona, não observamos infecções. Em relação às variáveis respiratórias, só temos dados sobre a presença de dispneia nos primeiros 35 pacientes; destes, 83% apresentavam dispneia na admissão, enquanto apenas 17% a apresentavam na alta (p< 0,0001). Observou-se também diferenças significativas na necessidade de O2 entre a admissão e a alta (p< 0,0001) e no grau de dependência medido pela escala de Barthel, com 55% dos pacientes apresentando dependência total ou grave na admissão e apenas 3,4% na alta. Conclusões: As intervenções realizadas na fase subaguda da doença foram associadas a melhorias significativas nas variáveis de interesse clínico. São necessários mais estudos para definir o papel e o momento exato do início dos corticosteroides e da reabilitação neste grupo de pacientes.

Variations in the treatment of acute peripheral facial paralysis. A nationwide survey / Encuesta nacional sobre la variabilidad en el tratamiento de la parálisis facial periférica aguda

Background Acute peripheral facial paralysis may be diagnosed and treated by different specialists. Objective The aim of this study was to explore the variability in the treatment of Bell’s palsy (BP) and Ramsay Hunt Syndrome (RHS) among different medical specialties. Methods An anonymous nationwide online survey was distributed among the Spanish Societies of Otorhinolaryngology (ORL), Neurology (NRL) and Family and Community Medicine (GP). Results 1039 responses were obtained. 98% agreed on using corticosteroids, ORL using higher doses than NRL and GP. Among all, only 13% prescribed antivirals in BP routinely, while 31% prescribed them occasionally. The percentage of specialists not using antivirals for RHS was 5% of ORL, 11% of NRL, and 23% of GP (GP vs. NRL p = 0.001; GP vs. ORL p < 0.0001; NRL vs. ORL p = 0,002). 99% recommended eye care. Exercises as chewing gum or blowing balloons were prescribed by 45% of the participants with statistically significant differences among the three specialties (GP vs. NRL p = 0.021; GP vs. ORL p < 0.0001; NRL vs. ORL p = 0.002). Conclusion There is general agreement in the use of corticosteroids and recommending eye care as part of the treatment of acute peripheral facial paralysis. Yet, there are discrepancies in corticosteroids dosage, use of antivirals and recommendation of facial exercises among specialties. (AU)

Introducción La parálisis facial periférica aguda puede ser diagnosticada y tratada por diferentes especialistas. Objetivo El objetivo de este estudio es analizar la variabilidad entre especialidades en el tratamiento de la parálisis de Bell (PB) y del síndrome de Ramsay-Hunt (SRH). Métodos Se distribuyó una encuesta anónima online entre los miembros de la Sociedad Española de Otorrinolaringología (ORL), la Sociedad Española de Neurología (NRL) y la Sociedad de Medicina Familiar y Comunitaria (MF). Resultados Se recopilaron 1039 respuestas. El 98% de los participantes coincidieron en el uso de corticoides, los ORL utilizaron dosis más altas que NRL y MF. Del total de encuestados, el 13% recomendaba antivirales en la PB de manera rutinaria, mientras que el 31% los recomendaba en ocasiones. El 5% de ORL, 11% de NRL, y 23% de MF (MF vs. NRL p = 0.001; MF vs. ORL p < 0.0001; NRL vs. ORL p = 0,002) no utilizaba antivirales en el tratamiento del SRH. El 99% de añadía cuidados del ojo al tratamiento de la parálisis facial. El 45% de los participantes aconsejaba ejercicios faciales como mascar chicle o inflar globos con diferencias estadísticamente significativas entre las tres especialidades (MF vs. NRL p = 0.021; MF vs. ORL p < 0.0001; NRL vs. ORL p = 0.002). Conclusión Existe acuerdo general en la utilización de corticoides y recomendar cuidados del ojo como parte del tratamiento de la parálisis facial periférica. A pesar de ello, existen diferencias en las dosis utilizadas, la utilización de antivirales o la recomendación de ejercicios faciales entre especialidades. (AU)

Variations in the treatment of acute peripheral facial paralysis. A nationwide survey.

BACKGROUND: Acute peripheral facial paralysis may be diagnosed and treated by different specialists. OBJECTIVE: The aim of this study was to explore the variability in the treatment of Bell's palsy (BP) and Ramsay Hunt Syndrome (RHS) among different medical specialties. METHODS: An anonymous nationwide online survey was distributed among the Spanish Societies of Otorhinolaryngology (ORL), Neurology (NRL) and Family and Community Medicine (GP). RESULTS: 1039 responses were obtained. 98% agreed on using corticosteroids, ORL using higher doses than NRL and GP. Among all, only 13% prescribed antivirals in BP routinely, while 31% prescribed them occasionally. The percentage of specialists not using antivirals for RHS was 5% of ORL, 11% of NRL, and 23% of GP (GP vs. NRL p = 0.001; GP vs. ORL p < 0.0001; NRL vs. ORL p = 0,002). 99% recommended eye care. Exercises as chewing gum or blowing balloons were prescribed by 45% of the participants with statistically significant differences among the three specialties (GP vs. NRL p = 0.021; GP vs. ORL p < 0.0001; NRL vs. ORL p = 0.002). CONCLUSION: There is general agreement in the use of corticosteroids and recommending eye care as part of the treatment of acute peripheral facial paralysis. Yet, there are discrepancies in corticosteroids dosage, use of antivirals and recommendation of facial exercises among specialties.

Continuous Unilateral Cephalalgia Due to Systemic Lupus Erythematosus: A Case Report / Cefaleia unilateral contínua por lúpus eritematoso sistêmico: relato de caso

BACKGROUND: Hemicrania continua is a rare form of cephalalgia featuring a chronic and persistent headache in only one side of the head. OBJECTIVES: In this report, we present a case of a patient with hemicrania continua and systemic lupus erythematosus (SLE). METHODS: We collected patient data through the electronic medical record. Afterward, we reviewed the literature regarding hemicrania continua and its pathophysiology and correlation with neurovascular alterations, inflammation, and SLE. RESULTS: A 42-year-old woman visited the emergency department due to worsening constant unilateral cephalalgia that had been present for the past 6 months. The patient reported a highly intense (10/10) headache in the entire left hemicrania that radiated to the left shoulder. During physical examination, she presented with nystagmus, vertigo, and aggravated cephalalgia associated to body movement and, despite having no optic nerve thickening. In addition, she had jaundice, tachycardia, and splenomegaly. Complimentary exams found deep anemia, depletion in complement system and anti-nuclear factors, suggesting a possible hemolytic anemia (AIHA) due to SLE. Treatment was initiated with hydrocortisone and prednisone, associated with amitriptyline, fluoxetine and diazepam, reaching full remission. CONCLUSION: These syndromes have aggravated each other, and possibly the explanation for the cephalalgia remission was the control of AIHA and SLE. It features a rare case in literature and thus warrants discussion.

INTRODUÇÃO: Hemicrania contínua é uma forma rara de cefaléia caracterizada por cefaleia crônica e persistente em apenas um lado da cabeça. OBJETIVOS: Neste relato apresentamos o caso de um paciente com hemicrania contínua e lúpus eritematoso sistêmico (LES). MÉTODOS: Coletamos dados dos pacientes por meio do prontuário eletrônico. Posteriormente, revisamos a literatura sobre a hemicrania contínua e sua fisiopatologia e correlação com alterações neurovasculares, inflamação e LES. RESULTADOS: Uma mulher de 42 anos recorreu ao serviço de urgência devido ao agravamento da cefaleia unilateral constante, presente nos últimos 6 meses. O paciente relatou cefaleia de alta intensidade (10/10) em toda a hemicrânia esquerda com irradiação para o ombro esquerdo. Ao exame físico apresentava nistagmo, vertigem e cefaléia agravada associada à movimentação corporal e, apesar de não apresentar espessamento do nervo óptico. Além disso, ela apresentava icterícia, taquicardia e esplenomegalia. Os exames complementares evidenciaram anemia profunda, depleção do sistema complemento e fatores antinucleares, sugerindo uma possível anemia hemolítica (AIHA) por LES. Iniciou-se tratamento com hidrocortisona e prednisona, associadas a amitriptilina, fluoxetina e diazepam, atingindo remissão completa. CONCLUSÃO: Essas síndromes agravaram-se mutuamente e possivelmente a explicação para a remissão da cefaléia foi o controle da AIHA e do LES. Apresenta um caso raro na literatura e, portanto, merece discussão.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

Abstract Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Non-surgical treatment of aseptic olecranon bursitis: A systematic review.

OBJECTIVE: Olecranon bursitis (OB), characterized by inflammation and fluid collection in the olecranon bursa is a commonly encountered out-patient condition. The data is heterogeneous regarding a stepwise and standardized approach to aseptic OB treatment and the efficacy of intra-bursal corticosteroid injections (CSI). The objective of this review is to systematically evaluate the non-surgical treatment options for aseptic OB. METHODS: This systematic review was conducted in accordance with PRISMA recommendations. The English and non-English literature search was performed in 5 medical databases to identify studies evaluating the treatment of OB. All included studies were evaluated for risk of bias (RoB) using the revised Cochrane RoB tool for randomized control trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for case-control and cohort studies. RESULTS: For the final analyses, 2 RCTs and 2 observational studies were included. The RoB for the RCTs was high and both failed to demonstrate a significant difference in terms of the resolution of OB and bursal tenderness among various invasive and non-invasive treatment options. Corticosteroid injection (CSI) was associated with a significant decline in the duration of symptoms. However, it was associated with a higher number of complications including bursal infection and skin atrophy. CONCLUSION: Based on the available data, it appears that the clinical resolution of aseptic OB can occur with conservative methods if implemented earlier in the disease course. Although CSI is more effective than other treatments, it should be reserved for refractory cases because of a higher complication rate.

Non-surgical treatment of aseptic olecranon bursitis: A systematic review / Tratamiento no quirúrgico de la bursitis olecraniana aséptica: revisión sistemática

Objective: Olecranon bursitis (OB), characterized by inflammation and fluid collection in the olecranon bursa is a commonly encountered out-patient condition. The data is heterogeneous regarding a stepwise and standardized approach to aseptic OB treatment and the efficacy of intra-bursal corticosteroid injections (CSI). The objective of this review is to systematically evaluate the non-surgical treatment options for aseptic OB. Methods: This systematic review was conducted in accordance with PRISMA recommendations. The English and non-English literature search was performed in 5 medical databases to identify studies evaluating the treatment of OB. All included studies were evaluated for risk of bias (RoB) using the revised Cochrane RoB tool for randomized control trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for case–control and cohort studies. Results: For the final analyses, 2 RCTs and 2 observational studies were included. The RoB for the RCTs was high and both failed to demonstrate a significant difference in terms of the resolution of OB and bursal tenderness among various invasive and non-invasive treatment options. Corticosteroid injection (CSI) was associated with a significant decline in the duration of symptoms. However, it was associated with a higher number of complications including bursal infection and skin atrophy. Conclusion: Based on the available data, it appears that the clinical resolution of aseptic OB can occur with conservative methods if implemented earlier in the disease course. Although CSI is more effective than other treatments, it should be reserved for refractory cases because of a higher complication rate.(AU)

Objetivo: La bursitis olecraniana (BO), que se caracteriza por inflamación y acumulación de líquido en la bolsa olecraniana, es una situación muy común en el ámbito ambulatorio. Existen datos heterogéneos en cuanto al enfoque terapéutico gradual y estandarizado de la BO séptica y la eficacia de las inyecciones de corticosteroides (CSI) intrabursales. El objetivo de esta revisión es evaluar sistemáticamente las opciones terapéuticas no quirúrgicas para la BO séptica. Métodos: Esta revisión sistemática se llevó a cabo de acuerdo con las recomendaciones PRISMA. La búsqueda en la literatura inglesa y no inglesa fue realizada en 5 bases de datos médicas para identificar los estudios que evalúan el tratamiento de la BO. Se evaluó el riesgo de sesgo (RoB) en todos los estudios incluidos, utilizando la herramienta RoB Cochrane revisada para ensayos controlados aleatorizados (ECA), y la escala Newcastle-Ottawa (NOS) para estudios de casos y controles y de cohortes. Resultados: Para los análisis finales se incluyeron 2 ECA y 2 estudios observacionales. El RoB para los ECA fue alto, no demostrando ambos estudios una diferencia significativa en términos de resolución de la BO y sensibilidad bursal entre las diversas opciones terapéuticas invasivas y no invasivas. La inyección de corticosteroides (CSI) estuvo asociada a una reducción significativa de la duración de los síntomas. Sin embargo, también estuvo asociada a un número más elevado de complicaciones, incluyendo infección bursal y atrofia cutánea. Conclusión: Sobre la base de los datos disponibles, parece que la resolución clínica de la BO séptica puede producirse con métodos conservadores si estos implementan con carácter temprano en el curso de la enfermedad. Aunque las CSI son más efectivas que otros tratamientos, deberían reservarse para casos refractarios, dada su tasa de complicación más alta.(AU)

Aplicação de ácido hialurônico e corticoide através de uma punção guiada por ultrassonografia no tratamento de disfunção da articulação temporomandibular: relato de caso / Hyaluronic and corticoid application through an ultrasound-guided puncture in the treatment of temporomandibular joint dysfunctions: case report / Aplicación de ácido hialurónico y corticoide a través de una punción guiada por ecografía en el tratamiento de la disfunción de la articulación temporomandibular: informe de un caso

Introdução: As Disfunções temporomandibulares (DTM) incluem desordens dos músculos da mastigação, das articulações temporomandibulares e da inervação local, frequentemente associadas a dor orofacial e que resultam em mioartropatias do Sistema Mastigatório. A tendência atual tende a começar com tratamento conservador e progredir a procedimentos mais invasivos na falha dos tratamentos iniciais. Relato de caso: O presente relato visa mostrar o resultado de uma técnica invasiva para o tratamento de uma DTM grave, com a aplicação do ácido hialurônico e de corticoide através de uma punção guiado por ultrassonografia. A paciente apresentava dor crônica e perda importante de peso devido a limitação da abertura da boca. A RM demonstrou disfunção das ATMs, com sinais de deslocamento parcial do disco direito anteromedialmente. Foi realizada a aplicação bilateral intra-articular de ácido hialurônico e de corticoide através de uma punção guiado por ultrassonografia. Considerações Finais: A associação destas classes na punção de ATMs ainda não está bem estabelecida havendo necessidade de estudos complementares para avaliar eficácia, como este relato de caso, que se mostrou favorável com grande melhora clínica da paciente... (AU)

Introduction: Temporomandibular dysfunctions (TMD) include disorders of the masticatory muscles, temporomandibular joints, and local innervation, often associated with orofacial pain and resulting in myoarthropathies of the masticatory system. The current trend tends to begin with conservative treatment and progress to more invasive procedures if the initial treatments fail. Case Report: The present report aims to show the result of an invasive technique for the treatment of a severe TMD, with the application of hyaluronic acid and corticoid through an ultrasound-guided puncture. The patient presented with chronic pain and significant weight loss due to limited mouth opening. MRI demonstrated TMJ dysfunction, with signs of partial anteromedial dislocation of the right disc. Bilateral intra-articular application of hyaluronic acid and corticoid was performed through an ultrasound guided puncture. Final considerations: The association of these classes in TMJ puncture is still not well established, and further studies are needed to evaluate efficacy, as in this case report, which proved favorable, with great clinical improvement for the patient... (AU)

Introducción: Los trastornos temporomandibulares (TTM) incluyen trastornos de los músculos masticatorios, de las articulaciones temporomandibulares y de la inervación local, a menudo asociados a dolor orofacial y que dan lugar a mioartropatías del sistema masticatorio. La tendencia actual es comenzar con un tratamiento conservador y progresar hacia procedimientos más invasivos al fracasar los tratamientos iniciales. Informe de un caso: El presente informe pretende mostrar el resultado de una técnica invasiva para el tratamiento de un TTM severo, con la aplicación de ácido hialurónico y corticoide a través de una punción guiada por ecografía. El paciente presentaba dolor crónico y una importante pérdida de peso debido a la limitación de la apertura bucal. La RMN demostró una disfunción de la ATM, con signos de dislocación parcial del disco derecho anteromedialmente. Se realizó la aplicación intraarticular bilateral de ácido hialurónico y corticoide mediante una punción guiada por ecografía. Consideraciones finales: La asociación de estas clases en la punción de la ATM aún no está bien establecida y se necesitan más estudios para evaluar la eficacia, como en el reporte de este caso, que resultó favorable con gran mejoría clínica del paciente... (AU)

Membranous nephropathy / Nefropatia membranosa

ABSTRACT Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.

RESUMO A nefropatia membranosa é uma glomerulopatia, cujo principal alvo acometido é o podócito, e acarreta consequências na membrana basal glomerular. Tem maior frequência em adultos, principalmente acima dos 50 anos. A apresentação clínica é a síndrome nefrótica, mas muitos casos podem evoluir com proteinúria não nefrótica assintomática. O mecanismo consiste na deposição de complexos imunes no espaço subepitelial da alça capilar glomerular com subsequente ativação do sistema do complemento. Grandes avanços na identificação de potenciais antígenos alvo têm ocorrido nos últimos vinte anos, e o principal é a proteína "M-type phospholipase-A2 receptor" (PLA2R) com o anticorpo anti-PLA2R circulante, o que possibilita avaliar a atividade e o prognóstico dessa nefropatia. Essa via de lesão corresponde aproximadamente a 70% a 80% dos casos da nefropatia membranosa caracterizada como primária. Nos últimos 10 anos vários outros antígenos alvo potenciais têm sido identificados. Esta revisão se propõe a apresentar de modo didático aspectos clínicos, etiopatogênicos e terapêuticos da nefropatia membranosa, incluídos os casos com ocorrência no transplante renal.

Tratamento do dedo em gatilho: revisão de ensaios clínicos e observacionais / Trigger finger treatment: review of clinical and observational trials

Introdução: O dedo em gatilho é uma das causas mais comuns de deficiência nas mãos. Possui uma distribuição bimodal, em pacientes com menos de dezoito anos de idade e adultos na quinta e sexta décadas de vida. As modalidades de tratamento conservador para o dedo em gatilho incluem modificaçãoda atividade manual do paciente, protocolos de exercícios para terapia manual, injeção de corticosteroides, medicamentos anti-inflamatórios não esteroidais orais ou injetáveis, e imobilização com uso de órteses. Enquanto o manejo cirúrgico consiste na liberação aberta ou percutânea da polia A1. Objetivo: Sintetizar, por meio de uma revisão de literatura científica, evidências sobre o tratamento do dedo em gatilho. Metodologia: Foram avaliados os ensaios clínicos publicados nos últimos cinco anos (2017-2022), obtidos na base de dados PUBMED com a utilização da seguinte estratégia de busca: "trigger finger"[title]. Resultados: Foram revisados 14 estudos, que eram compostos de 12 artigos e duas cartas aos editores. Conclusão: O tratamento mais citado foi a injeçãode corticosteroides, e se observou que as aplicações com doses maiores geram respostas de maior sucesso. Em relação a procedimentos cirúrgicos a liberação percutânea da polia A1 apresenta maior nível de recuperação e satisfação, além de menor taxa de recorrência e dor em comparação à injeção de corticosteroides

Introduction: The trigger finger is one of the most common causes of disability in the hands. It has a bimodal distribution in patients under eighteen years of age and adults in the fifth and sixth decades of life. Conservative trigger finger treatment modalities include modification of the patient's manual activity, exercise protocols for manual therapy, corticosteroid injection, oral or injectable non-steroidal anti-inflammatory drugs, and immobilization with the use of orthotics. While surgical management consists of the open or percutaneous release of the A1 pulley. Objective: To synthesize, through a review of scientific literature, evidence on trigger finger treatment. Methodology: We evaluated the clinical trials published in the last five years (2017-2022), obtained from the PUBMED database using the following search strategy: "Trigger finger"[title]. Results: 14 studies were reviewed, which were composed of 12 articles and two letters to the editors. Conclusion: The most cited treatment was corticosteroid injection, and it was observed that applications with higher doses generate more successful responses. In relation to surgical procedures, the percutaneous release of the A1 pulley presents a higher level of recovery and satisfaction, as well as a lower rate of recurrence and pain compared to corticosteroid injection

Introducción: El dedo en gatillo es una de las causas más comunes de deficiencia en las manos. Tiene una distribución bimodal, en pacientes menores de dieciocho años y adultos en la quinta y sextas décadas de vida. Las modalidades de tratamiento conservador para el dedo en gatillo incluyen la modificación de la actividad manual del paciente, Protocolos de ejercicio para terapia manual, inyección de corticosteroides, medicamentos antiinflamatorios no esteroideos orales o inyectables, e inmovilización con el uso de aparatos ortopédicos. Mientras que el manejo quirúrgico consiste en la liberación abierta o percutánea de la polea A1. Objetivo: Sintetizar, a través de una revisión de la literatura científica, evidencias sobre el tratamiento del dedo en gatillo. Metodología: Se evaluaron los ensayos clínicos publicados en los últimos cinco años (2017-2022), obtenidos en la base de datos PUBMED mediante la siguiente estrategia de búsqueda: "trigger finger"[title]. Resultados: Se identificaron 14 estudios y después de leer el título y el resumen, en los que se incluyeron 12 artículos y dos cartas a los editores en el estudio. Conclusión: El tratamiento más citado fue la inyección de corticoides, y se observó que las aplicaciones con dosis más altas generan respuestas más exitosas. En relación a los procedimientos quirúrgicos, la liberación percutánea de la polea A1 presenta un mayor nivel de recuperación y satisfacción, así como una menor tasa de recurrencia y dolor en comparación con la inyección de corticosteroides

Pharmacotherapy and clinical outcomes of hospitalized COVID-19 patients in Chile during the first wave of pandemic

Background: The largest growth in cases of COVID-19 worldwide during 2020 was in the Americas, and Chile was one of the most affected countries. Aim: To describe, characterize, and evaluate the use of drugs as treatment for COVID-19 in hospitalized patients in Chile during the first wave of the pandemic. Methods: We performed a multicenter, observational study that included 442 patients with confirmed SARS-CoV-2 infection admitted in Chilean hospitals between March 21 and September 22, 2020. The analysis included demographics, comorbidities, specific drug therapy, and outcomes over a 28-day follow-up period. Results: The median age of patients was 68 years (IQR 55-73), and 38.9% were women. The most common comorbidities were hypertension (57.7%) and diabetes (36.9%). Fifty-seven (12.9%) patients died. Hypertension (HR 2.99; CI 95% 1.43-6.26) and age ≥ 65 (2.14; CI 95% 1.10- 4.17) were the main predictors of mortality. Primary drugs were azithromycin (58.8%) and corticosteroids (51.1%). In this sample, azithromycin was a protective factor regarding mortality (HR 0.53; CI 95% 0.31-0.90), increasing clinical improvement and avoiding progression. Conclusions: The patterns of use of drugs to treat COVID-19 in Chile during the first wave of the pandemic were very dynamic and followed the international, evidence-based guidelines. The low mortality rate indicates that the clinical management of hospitalized patients was adequate.

Antecedentes: Durante 2020, el mayor incremento de casos de COVID-19 se observó en el continente americano, donde Chile fue uno de los países más afectados. Objetivos: Describir, caracterizar y evaluar el uso de fármacos indicados para tratar el COVID-19 en pacientes hospitalizados en Chile durante la primera ola de pandemia. Pacientes y Métodos: Un estudio multicéntrico observacional incorporó a 442 pacientes con infección confirmada por SARS- CoV-2 admitidos en hospitales chilenos entre el 21 de marzo y el 22 de septiembre de 2020. Se analizaron variables demográficas, comorbilidades, terapia farmacológica específica y desenlaces clínicos para un período de seguimiento de 28 días. Resultados: La mediana de la edad fue de 68 años (RIC 55-73), y un 38,9% fueron mujeres. Las comorbilidades más comunes fueron hipertensión (57,7%) y diabetes (36,9%). Cincuenta y siete (12,9%) de los pacientes murieron. Los principales predictores de mortalidad fueron la hipertensión (HR 2,99; IC 95% 1,43-6,26) y la edad ≥ 65 años (2,14; IC 95% 1,10- 4,17). Los fármacos más utilizados fueron azitromicina (58,8%) y corticosteroides (51,1%). En esta muestra, la azitromicina fue un factor de protección respecto a la mortalidad (HR 0,53; IC 95% 0,31-0,90), incrementando igualmente la mejoría y evitando la progresión. Conclusiones: Los patrones de uso de fármacos para tatar COVID-19 en Chile durante la primera ola de pandemia fueron muy dinámicos y siguieron las directrices internacionales basadas en la evidencia. La baja mortalidad sugiere que el manejo de los pacientes hospitalizados fue adecuado.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 1: Use of High-Dose Corticosteroids / Tratamento das lesões agudas da medula espinal: Uma pesquisa entre cirurgiões de coluna iberoamericanos - Parte 1: Uso de corticosteroides em altas doses

Abstract Objective The aim of the present study was to evaluate the current practice of using of methylprednisolone sodium succinate (MPSS) in acute spinal cord Injuries (ASCIs) among spine surgeons from Iberolatinoamerican countries. Methods A descriptive cross-sectional study design as a survey was conducted. A questionnaire composed of 2 sections, one on demographic data regarding the surgeons and MPSS administration, was sent by email to members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results A total of 182 surgeons participated in the study: 65.4% (119) orthopedic surgeons and 24.6% (63) neurosurgeons. Sixty-nine (37.9%) used MPSS in the initial management of ASCIs. There were no significant differences between countries (p = 0.451), specialty (p = 0.352), or surgeon seniority (p = 0.652) for the use of corticosteroids in the initial management of ASCIs. Forty-five (65.2%) respondents reported using an initial high-dose bolus (30 mg/Kg) followed by a perfusion (5.4 mg/ kg/h). Forty-six (66.7%) surgeons who used MPSS only prescribed it if the patients presented within 8 hours of the ASCI. Most of the surgeons (50.7% [35]) administered high-dose corticosteroids because of the conviction that it has clinal benefits and improves neurological recovery. Conclusion Results from the present survey show that MPSS use in ASCI is not widespread within spine surgeons and that the controversy regarding its use remains unresolved. This is probably due to the low level of evidence of the available data, to variations over the years, to inconsistencies in acute care protocols, and to health service pathways.

Resumo Objetivo O objetivo do presente estudo foi avaliar a prática atual de uso do succinato sódico de metilprednisolona (MPSS, na sigla em inglês) nas lesões agudas da medula espinal (LAMEs) entre cirurgiões de coluna de países ibero-americanos. Métodos Um estudo transversal descritivo foi realizado. O questionário continha duas seções, uma sobre os dados demográficos dos cirurgiões e acerca da administração de MPSS, e foi enviado por correio eletrônico aos membros da Sociedad Ibero Latinoamericana de Columna (SILACO, na sigla em espanhol) e sociedades associadas. Resultados No total, 182 cirurgiões participaram do estudo: 65,4% (119) eram cirurgiões ortopédicos e 24,6% (63), neurocirurgiões. Sessenta e nove (37,9%) usaram MPSS no tratamento inicial da LAME. Não houve diferenças significativas entre países (p = 0,451), especialidades (p = 0,352) ou senioridade do cirurgião (p =0,652) em relação ao uso de corticosteroides no tratamento inicial da LAME. Destes, 45 (65,2%) relataram a administração de um bolus de alta dose (30 mg/kg) seguido por perfusão (5,4 mg/kg/h). Quarenta e seis (66,7%) dos cirurgiões que usam MPSS apenas o prescrevem a pacientes tratados nas primeiras 8 horas após a LAME. A maioria dos cirurgiões (50,7% [35]) administrou corticosteroides em alta dose devido à convicção de seus benefícios clínicos e melhora da recuperação neurológica. Conclusão Os resultados do presente questionário mostram que o uso de MPSS na LAME não está disseminado entre os cirurgiões de coluna e que a controvérsia sobre sua administração ainda não foi resolvida. É provável que isto se deva ao baixo nível de evidência dos dados existentes, a variações ao longo dos anos, a inconsistências nos protocolos terapêuticos agudo e a diferentes sistemas de saúde.

[Management of cytokine release syndrome and macrophage activation syndrome following CAR-T cell therapy: Guidelines from the SFGM-TC]. / Prise en charge du syndrome de relargage cytokinique et du syndrome d'activation macrophagique après traitement par CAR-T cells : recommandations de la SFGM-TC.

The use of chimeric antigen receptor T cells (CAR-T) has increased since their approval in the treatment of several relapsed/refractory B cell malignancies. The management of their specific toxicities, such as cytokine release syndrome (CRS), tends to be better understood and well-defined. During the twelfth edition of practice harmonization workshops of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), a working group focused its work on the management of patients developing CRS following CAR-T cell therapy. A special chapter has been allocated to macrophage activation syndrome (MAS), a rare but life-threatening complication post-CAR-T. In addition to symptomatic measures and preemptive broad-spectrum antibiotics, immunomodulators such as tocilizumab and corticosteroids remain the corner stone for the treatment of CRS. Tocilizumab/corticosteroids-resistant CRS associated with haemophagocytosis markers (spleen and liver enlargement, hyperferritinaemia>10,000ng/mL, hypofibrinogenemia…) should direct the diagnosis towards an overlapping CRS/MAS. An adapted treatment will be based on high-dose IV anakinra and corticosteroids and chemotherapy with etoposide at late refractory stages. These complications and others delignate the need of close collaboration with an intensive care unit.

[Management of neurotoxicity following CAR-T cell therapy: Recommendations of the SFGM-TC]. / Prise en charge du syndrome de neurotoxicité associée au traitement par cellules CAR-T chez l'adulte et l'enfant : recommandations de la SFGM-TC.

The immune effector cell-associated syndrome (ICANS) has been described as the second most frequent specific complication following CAR-T cell therapy. The median time to the onset of neurological symptoms is five days after CAR-T infusion. ICANS can be concomitant to cytokine release syndrome but often follows the resolution of the latter. However, 10 % of patients experience delayed onset after 3 weeks of CAR-T cell infusion. The duration of symptoms is usually short, around five days if an early appropriate treatment is given. Symptoms are heterogeneous, ranging from mild symptoms quickly reversible (alterations of consciousness, deterioration in handwriting) to more serious forms with seizures or even a coma. The ICANS severity is currently based on the ASTCT score. The diagnosis of ICANS is clinical but EEG, MRI and lumbar punction can help ruling out alternative diagnoses. The first line treatment consists of high-dose corticosteroids. During the twelfth edition of practice harmonization workshops of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), a working group focused its work on updating the SFGM-TC recommendations on the management of ICANS. In this review we discuss the management of ICANS and other neurological toxicities in patients undergoing of CAR-T cell therapy. These recommendations apply to commercial CAR-T cells, in order to guide strategies for the management neurological complications associated with this new therapeutic approach.

Weight Loss and Vitamin D Improve Hyporesponsiveness to Corticosteroids in Obese Asthma

Background: Obesity negatively impacts on the response of asthma patients to inhaled corticosteroids. The mechanisms underlying this impact are unknown. Objective: To demonstrate that the poor response to inhaled corticosteroids in obese asthma patients is associated with impaired anti-inflammatory activity of corticosteroids and vitamin D deficiency, both of which are improved by weight loss. Methods: The study population comprised 23 obese asthma patients (OA) (18 females; median (IQR) age 56 [51-59] years), 14 nonobese asthma patients (NOA) (11 females; 53 [43-60] years), 15 obese patients (OP) (13 females; 47 [45-60] years), and 19 healthy controls (HC) (14 females; 43 [34-56] years). Ten OA and 11 OP were evaluated at baseline (V1) and 6 months after bariatric surgery (V2). Corticosteroid response was measured using dexamethasone-induced inhibition of peripheral blood mononuclear cell (PBMC) proliferation. Lung function and serum levels of leptin, adiponectin, and vitamin D were measured at V1 and V2. Results: We found a reduced response to dexamethasone in PBMCs of OP and OA with respect to NOA and HC; this inversely correlated with the adiponectin/leptin ratio and vitamin D levels. Bariatric surgery improved corticosteroid responses in OP and OA and normalized the adiponectin/leptin ratio and vitamin D levels. Exposure of PBMCs to vitamin D potentiated the antiproliferative effects of corticosteroids. Dexamethasone and vitamin D induced similar MKP1 expression in OP and OA. (AU)

Antecedentes: La obesidad tiene un impacto negativo en la respuesta del asma a los corticosteroides inhalados por mecanismos desconocidos. Objetivo: Demostrar que la mala respuesta a los corticosteroides inhalados en pacientes obesos asmáticos se asocia con una actividad antiinflamatoria alterada de los corticosteroides, así como también a la deficiencia de vitamina D, ambos mejorados por la pérdida de peso. Métodos: 23 obesos asmáticos (OA) (18 mujeres; mediana de edad [rango intercuartílico] 56 [51-59] años), 14 asmáticos no obesos (NOA) (11 mujeres; 53 [43-60] años), 15 obesos (O) (13 mujeres; 47 [45-60] años), y 19 controles sanos (HC) (14 mujeres; 43 [34-56] años) fueron incluidos. Se evaluaron 10 pacientes OA y 11 O al inicio (V1) y seis meses después (V2) de cirugía bariátrica. La respuesta a los corticosteroides se midió mediante la inhibición con dexametasona de la proliferación de células mononucleares de sangre periférica (PBMC). La función pulmonar, los niveles séricos de leptina, adiponectina y vitamina D se midieron en V1 y V2. Resultados: Encontramos una respuesta reducida a la dexametasona en PBMC de pacientes O y OA con respecto a los NOA y HC, que se correlacionó de forma inversamente proporcional con la relación adiponectina/leptina y los niveles de vitamina D. La cirugía bariátrica mejoró las respuestas de los corticosteroides en los grupos de pacientes O y OA, y normalizó la relación adiponectina/leptina y los niveles de vitamina D. La exposición de las PBMC a la vitamina D potenció los efectos antiproliferativos de los corticosteroides. La dexametasona y la vitamina D indujeron una expresión similar de MKP-1 en los pacientes O y OA. (AU)

Spanish Consensus on the Management of Chronic Rhinosinusitis With Nasal Polyps (POLIposis NAsal/POLINA 2.0)

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a highly prevalent and burdensome disease for both individuals and health systems. Its management involves many specialties, including otorhinolaryngology, allergology, pulmonology, primary care, pharmacy, and pediatrics. A multidisciplinary approach and the participation of the patient in decision-making are essential, both for diagnosis and for therapy. The authors of the consensus aim to translate current knowledge into an easy-to-read practical guide and emphasize those aspects requiring further discussion or with unmet needs owing to the lack of appropriate scientific evidence. An iterative approach for the development of an evidence-based systematic review with recommendations was followed using a standard quality assessment approach (Scottish Intercollegiate Guidelines Network [SIGN] and National Institute for Health and Care Excellence [NICE]). The guideline was critically evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) and Recommendation Excellence (AGREE REX) instruments. Consequently, POLINA has been considered a high-quality guideline by an independent agency. The POLINA consensus provides new definitions of control, therapeutic management (including surgery and evaluation of severity), indications for use of biologics, and response. Finally, this guideline focuses on unmet research needs in CRSwNP (AU)

La rinosinusitis crónica con pólipos nasales (RSCcPN) es una enfermedad de alta prevalencia y onerosa para las personas y los sistemas de salud cuyo manejo involucra a muchas especialidades: otorrinolaringología, alergología, neumología, atención primaria, farmacia y pediatría. El abordaje multidisciplinar y la participación del paciente en la toma de decisiones son fundamentales, tanto para el diagnóstico como para la estrategia terapéutica. Los autores del consenso pretenden traducir los conocimientos actuales en una guía práctica de fácil lectura y enfatizar aquellos aspectos en los que todavía hay discusión o necesidades no cubiertas por falta de evidencia científica adecuada. Se utilizó un enfoque iterativo para el desarrollo de una revisión sistemática basada en evidencia con recomendaciones, utilizando un esquema de evaluación de calidad estándar (Scottish Intercollegiate Guidelines Network -SIGN- y National Institute for Health and Care Excellence -NICE-), y una evaluación crítica de la directriz se ha llevado a cabo a través del instrumento Evaluación de Directrices para la Investigación y Evaluación (AGREE II) y Recomendación de Excelencia (AGREE REX). Con base en lo anterior, la guía POLINA ha sido considerada una guía de buena calidad por una agencia independiente El consenso POLINA aporta nuevos esquemas para la definición de control, manejo terapéutico incluyendo evaluación de gravedad, indicaciones de la cirugía y del uso de biológicos, y la respuesta al tratamiento. Finalmente, esta guía se enfoca en las necesidades de investigación insatisfechas en la RSCcPN (AU)