[Drug allergy: Fundamental aspects in diagnosis and treatment.] / Alergia a medicamentos: aspectos fundamentales en el diagnóstico y tratamiento. Reporte de grupo del Colegio Mexicano de Inmunología Clínica y Alergia.

BACKGROUND: Any substance used as a treatment for any disease can produce harmful or unpleasant events called adverse drug reactions (ADRs). They are due to inherent biological effects of the drug and are caused by immunological and non-immunological mechanisms. OBJECTIVES: To describe the immunological mechanisms of hypersensitivity reactions (HSR) to drugs, their epidemiology, risk factors, classification, clinical manifestations, diagnosis, treatment, and prognosis. METHODS: A review of the most current literature in English and Spanish was carried out, in the main databases, related to the HSR of various drug groups. RESULTS: This study describes the terms used to define ADRs and HSRs, their classification and clinical manifestations, current diagnostic tools, treatment algorithms and prognosis of the most frequently used medications and with the highest prevalence of reported adverse events. CONCLUSION: ADRs are a challenging entity, with a complex pathophysiology that has not been fully understood. Its approach requires a careful consideration since not all drugs have validated tests for their diagnosis nor a specific treatment. When indicating the use of any drug, the severity of the disease, the availability of other treatments and the potential risks of developing future adverse events should always be taken into consideration.

ANTECEDENTES: Cualquier sustancia prescrita en el tratamiento de algún padecimiento es capaz de producir eventos dañinos o desagradables, y se denominan reacciones adversas a medicamentos. Estas reacciones se originan por mecanismos inmunológicos y no inmunológicos. OBJECTIVOS: Describir los mecanismos inmunológicos de las reacciones de hipersensibilidad a medicamentos, epidemiologia, factores de riesgo, clasificación, manifestaciones clínicas, diagnóstico, tratamiento y pronóstico. MÉTODOS: Se revisó la bibliografía actualizada, en inglés y español, asociada con reacciones de hipersensibilidad a medicamentos en las principales bases de datos. RESULTADOS: Se describen los términos para definir las reacciones adversas y de hipersensibilidad a medicamentos, su clasificación y manifestaciones clínicas, métodos diagnósticos actuales y en estudio, algoritmos de tratamiento y pronóstico de los medicamentos más frecuentemente prescritos y con mayor prevalencia de eventos adversos reportados. CONCLUSIÓN: Las reacciones adversas a medicamentos representan un reto, con una fisiopatología compleja y no del todo comprendida. Su abordaje requiere un enfoque cuidadoso, porque no todos los fármacos cuentan con pruebas validadas para establecer el diagnóstico y tratamiento específico. Antes de indicar cualquier medicamento debe considerarse la gravedad de la enfermedad, disponibilidad de otros tratamientos y riesgos potenciales de sufrir eventos adversos.

Características de los pacientes con neoplasias hematológicas y con tumores sólidos atendidos por un equipo de soporte paliativo hospitalario / Characteristics of patients with hematological and solid tumors malignancies attended by a hospital palliative care service

Antecedentes y objetivo: El interés por la atención paliativa en pacientes con neoplasias hematológicas está aumentando. Nuestro objetivo es describir las características de pacientes oncológicos valorados por un equipo de soporte paliativo en un hospital terciario y analizar las diferencias entre pacientes hematológicos y con tumores sólidos. Método: Estudio observacional descriptivo longitudinal retrospectivo con una cohorte de pacientes hospitalizados con enfermedad oncológica (hematológica o tumor sólido) valorados por equipo de soporte paliativo hospitalario. Comparamos variables clínicas, asistenciales y de supervivencia. El análisis de datos se realizó con la versión 15 del programa SPSS. Resultados: De enero de 2015 a diciembre de 2018 se valoraron 1025 pacientes oncológicos (10,8 % hematológicos, 89,2 % sólidos). No se encontraron diferencias en situación funcional medida por la Palliative Performance Scale, presentación de síntoma principal, porcentaje de pacientes con dolor, tiempo de seguimiento ni en porcentaje de fallecidos en el ingreso en que fueron valorados. El paciente hematológico, comparado con el oncológico, tiene menos tratamiento opioide pautado (43 vs. 53 %; p = 0,035), es seguido con más frecuencia por recurso paliativo hospitalario que domiciliario (46,55 vs. 29,44 % el primero; 15,5 vs. 33,06 % el segundo; p = 0,001 en distribución) y fallece más en hospital (82,9 vs. 65,5 %; p = 0,024). Conclusiones: Los pacientes con neoplasia hematológica presentan una carga sintomática similar a los pacientes con tumor sólido. Es importante identificar mejor sus necesidades para que puedan beneficiarse, como se ha demostrado con los pacientes oncológicos, de la atención integrada junto a los servicios de hematología con modelos de intervención acordes a sus necesidades y las trayectorias específicas de las enfermedades hematológicas. (AU)

Background and objective: Interest in palliative care for patients with hematologic malignancies is increasing. Our goal is to describe the features of cancer patients evaluated by a supportive and palliative care service in a tertiary referral hospital, and to analyze the differences between patients with hematological malignancies and solid tumors. Method: A retrospective longitudinal descriptive observational study was carried out in a cohort of hospitalized patients with oncological diseases (hematological or solid tumor) evaluated by a palliative care service. We compared clinical, healthcare and survival variables between both groups. The analysis was performed using the SPSS v.15 package. Results: From January 2015 to December 2018, 1025 cancer patients were evaluated (10.8 % hematological tumor, 89.2 % solid tumors). No differences were found in functional status as measured by the Palliative Performance Scale, presentation of main symptom, percentage of patients with pain, time of follow-up, or percentage of deaths on admission to the evaluation. The hematological patient, compared to the oncological one, has less prescribed opioid treatment (43 % vs 53 %, p = 0.035), received greater hospital palliative care rather than home-based care (46.55 % vs 29.44 % the former and 15.5 % vs 33.06 % the latter, p = 0.001), and dies more frequently in a hospital (82.9 % vs. 65.5 %, p = 0.024). Conclusions: Patients with hematological malignancies present a symptomatic burden similar to that of those with solid tumors. It is important to better identify their needs so that they can benefit, as has been demonstrated with cancer patients, from integrated care together with hematology services using intervention models according to their needs and specific disease trajectories. (AU)

Measuring Psychological Flexibility: The Cultural Adaptation and Psychometric Properties of the AAQ for Substance Abuse among Spanish Speaking Population in Correctional and Community settings.

Evaluating psychological flexibility is key in determining the mechanism of action of an ACT intervention. This study aims to evaluate the psychometric properties of the Spanish version of the Acceptance and Action Questionnaire - Substance Abuse (AAQ-SA), a measure of psychological flexibility, among 402 adults with Substance Use Disorders (SUDs) in Puerto Rico recruited from either a prison population or community treatment settings. To evaluate the factor structure of the AAQ-SA, we conducted confirmatory factor analyses with the two-factor structure proposed by the original authors and the three-factor structure found in a Mexican sample. We found the two-factor structure to be a better fit of the data from our sample. After implementing modifications to the model, the two-factor structure demonstrated adequate model fit indices. To gather evidence of convergent validity, we evaluated correlations between scores of the AAQ-SA and those of depression, self-efficacy, and self-stigma measures. The current study suggests that the AAQ-SA is a promising measure of psychological flexibility for the present target populations. Further research is needed to examine the psychometric properties of scores of the AAQ-SA, including discriminant validity.

Los deseos de información en pacientes con cáncer avanzado / The desire for information in patients with advanced cancer

Objetivo: Comprobar los deseos de información, y las variables asociadas a ello, en los pacientes con cáncer avanzado atendidos por un Equipo de Soporte Hospitalario de Cuidados Paliativos. Método: Noventa pacientes con cáncer avanzado, fueron evaluados, mediante una entrevista estructurada sobre si tenían información sobre su enfermedad de los siguientes tipos: diagnóstico, curación, gravedad, objetivos del tratamiento y final de vida, y de su deseo de tener información en cada uno de esto cinco tipos de información. Además, se recogieron los datos sociodemográficos y clínicos, y se administraron: la Escala de Capacidad Funcional, el Índice de Comorbilidad de Charlson, y la Escala de Ansiedad y Depresión Hospitalaria. Resultados. Los resultados muestraron que la mayoría de los pacientes estaban informados del diagnóstico, y de la gravedad, pero no de los objetivos de tratamiento, la curación y el final de vida. De los pacientes no informados el 77,8% (14) deseaban conocer el diagnostico, el 60,0% (11) la gravedad, el 77,8% (35) el objetivo del tratamiento, el 76,7% (24) la curación y un 34,4% (10) el final de vida. Las variables asociadas al deseo de: a) información diagnóstica fueron: tener un cuidador principal más joven (p=,023); con pareja (p=,018), no religiosos (p=,025) y mayor número de visitas a urgencias (p=,004); b) información sobre gravedad fueron: ser joven (p=,009); con pareja (p=,04), y mejor estado ánimo (p=,009); c). Información sobre objetivos del tratamiento: ser joven (p=,001), Con pareja (p=,04), mejor estado ánimo (p=,001). d) información sobre curación: ser hombre (p=,018), con pareja (p=,04), no religiosos (p=,023). En el caso de información sobre el tiempo de vida no se encontró ninguna diferencia significativa

Objective: to study the desire for information in patients with avanzado cancer, and the variables associated with it. Method: Ninety patients with avanzado cancer were evaluated through a structured interview about the information of their disease of the following types: Diagnosis, cure, severity, goal of treatment and time for the end of life, and their desire to have information about each of these five types of information. In addition, sociodemographic and clinical data were collected and administered: the Functional Capacity Scale, the Charlson Comorbidity Index and the Hospital Anxiety and Depression Scale. Results. The results showed that most patients are informed about the diagnosis and its severity, but scarcely about the goals of treatment, cure and end-of-life. Of the uninformed patients, 77.8% (14) wanted to know the diagnosis, 60.0% (11) the severity, 77.8% (35) the treatment goal, 76.7% (24 ) healing and 34.4% (10) end-of-life. The variables associated with the desire for: a) diagnostic information were: having a younger primary caregiver (p=.023); with a partner (p=.018), non-religious (p=.025) and a greater number of visits to the emergency room (p=.004); b) severity information were: being young (p=.009); with a partner (p=.04), and low depression (p=.009); C). Information about the goals of treatment: being young (p=.001), being in a relationship (p=.04), and low depression (p=.001). d) information about healing: being a man (p=.018), with a partner (p=.04), not religious (p=.023). In the case of lifetime information, no significant difference was found. Conclusions: it is necessary to evaluate the information and desires that patients have about the different types of information, so the creation of a standardized tool in future research is a priority

Fatores associados a anormalidades na cintilografia de perfusão miocárdica de pacientes diabéticos / Factors associated with abnormalities on myocardial perfusion scintigraphy in diabetic patients

O diabetes melito é o maior fator de risco para doença arterial coronariana. Além da longa duração de diabetes, outros fatores, como presença de doença arterial periférica e tabagismo são fortes preditores para anormalidades na cintilografia de perfusão do miocárdio. O objetivo deste estudo foi avaliar o impacto dos fatores de risco de pacientes diabéticos nos resultados da cintilografia de perfusão do miocárdio e comparar com os resultados de pacientes não diabéticos em uma clínica de medicina nuclear. Foi realizado um estudo transversal retrospectivo por meio da análise de prontuários de pacientes que realizaram cintilografia miocárdica no período de 2010 a 2019. Foram avaliados 34.736 prontuários. Analisando a fase de estresse da cintilografia de perfusão do miocárdio, os portadores de diabetes melito precisaram receber estímulo farmacológico duas vezes mais que os não diabéticos para sua realização. Também foram avaliados fatores que tivessem impacto negativo no resultado da cintilografia de perfusão do miocárdio, e foi visto que o diabetes melito (33,6%), a insulinoterapia (18,1%), a hipertensão arterial sistêmica (69,9%), a dislipidemia (53%), o sedentarismo (83,1%), o uso de estresse farmacológico (50,6%), a dor torácica típica (8,5%) e a angina limitante durante o teste (1,7%) estiveram associados significativamente (p<0,001) a anormalidades neste exame. (AU)

Diabetes mellitus (DM) is the greatest risk factor for coronary artery disease. In addition to a long duration of diabetes, the presence of peripheral arterial disease and smoking are strong predictors of abnormalities on myocardial perfusion scintigraphy (MPS). This study aimed to assess the impact of risk factors in diabetic patients on MPS results and compare them with those of non-diabetic patients in a nuclear medicine clinic. A retrospective cross-sectional study was performed through the analysis of the medical records of patients who underwent MPS in 2010­2019. A total of 34,736 medical records were evaluated. Analyzing the stress phase of MPS, DM patients required two-fold more pharmacological stimulation than non-diabetic patients for MPS. Factors that negatively impact the MPS results were also evaluated, and DM (33.6%), insulin therapy (18.1%), systemic arterial hypertension (69.9%), dyslipidemia (53%), sedentary lifestyle (83.1%), use of pharmacological stress (50.6%), typical chest pain (8.5%), and limiting angina during the test (1.7%) were significantly associated (p < 0.001) with test abnormalities. (AU)

Leachate treatment: comparison of a bio-coagulant (Opuntia ficus mucilage) and conventional coagulants using multi-criteria decision analysis.

The main aim of this research was to compare a bio-coagulant, organic coagulant, and a conventional coagulant applied to the treatment of leachates. Coagulant options were Stage 1 FeCl3, Stage 2 Polyamine, and Stage 3 Opuntia ficus mucilage (OFM). Optimal conditions for maximum chemical oxygen demand (COD) removal were determined by experimental data and Response Surface Methodology. The application of Multiple Criteria Decision Analysis using Multi-Criteria Matrix (MCM) was explored by evaluating the Coagulation-Flocculation processes. Maximum COD removal (%) and the best MCM scores (on a scale from 0 to 100) were: Stage 1: 69.2±0.9 and 48.50, Stage 2: 37.8±1.1 and 79.0, and Stage 3: 71.1±1.7, and 81.5. Maximum COD removal using FeCl3 and OFM was not statistically different (p 0.15 < 0.05). OFM extraction process was evaluated (yield 0.70 ± 1.17%, carbohydrate content 32.6 ± 1.18%). MCM allows the evaluation of additional technical aspects, besides oxygen COD removal, as well as economic aspects, permitting a more comprehensive analysis. Significant COD removals indicate that the use of OFM as a coagulant in the treatment of stabilized leachate was effective. Opuntia ficus cladodes, a residue, were used to treat another residue (leachates).

Coronavirus disease 2019, allergic diseases, and allergen immunotherapy: Possible favorable mechanisms of interaction.

Background: Both, allergen immunotherapy (AIT) and SARS-COV-2 infection cause a set of immunologic changes that respectively vary during the course of the treatment or the disease. Objective: To review immune changes brought along by each of these entities and how they might interrelate. Methods: We start presenting a brief review of the structure of the new coronavirus and how it alters the functioning of the human immune system. Subsequently, we describe the immune changes induced by AIT and how these changes could be favorable or unfavorable in the allergic patient infected with SARS-CoV-2 at a particular point of time during the evolving infection. Results: We describe how a healthy immune response against SARS-CoV-2 develops, versus an immune response that is initially suppressed by the virus, but ultimately overactivated, leading to an excessive production of cytokines (cytokine-storm-like). These changes are then linked to the clinical manifestations and outcomes of the patient. Reviewing the immune changes secondary to AIT, it becomes clear how AIT is capable of restoring a healthy innate immunity. Investigators have previously shown that the frequency of respiratory infections is reduced in allergic patients treated with AIT. On the other hand it also increases immunoregulation. Conclusion: As there are many variables involved, it is hard to predict how AIT could influence the allergic patient's reaction to a SARS-CoV-2 infection. In any case, AIT is likely to be beneficial for the patient with allergic rhinitis and/or allergic asthma in the context of the SARS-CoV-2 pandemic as controlling allergic diseases leads to a reduced need for contact with healthcare professionals. The authors remind the reader that everything in this article is still theoretical, since at the moment, there are no published clinical trials on the outcome of COVID-19 in allergic patients under AIT.

Cutaneous Manifestations Related to COVID-19 Immune Dysregulation in the Pediatric Age Group.

PURPOSE OF REVIEW: At the juncture of the COVID-19 pandemic, the world is currently in an early phase of collecting clinical data and reports of its skin manifestations, and its pathophysiology is still highly conjectural. We reviewed cutaneous manifestations associated with COVID-19 in the pediatric age group. RECENT FINDINGS: Children infected by SARS-CoV-2 usually develop milder respiratory symptoms, but cutaneous manifestations seem a little more prevalent than in adults. These skin features of infection by the coronavirus can be similar to those produced by other common viruses, but there are also reports of cases with more heterogeneous clinical pictures, which have made their classification difficult. To date, the more frequently reported skin variants featured in pediatric cases are purpuric (pseudo-chilblain, necrotic-acral ischemia, hemorrhagic macules, and/or cutaneous necrosis), morbilliform/maculopapular, erythema multiforme, urticarial, vesicular, Kawasaki-like, and miscellaneous (highly variable in both frequency and severity). Their pathophysiological mechanism is still elusive and is likely to be the result of the complex involvement of one or more mechanisms, like direct virus-induced skin damage, vasculitis-like reactions, and/or indirect injury as a consequence of a systemic inflammatory reaction. In this review, we presented and discussed clinical cases as examples of different cutaneous responses reported in some children with SARS-CoV-2 infection, differential diagnosis considerations, and a preliminary conceptual approach to some of their probable associated pathologic mechanisms.

[Psychometric Properties of the Scale of Negative Attitudes Towards Trans People in Healthcare Providers in Puerto Rico]. / Propiedades psicométricas de la Escala de Actitudes Negativas hacia Personas Trans en proveedores de salud en Puerto Rico.

The ignorance towards the Trans people can cause healthcare providers to assume negative attitudes towards this population. It is relevant to understand with more amplitude the manifestations of stigma towards the Trans population using instruments whose psychometry is adequate. The main objective of the present study was to evaluate the reliability of the Scale of Negative Attitudes towards Trans People (EANT, in Spanish) and its factorial structure in healthcare providers in Puerto Rico. As a secondary objective, differences in attitudes towards Trans people between physical healthcare providers and mental healthcare providers were evaluated. The sample consisted of 67 healthcare providers recruited according to their availability. A point-biserial correlation, a Cronbach's alpha analysis, a Confirmatory Factor Analysis (CFA), and the non-parametric Mann-Whitney test were carried out to examine our objectives. The results confirmed that the EANT has a one-dimensional structure. The Cronbach's alpha internal consistency index of the scale was .75. No significant differences were found in attitudes towards Trans people between physical healthcare providers and mental healthcare providers. Finally, a discussion of the research findings is presented, as well as its limitations and contributions.

Enhancing innate immunity against virus in times of COVID-19: Trying to untangle facts from fictions.

INTRODUCTION: In light of the current COVID-19 pandemic, during which the world is confronted with a new, highly contagious virus that suppresses innate immunity as one of its initial virulence mechanisms, thus escaping from first-line human defense mechanisms, enhancing innate immunity seems a good preventive strategy. METHODS: Without the intention to write an official systematic review, but more to give an overview of possible strategies, in this review article we discuss several interventions that might stimulate innate immunity and thus our defense against (viral) respiratory tract infections. Some of these interventions can also stimulate the adaptive T- and B-cell responses, but our main focus is on the innate part of immunity. We divide the reviewed interventions into: 1) lifestyle related (exercise, >7 h sleep, forest walking, meditation/mindfulness, vitamin supplementation); 2) Non-specific immune stimulants (letting fever advance, bacterial vaccines, probiotics, dialyzable leukocyte extract, pidotimod), and 3) specific vaccines with heterologous effect (BCG vaccine, mumps-measles-rubeola vaccine, etc). RESULTS: For each of these interventions we briefly comment on their definition, possible mechanisms and evidence of clinical efficacy or lack of it, especially focusing on respiratory tract infections, viral infections, and eventually a reduced mortality in severe respiratory infections in the intensive care unit. At the end, a summary table demonstrates the best trials supporting (or not) clinical evidence. CONCLUSION: Several interventions have some degree of evidence for enhancing the innate immune response and thus conveying possible benefit, but specific trials in COVID-19 should be conducted to support solid recommendations.

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, 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.

Primer reporte ecuatoriano de cirugía bariátrica en ancianos / First Ecuadorian report on bariatric surgery in the elderly

Introducción: La cirugía bariátrica es el tratamiento más eficaz para la obesidad, con beneficios metabólicos adicionales a la pérdida de peso. La evaluación preoperatoria adecuada y planificación quirúrgica son esenciales para su éxito, especialmente en pacientes de edad avanzada. Objetivo: determinar variación de peso, beneficios metabólicos y seguridad de cirugía bariátrica en ancianos, con seguimiento de dos años. Metodología: se incluyeron adultos ≥65 años sometidos a cirugía bariátrica laparoscópica en un hospital terciario privado de referencia en Ecuador, entre 2010 y 2019. Se midió pérdida de peso, mejoría de comorbilidades endocrino-metabólicas y complicaciones. Resultados: se incluyeron 16 pacientes; edad media: 68.5 años (DE: ± 4.2); 12 (75%) mujeres; 56.25% se sometió a bypass gástrico; 37.5% a gastrectomía en manga y 6.25% a un procedimiento revisional. En dos años, 13 pacientes mostraron un porcentaje de pérdida de peso total (%TWL) de 31.5% (DE: ± 3.0%) y un porcentaje de pérdida de exceso de peso (% EWL) de 72.9% (DE: ± 11.0) con bypass gástrico; y de 22.7% (DE: ± 3.2%) y 65.6% (DE: ± 13.0) con gastrectomía en manga, respectivamente. Diabetes mellitus tipo 2 remitió en 80%, hipertensión en 62.5% y dislipidemia en 60%. El 50% de complicaciones postoperatorias fueron Grado I según la clasificación Clavien Dindo. Conclusión: este es el primer reporte ecuatoriano sobre cirugía bariátrica en adultos mayores, demostrando su seguridad con baja tasa de complicaciones, su efectividad como tratamiento a corto plazo para la obesidad y sus comorbilidades, y beneficios similares a los presentados en sujetos más jóvenes

Background: Bariatric surgery is currently the most effective obesity treatment, with metabolic benefits in addition to weight loss. Adequate preoperative evaluation and surgical planning are essential for success, especially in elderly patients. Objective: determine up to 2-year weight change, metabolic benefits and safety of bariatric surgery in the elderly. Methodology: older adults ≥ 65y who underwent laparoscopic bariatric surgery at a private tertiary referral hospital in Ecuador, between 2010 and 2019, were included. Weight loss, improvement of endocrine and metabolic comorbidities, and surgical complications were measured up to two years after the procedure. Results: sixteen patients were included. The mean age was 68.5 years (SD: ± 4.2); 12 (75%) were female. Gastric bypass was performed in 56.25% of patients; sleeve gastrectomy in 37.5%, and 6.25% had a revision procedure. Thirteen patients completed a two-year follow-up, where percentage of total weight loss (%TWL) was 31.5% (SD: ±3.0%), and percentage of excess weight loss (%EWL) was 72.9% (SD: ± 11.0) with gastric bypass; and 22.7% (SD: ±3.2%) and 65.6% (SD: ± 13.0) with sleeve gastrectomy, respectively. Remission for type 2 diabetes mellitus (T2DM) was 80%, 62.5% for hypertension (HT) and 60% for dyslipidemia. Fifty percent of postoperative complications were Grade I. Conclusion: this is the first report from a tertiary referral hospital in Ecuador about bariatric surgery in the elderly demonstrating its safety with a low complication rate, effectiveness as a short-term treatment for obesity and its comorbidities, and benefits similar to those presented globally in younger subjects

Chronic urticaria and thyroid pathology.

Urticaria is defined as the sudden appearance of erythematous, itchy wheals of variable size, with or without angioedema (AE) (swelling of the deeper layers of the skin). Its classification depends on time course of symptoms and the presence of eliciting factors. When it lasts less than 6 weeks it is classified as acute urticaria (AU), and if the symptoms persist for more than 6 weeks, it is classified as chronic urticaria (CU). Current International Guidelines also classify CU as chronic spontaneous urticaria (CSU) and inducible urticarial, according to the absence or presence of environmental triggering factors. CSU is defined as urticaria and/or angioedema in which there is no evidence of a specific eliciting factor. CSU is associated with autoimmunity in 30-45% of the cases, sharing some immunological mechanisms with other autoimmune diseases, and is associated with autoimmune thyroid disease (ATD) in about 4.3%-57.4% patients. Several studies suggest that adequate therapy with anti-thyroid drugs or levothyroxine in early stages of ATD and CSU, may help to remit the latter; but there is still a lack of double-blind, placebo-controlled studies that support this hypothesis in patients without abnormal thyroid hormone levels. The objective of this review is to describe the pathophysiology of chronic spontaneous urticaria and its association with autoimmune thyroid disease.

"Effect of valerenic acid on neuroinflammation in a MPTP-induced mouse model of Parkinson's disease".

Parkinson´s disease is the most important neuromotor pathology due to the prominent loss of dopaminergic neurons in the substantia nigra pars compacta. There is an inherent deficiency of dopamine in Parkinson´s disease, which is aggravated when neuroinflammatory processes are present. Several biomolecules are interesting candidates for the regulation of inflammation and possible neuroprotection, such as valerenic acid, one of the main components of Valeriana officinalis. A 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine hydrochloride (MPTP)-induced mouse model of Parkinson's disease was developed to evaluate the motor effects of valerenic acid. The evaluation was carried out with four tests (an invert screen test for muscle strength, cross beam test, open field mobility test and lifting on hind legs test). Subsequently, the neuroinflammatory process was evaluated through ELISA of pro-inflammatory cytokines (IL-1ß, IL-6, TNF-α and IFN-γ). The decreases in the inflammatory and neurodegenerative processes were evaluated by Western blot and immunohistochemistry analyses of the tissues, which included an evaluation of the tyrosine hydroxylase and GFAP proteins. Finally, the predicted mechanism of action of valerenic acid was supported by molecular docking calculations with the 5-HT5A receptor. The results indicate that the use of valerenic acid as a co-treatment decreases the neuroinflammation in Parkinson's disease induced by MPTP and provides evidence of a decrease in the evaluated pro-inflammatory cytokines and in the amount of GFAP in the mesencephalic area. Valerenic acid prevents neuroinflammation in a Parkinson's disease mouse model, which might reflect the neuroprotection of dopaminergic neurons with the recovery of motor ability.

[Clinical Practice Guide for Anaphylaxis in Latin America (Galaxia-Latam)]. / Guía de Actuación en Anafilaxia en Latinoamérica. Galaxia-Latam.

Anaphylaxis is a severe allergic reaction with a rapid onset and it is potentially life-threatening. Its clinical manifestations are varied; they may affect the skin, the cardiovascular system, the respiratory system, and the digestive system, among others. The treatment of choice, which is an intra-muscular injection of epinephrine (adrenaline), must be applied promptly. Therefore, being prepared to recognize it properly is of crucial importance. The objective of this clinical practice guide is to improve the knowledge of health professionals about anaphylaxis and, consequently, to optimize the treatment and long-term management of this reaction. This guide is adapted to the peculiarities of Latin America; especially in matters regarding the treatment. The need to introduce epinephrine auto-injectors in countries that don't have them yet is highlighted.

La anafilaxia es una reacción alérgica grave de instauración rápida y potencialmente mortal. Sus manifestaciones clínicas son muy variadas, pudiendo afectar la piel, el sistema cardiovascular, el aparato respiratorio y el digestivo, entre otros. El tratamiento de elección, mediante la inyección intramuscular de adrenalina, debe ser precoz. Por lo anterior, es vital estar preparados para reconocerla adecuadamente. El objetivo de la presente guía de actuación clínica es mejorar el conocimiento de los profesionales sanitarios sobre anafilaxia y, consecuentemente, optimizar el tratamiento y manejo a largo plazo de esta entidad. La guía está adaptada a las peculiaridades de América Latina, especialmente en los aspectos relativos al tratamiento. Se destaca la necesidad de introducir los autoinyectores de adrenalina en los países que no dispongan de ellos.

[GUIMIT 2019, Mexican Guideline on Immunotherapy. Guideline on the diagnosis of IgE-mediated allergic disease and immunotherapy following the ADAPTE approach]. / GUIMIT 2019, Guía Mexicana de Inmunoterapia. Guía de diagnóstico de alergia mediada por IgE e inmunoterapia aplicando el método ADAPTE.

BACKGROUND: In Mexico, allergen immunotherapy (AIT) and immunotherapy with hymenoptera venom (VIT) is traditionally practiced combining aspects of the European and American school. In addition, both types of extracts (European and American) are commercially available in Mexico. Moreover, for an adequate AIT/VIT a timely diagnosis is crucial. Therefore, there is a need for a widely accepted, up-to-date national immunotherapy guideline that covers diagnostic issues, indications, dosage, mechanisms, adverse effects and future expectations of AIT (GUIMIT 2019). METHOD: With nationwide groups of allergists participating, including delegates from postgraduate training-programs in Allergy/Immunology-forming, the guideline document was developed according to the ADAPTE methodology: the immunotherapy guidelines from European Academy of Allergy and Clinical Immunology, German Society for Allergology and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma, and Immunology were selected as mother guidelines, as they received the highest AGREE-II score among international guidelines available; their evidence conforms the scientific basis for this document. RESULTS: GUIMIT emanates strong or weak (suggestions) recommendations about practical issues directly related to in vivo or in vitro diagnosis of IgE mediated allergic diseases and the preparation and application of AIT/VIT and its adverse effects. GUIMIT finishes with a perspective on AIT modalities for the future. All the statements were discussed and voted on until > 80 % consensus was reached. CONCLUSIONS: A wide and diverse group of AIT/VIT experts issued transculturized, evidence-based recommendations and reached consensus that might improve and standardize AIT practice in Mexico.

Antecedentes: En México, la inmunoterapia con alérgenos (ITA) y con veneno de himenópteros (VIT) se practica tradicionalmente combinando criterios de las escuelas europea y estadounidense; los dos tipos de extractos están comercialmente disponibles en México. Para una ITA adecuada es crucial un diagnóstico oportuno. Objetivo: Presentar GUIMIT 2019, Guía Mexicana de Inmunoterapia 2019, de base amplia, actualizada, que abarca temas de diagnóstico, indicaciones, dosificación, mecanismos, efectos adversos de la ITA y expectativas con esta modalidad de tratamiento. Método: Con la participación de múltiples grupos mexicanos de alergólogos, que incluían los centros formadores universitarios en alergia e inmunología, se desarrolló el documento de la guía según la metodología ADAPTE. Las guías de inmunoterapia de la European Academy of Allergy and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology, German Society for Allergology and Clinical Immunology y del American College of Allergy, Asthma, and Immunology se seleccionaron como guías fuente, ya que recibieron la puntuación AGREE-II más alta entre las guías internacionales disponibles; su evidencia conforma la base científica de GUIMIT 2019. Resultados: En GUIMIT 2019 se emiten recomendaciones fuertes o débiles (sugerencias) acerca de temas directamente relacionados con el diagnóstico in vivo o in vitro de las enfermedades alérgicas mediadas por IgE, la preparación y aplicación de ITA o VIT y sus efectos adversos; se incluye la revisión de las modalidades de ITA para el futuro. Todos los argumentos que se exponen fueron discutidos y votados con > 80 % de aprobación. Conclusión: Un grupo amplio y diverso de expertos en ITA y VIT emitió recomendaciones transculturizadas basadas en evidencia, que alcanzaron consenso; con ellas se pretende mejorar y homologar la práctica de la inmunoterapia en México.

Factores relacionados con el proceso de información en pacientes con cáncer avanzado / Factors related to the information process in patients with advanced cancer

OBJETIVO: Nuestro objetivo fue determinar el grado de conocimiento de su enfermedad que tienen los pacientes con cáncer avanzado atendidos por un Equipo de Soporte Paliativo Hospitalario (ESPH) en un hospital terciario y los factores relacionados con el grado de conocimiento. MÉTODO: Se realizó un estudio observacional prospectivo con una cohorte de pacientes valorados por un ESPH que cumplían los siguientes criterios de inclusión: mayor de 18 años, buena comprensión y expresión del castellano, PPS = 30, ausencia de deterioro cognitivo que impidiera la adecuada realización de las entrevistas y fi rma el consentimiento informado. Se realizó una entrevista semiestructurada y se recogieron datos clínicos y asistenciales de la historia clínica. Se desarrolló una escala con el objetivo de evaluar el grado de conocimiento sobre el proceso de enfermedad del paciente en situación de enfermedad oncológica avanzada. La puntuación podía variar entre 0 y 4, asignando el valor de 1 o 0 al conocimiento sobre los diferentes aspectos de la enfermedad. Se realizó una estadística descriptiva básica expresándose los datos de las variables cuantitativas como media (desviación estándar) y mediana (rango intercuartílico) y los datos de las variables cualitativas como proporción. Para estudiar la asociación de variables cualitativas se utilizó el test de Chi-cuadrado o el test exacto de Fisher y para la comparación de medias de grupos independientes, el test de U de Mann Whitney. Para el análisis de estos datos se utilizó la versión 15 del programa SPSS. RESULTADOS: Se realizaron 50 entrevistas. El 82 % de los pacientes estaba informado correctamente del diagnóstico de la enfermedad que padecían y el 76 % sabía que era una enfermedad grave, aunque el 47 % conocía que el objetivo del tratamiento no era la curación y solo el 39 % que no se podían curar. En el análisis de la relación de los factores estudiados con el grado de conocimiento del proceso de enfermedad, se encontraron diferencias clínicamente relevantes (diferencias de = 0,8 puntos en la escala) y estadísticamente significativas respecto al nivel de estudios (bajo: 2,1 ± 1,3 vs. alto: 3,3 ± 0,9; p = 0,03) y al número de visitas a urgencias en los 6 meses previos (= 2 visitas 1,9 ± 1,2 vs. > 2 visitas 2,8 ± 1,3; p = 0,02). CONCLUSIONES: En esta cohorte de pacientes hay un escaso conocimiento del pronóstico de la enfermedad y, por lo tanto, resulta difícil que puedan participar en decisiones importantes sobre el final de su vida. Aunque estos datos no son extrapolables, sí sugieren la necesidad de un mayor esfuerzo por parte de los profesionales en valorar la necesidad de información de los pacientes sobre su proceso de enfermedad. Por otro lado, el estudio pone de manifiesto la necesidad de desarrollar una herramienta que permita estandarizar la valoración y el registro del grado de conocimiento sobre el proceso de enfermedad. Se propone una escala de grado de conocimiento del proceso de enfermedad que podría permitir valorar el conocimiento sobre diagnóstico, gravedad, objetivo de tratamiento y conciencia de final de vida. Se precisan futuros estudios que permitan valorar su utilidad en la práctica clínica y en la realización de estudios sobre información

OBJECTIVE: Our goal was to determine the degree of knowledge advanced cancer patients have about their condition while being cared for by a Hospital Palliative Care Team (HPCT) in a tertiary referral hospital, and the factors associated therewith. METHODS: A prospective observational study was carried out in a cohort of patients cared for by an HPCT. All of them complied with the following inclusion criteria: over 18 years of age, good understanding and use of the Spanish language, PPS = 30, absence of cognitive impairment that could potentially hamper the interviewing process, and signing of an informed consent form. A semi-structured interview was performed during which medical history data were obtained. A scale was developed to assess degree of knowledge about their disease in patients with advanced cancer. Scores ranged from 0 to 4, with 1 or 0 being assigned to different aspects of the condition involved. Basic descriptive statistics were used to express quantitative variables as mean (standard deviation) and median (interquartile range) values, and qualitative variables as proportions. In order to study the association of qualitative variables the Chi-squared or Fisher's exact tests were used; the Mann-Whitney U-test was used to compare mean values for independent groups. The analysis was performed using the SPSS V.15 package. RESULTS: Fifty interviews were performed; 82% of subjects were correctly informed about their illness, and 76% knew it was a serious disease, although only 47% of patients knew that the goal of their treatment was not total recovery, and only 39% were aware that they could not be cured. After analyzing the relationship between the factors under study and the degree of knowledge about the course of disease, clinically relevant differences were found (differences = 0.8 points within the scale), which were statistically significant with respect to educational background (low: 2.1 ± 1.3 vs. high: 3.3 ± 0.9; p = 0.03) and number of visits to the emergency room over the previous six months (= 2 visits, 1.9 ± 1.2 vs > 2 visits, 2.8 ± 1.3; p = 0.02). CONCLUSIONS: In this cohort of patients knowledge was poor about disease prognosis; consequently, patients could hardly take part in the important decisions required about the end of their lives. Although these data may not be extrapolated, they do suggest the need for greater efforts by professionals in assessing the need for information patients have about their disease. Also, the study highlights the need for developing a tool to help standardize the process of assessing and recording degree of disease knowledge. A disease knowledge scale is proposed to assess knowledge regarding diagnosis, severity, treatment goals, and end-of-life awareness. Further studies are needed to evaluate its usefulness for clinical practice, and to help carry out informative studies

Adverse immune reactions and non-immune medications for perioperative use. / Reacciones adversas inmunitarias y no inmunitarias a fármacos de uso perioperatorio.

Reactions to medications can occur through a mechanism mediated by immunoglobulin or otherwise, not both. Drug allergy is a type of adverse reaction to the drug and comprises a range of hypersensitivity reactions mediated by different immunological mechanisms with diverse clinical manifestations. A rate of 3.2 fatal cases of anaphylaxis associated with drugs per 100,000 inhabitants per year is estimated, which seems to be approximately 10 times higher in hospitalized patients. The incidence of perioperative anaphylactic reactions is estimated at 1 in 10,000-20,000 anesthetic procedures. The diagnosis is based on a careful clinical history and physical examination. In some cases, skin tests, progressive challenges and methods to induce tolerance to the medication may be required. In hospitalized patients and at perioperative intervals, muscle relaxants, neuroleptics and morphinomimetics are frequently used and adverse reactions may occur to these drugs. This review shows a general description of the reactions of these medications, emphasizes allergic reactions and analyzes strategies for the diagnosis and treatment of these reactions.

Las reacciones a medicamentos pueden ocurrir por mecanismos mediados o no por imunoglobulina E. La alergia a fármacos es un tipo de interacción adversa y comprende una gama de reacciones de hipersensibilidad mediadas por distintos mecanismos inmunológicos con diversas manifestaciones clínicas. Se estima una tasa anual de 3.2 casos fatales de anafilaxia asociados con los fármacos por cada 100 000 habitantes, que parece ser aproximadamente 10 veces mayor en los pacientes hospitalizados. La incidencia de reacciones anafilácticas perioperatorias se estima en uno de cada 10 000-20 000 procedimientos anestésicos. El diagnóstico se basa en una cuidadosa historia clínica y en el examen físico. En algunos casos pueden requerirse pruebas cutáneas, pruebas de retos progresivos y procedimientos de inducción de tolerancia al medicamento. En los pacientes hospitalizados y en el intervalo perioperatorio frecuentemente se emplean relajantes musculares, neurolépticos y morfinomiméticos, por lo que pueden presentarse respuestas adversas a estos fármacos. En esta revisión se hace énfasis en las reacciones alérgicas a los medicamentos y se abordan estrategias para su diagnóstico y manejo.