[Economic burden assessment for the management of asthma patients at Mexico's National Institute for Respiratory Diseases]. / Evaluación de la carga económica para el tratamiento de pacientes con asma en el Instituto Nacional de Enfermedades Respiratorias de México.

OBJETIVO: Determinar la carga económica anual del asma, desde una perspectiva institucional y con base en la clasificación recomendada por GINA, en una cohorte retrospectiva de adultos atendidos en el Instituto Nacional de Enfermedades Respiratorias (INER) de México. MÉTODOS: Estudio observacional, longitudinal y retrospectivo, llevado a cabo a partir de la información recabada de 247 pacientes femeninas con asma. Se estimaron los costos directos anuales: visitas, pruebas de laboratorio, tratamiento farmacológico y de las crisis o exacerbaciones, para determinar la carga anual de la enfermedad desde una perspectiva institucional, y según la clasificación de la Iniciativa Global para el Asma. RESULTADOS: El costo promedio anual fue de $43,813,92, que aumentó en relación con la necesidad de aumento de dosis de corticoides inhalados y beta-agonistas de acción prolongada. El costo promedio de la consulta médica fue de $2004.57, $982.82 por gestión de crisis y $2645.95 por pruebas de laboratorio. El tratamiento farmacológico representó la principal carga económica, con un costo promedio anual de $38,180.58. CONCLUSIONES: Los resultados resaltan una carga económica del asma estimada en un costo anual por paciente de $43,813.92 MXN (DE=93,348.85), en el contexto del tercer nivel de atención en el sistema de salud público mexicano. La gravedad del asma, los tratamientos y los biológicos fueron los principales factores que aumentaron los costos directos de la atención.

OBJECTIVE: Determine the annual economic burden of the disease from an institutional perspective and based on GINA's recommended classification in a retrospective cohort of adults treated at Instituto Nacional de Enfermedades Respiratorias (INER) of Mexico City. METHODS: A retrospective, longitudinal observational study comprised by data from 247 female asthma patients, annual direct costs were estimated including: visits, laboratory tests, pharmacological treatment and management of crisis or exacerbations, to determine the annual burden of the disease from an institutional perspective and according to Global Initiative for Asthma classification. RESULTS: The average annual cost was $43,813.92, which increased in relation to the need of inhaled corticosteroids and long-acting beta agonists dosage increase. The average doctor's appointment cost was $2,004.57, $982.82 for crisis management and $2,645.95 for laboratory testing. Pharmacological treatment represented the main economic burden with an annual average cost of $38,180.58. CONCLUSIONS: The results highlight an economic burden of asthma estimated at an annual cost per patient of $43,813.92 MXN (SD=93,348.85) in the context of the third level of care in the Mexican public health system. The asthma severity and treatments such as biologics were the main factors that increased direct costs of care.

An independent in-depth analysis proposing adjusted Global Initiative on Asthma Step 1-2 treatment suggestions.

The Global Initiative on Asthma (GINA) strategy included major changes for the treatment of mild asthma in the 2020 version that are even taken to the next level in 2021, leaving a preferred track with only rescue therapy with inhaled corticosteroid and formoterol (ICS-FORM) for steps 1-2 in 12+ years old. It has been questioned how solid the evidence behind these recommendations is. We decided to independently conduct an in-depth analysis of published evidence based on a comprehensive evaluation of original articles and related appendices and publications, including quality of evidence and risk of bias per article. We first defined the major asthma treatment goals and proceeded to review how these were met in publications referenced in the main asthma guidelines. For patients with GINA (2021) Step 1 characteristics, the analysis supports GINA's decision to avoid SABA monotherapy and to prefer ICS-FORM rescue with an alternative ICS rescue every time a SABA is used for ≥12 years, even though evidence is extrapolated from step 2 patients. For 6- to 11-year-olds, we propose to consider ICS-FORM rescue as an alternative, as its use has been approved in this age group, be it not as rescue medication. For patients with GINA 2021 Step 2 characteristics, our proposal slightly differs from GINA 2021. We propose to continue avoiding the separate use of SABA, using ICS rescue whenever a fast-acting bronchodilator is taken (even with ICS maintenance). Also, the superiority of ICS-FORM rescue over classical step 2 treatment is not uniform and year-long experience is lacking. Consequently, for now, both treatment options seem equal: ICS-FORM rescue or ICS maintenance with SABA (+ICS) rescue. For 6- to 11-year-olds, ICS rescue every time a SABA is used has the advantage of lower total ICS dose; as alternative we suggest ICS-FORM rescue. The best treatment option depends on patient characteristics and treatment goals. Recommendations should be reviewed as soon as new evidence becomes available.

A bioinformatics pipeline for Mycobacterium tuberculosis sequencing that cleans contaminant reads from sputum samples.

Next-Generation Sequencing (NGS) is widely used to investigate genomic variation. In several studies, the genetic variation of Mycobacterium tuberculosis has been analyzed in sputum samples without previous culture, using target enrichment methodologies for NGS. Alignments obtained by different programs generally map the sequences under default parameters, and from these results, it is assumed that only Mycobacterium reads will be obtained. However, variants of interest microorganism in clinical samples can be confused with a vast collection of reads from other bacteria, viruses, and human DNA. Currently, there are no standardized pipelines, and the cleaning success is never verified since there is a lack of rigorous controls to identify and remove reads from other sputum-microorganisms genetically similar to M. tuberculosis. Therefore, we designed a bioinformatic pipeline to process NGS data from sputum samples, including several filters and quality control points to identify and eliminate non-M. tuberculosis reads to obtain a reliable genetic variant report. Our proposal uses the SURPI software as a taxonomic classifier to filter input sequences and perform a mapping that provides the highest percentage of Mycobacterium reads, minimizing the reads from other microorganisms. We then use the filtered sequences to perform variant calling with the GATK software, ensuring the mapping quality, realignment, recalibration, hard-filtering, and post-filter to increase the reliability of the reported variants. Using default mapping parameters, we identified reads of contaminant bacteria, such as Streptococcus, Rhotia, Actinomyces, and Veillonella. Our final mapping strategy allowed a sequence identity of 97.8% between the input reads and the whole M. tuberculosis reference genome H37Rv using a genomic edit distance of three, thus removing 98.8% of the off-target sequences with a Mycobacterium reads loss of 1.7%. Finally, more than 200 unreliable genetic variants were removed during the variant calling, increasing the report's reliability.

Dysbiosis and structural disruption of the respiratory microbiota in COVID-19 patients with severe and fatal outcomes.

The COVID-19 outbreak has caused over three million deaths worldwide. Understanding the pathology of the disease and the factors that drive severe and fatal clinical outcomes is of special relevance. Studying the role of the respiratory microbiota in COVID-19 is especially important as the respiratory microbiota is known to interact with the host immune system, contributing to clinical outcomes in chronic and acute respiratory diseases. Here, we characterized the microbiota in the respiratory tract of patients with mild, severe, or fatal COVID-19, and compared it to healthy controls and patients with non-COVID-19-pneumonia. We comparatively studied the microbial composition, diversity, and microbiota structure between the study groups and correlated the results with clinical data. We found differences in the microbial composition for COVID-19 patients, healthy controls, and non-COVID-19 pneumonia controls. In particular, we detected a high number of potentially opportunistic pathogens associated with severe and fatal levels of the disease. Also, we found higher levels of dysbiosis in the respiratory microbiota of patients with COVID-19 compared to the healthy controls. In addition, we detected differences in diversity structure between the microbiota of patients with mild, severe, and fatal COVID-19, as well as the presence of specific bacteria that correlated with clinical variables associated with increased risk of mortality. In summary, our results demonstrate that increased dysbiosis of the respiratory tract microbiota in patients with COVID-19 along with a continuous loss of microbial complexity structure found in mild to fatal COVID-19 cases may potentially alter clinical outcomes in patients. Taken together, our findings identify the respiratory microbiota as a factor potentially associated with the severity of COVID-19.

Emergence and spread of the potential variant of interest (VOI) B.1.1.519 of SARS-CoV-2 predominantly present in Mexico.

SARS-CoV-2 variants emerged in late 2020, and at least three variants of concern (B.1.1.7, B.1.351, and P1) have been reported by WHO. These variants have several substitutions in the spike protein that affect receptor binding; they exhibit increased transmissibility and may be associated with reduced vaccine effectiveness. In the present work, we report the identification of a potential variant of interest, harboring the mutations T478K, P681H, and T732A in the spike protein, within the newly named lineage B.1.1.519, that rapidly outcompeted the preexisting variants in Mexico and has been the dominant virus in the country during the first trimester of 2021.

[MIA 2021, Comprehensive Asthma Management. Guidelines for Mexico]. / MIA 2021, Manejo Integral del Asma. Lineamientos para México.

BACKGROUND: Asthma continues to be one of the most frequent chronic respiratory diseases in our country. New methods for diagnosis and treatment have been described; accordingly, the international guidelines were renewed. OBJECTIVE: To create a national platform for the development of updated guidelines, solidly based on evidence: Comprehensive Asthma Management (Spanish acronym: MIA). METHODS: MIA uses the ADAPTE method. The MIA development group consists of experts in pulmonology-allergology-methodology and representatives of 13 institutions and societies of specialties that manage asthma. The international reference guidelines (selected with AGREE-II): GINA 2020, GEMA 5.0, BTS/SIGN 2019 and ATS/ERS consensus document 2014-2019 on severe asthma. MIA covers suspected asthma, diagnosis, treatment, and special groups. Key clinical questions were formulated on treatment steps 1-3, biomarkers and severe asthma. RESULTS: Based on evidence, safety, cost and local reality, the core group developed responses. Through a Delphi process the broad MIA development group suggested adjustments until consensus was reached. CONCLUSION: A document was generated with multiple figures and algorithms, solidly based on evidence about asthma management, adjusted for Mexico with a broad base among different societies that participated in its development. It does not include guidelines for acute asthma.

Antecedentes: El asma sigue siendo una patología respiratoria crónica frecuente en México. Se han descrito nuevos métodos para el diagnóstico y tratamiento conforme se renuevan las guías internacionales. Objetivo: Crear la plataforma nacional Manejo Integral del Asma (MIA), para el desarrollo de lineamientos actualizados con base en evidencia. Métodos: Se utilizó el método ADAPTE. El grupo de desarrollo de MIA estuvo integrado por expertos en neumología, alergología y metodología y representantes de 13 instituciones y sociedades de especialidades que manejan asma. Las guías internacionales de referencia (seleccionadas con AGREE-II) fueron GINA 2020, GEMA 5.0, BTS/SIGN 2019 y consenso ATS/ERS 2014-2019. En MIA se aborda sospecha de asma, diagnóstico, tratamiento y grupos especiales. Se formularon preguntas clínicas clave sobre tratamiento en los pasos 1 a 3, biomarcadores y asma grave. Resultados: Con base en evidencia, seguridad, costo y realidad local, el grupo nuclear desarrolló respuestas. Mediante proceso Delphi, el grupo amplio de desarrollo sugirió ajustes hasta que se logró el consenso. Conclusión: El documento generado contiene múltiples figuras y algoritmos, está sólidamente basado en evidencia acerca del manejo del asma y fue ajustado para México con participación de diferentes sociedades para su desarrollo; no se incluyeron lineamientos para la crisis asmática.

Clinical and Immunological Factors That Distinguish COVID-19 From Pandemic Influenza A(H1N1).

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), is a global health threat with the potential to cause severe disease manifestations in the lungs. Although COVID-19 has been extensively characterized clinically, the factors distinguishing SARS-CoV-2 from other respiratory viruses are unknown. Here, we compared the clinical, histopathological, and immunological characteristics of patients with COVID-19 and pandemic influenza A(H1N1). We observed a higher frequency of respiratory symptoms, increased tissue injury markers, and a histological pattern of alveolar pneumonia in pandemic influenza A(H1N1) patients. Conversely, dry cough, gastrointestinal symptoms and interstitial lung pathology were observed in COVID-19 cases. Pandemic influenza A(H1N1) was characterized by higher levels of IL-1RA, TNF-α, CCL3, G-CSF, APRIL, sTNF-R1, sTNF-R2, sCD30, and sCD163. Meanwhile, COVID-19 displayed an immune profile distinguished by increased Th1 (IL-12, IFN-γ) and Th2 (IL-4, IL-5, IL-10, IL-13) cytokine levels, along with IL-1ß, IL-6, CCL11, VEGF, TWEAK, TSLP, MMP-1, and MMP-3. Our data suggest that SARS-CoV-2 induces a dysbalanced polyfunctional inflammatory response that is different from the immune response against pandemic influenza A(H1N1). Furthermore, we demonstrated the diagnostic potential of some clinical and immune factors to differentiate both diseases. These findings might be relevant for the ongoing and future influenza seasons in the Northern Hemisphere, which are historically unique due to their convergence with the COVID-19 pandemic.

Low Incidence and Mortality by SARS-CoV-2 Infection Among Healthcare Workers in a Health National Center in Mexico: Successful Establishment of an Occupational Medicine Program.

Background: Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Healthcare workers (HCWs) constitute a population which is significantly affected by SARS-CoV-2 infection worldwide. In Mexico, the Instituto Nacional de Enfermedades Respiratorias (INER) is the principal national reference of respiratory diseases. Aim: To evaluate the efficiency of the INER-POL-TRAB-COVID19 program to mitigate the SARS-CoV-2 infection risk among the INER-healthcare workers (INER-HCW). Methods: Currently, the INER has 250 beds and 200 respiratory ventilators to support COVID-19 patients in critical condition. On March 1st, 2020, the INER-POL-TRAB-COVID19 program was launched to mitigate the SARS-CoV-2 infection risk among the INER-HCW. Findings: From March 1st to October 1st, 2020, 71.5% of INER-HCWs were tested for SARS-CoV-2 infection, and 77% of them were frontline workers. Among the tested INER-HCWs, 10.4% were positive for SARS-CoV-2 infection. Nonetheless, nosocomial infection represented only 3.8% of the cases and the mortality was null. Fifty-three of INER-HCWs positive to SARS-CoV-2 had a negative test 42-56 days post-diagnosis and were returned to service. Finally, although a change in the PPE implemented on May 11th, 2020, the incidence of SARS-CoV-2 infection was not affected. Conclusion: INER has a lower incidence of HCWs infected with SARS-CoV-2 as compared to the mean of the national report. The implementation of the INER-POL-TRAB-COVID19 program is efficient to decrease the risk of infection among the HCWs. Our findings suggest that the implementation of a similar program at a national level can be helpful to provide a safe environment to HCWs and to prevent the collapse of health institutions.

Genomic Analysis of Early SARS-CoV-2 Variants Introduced in Mexico.

The coronavirus disease 2019 (COVID-19) pandemic has affected most countries in the world. Studying the evolution and transmission patterns in different countries is crucial to enabling implementation of effective strategies for disease control and prevention. In this work, we present the full genome sequence for 17 SARS-CoV-2 isolates corresponding to the earliest sampled cases in Mexico. Global and local phylogenomics, coupled with mutational analysis, consistently revealed that these viral sequences are distributed within 2 known lineages, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lineage A/G, containing mostly sequences from North America, and lineage B/S, containing mainly sequences from Europe. Based on the exposure history of the cases and on the phylogenomic analysis, we characterized 14 independent introduction events. Additionally, three cases with no travel history were identified. We found evidence that two of these cases represented local transmission cases occurring in Mexico during mid-March 2020, denoting the earliest events described for the country. Within this local transmission cluster, we also identified an H49Y amino acid change in the Spike protein. This mutation represents a homoplasy occurring independently through time and space and may function as a molecular marker to follow any further spread of these viral variants throughout the country. Our results provide a general picture of the SARS-CoV-2 variants introduced at the beginning of the outbreak in Mexico, setting the foundation for future surveillance efforts.IMPORTANCE Understanding the introduction, spread, and establishment of SARS-CoV-2 within distinct human populations as well as the evolution of the pandemics is crucial to implement effective control strategies. In this work, we report that the initial virus strains introduced in Mexico came from Europe and the United States and that the virus was circulating locally in the country as early as mid-March. We also found evidence for early local transmission of strains with a H49Y mutation in the Spike protein, which could be further used as a molecular marker to follow viral spread within the country and the region.

High performance of rapid influenza diagnostic test and variable effectiveness of influenza vaccines in Mexico.

OBJECTIVES: To evaluate the performance of rapid influenza diagnostic tests (RIDT) and influenza vaccines' effectiveness (VE) during an outbreak setting. METHODS: We compared the performance of a RIDT with RT-PCR for influenza virus detection in influenza-like illness (ILI) patients enrolled during the 2016/17 season in Mexico City. Using the test-negative design, we estimated influenza VE in all participants and stratified by age, virus subtype, and vaccine type (trivalent vs quadrivalent inactivated vaccines). The protective value of some clinical variables was evaluated by regression analyses. RESULTS: We enrolled 592 patients. RT-PCR detected 93 cases of influenza A(H1N1)pdm09, 55 of AH3N2, 141 of B, and 13 A/B virus infections. RIDT showed 90.7% sensitivity and 95.7% specificity for influenza A virus detection, and 91.5% sensitivity and 95.3% specificity for influenza B virus detection. Overall VE was 33.2% (95% CI: 3.0-54.0; p = 0.02) against any laboratory-confirmed influenza infection. VE estimates against influenza B were higher for the quadrivalent vaccine. Immunization and occupational exposure were protective factors against influenza. CONCLUSIONS: The RIDT was useful to detect influenza cases during an outbreak setting. Effectiveness of 2016/17 influenza vaccines administered in Mexico was low but significant. Our data should be considered for future local epidemiological policies.

Mold burden in house dust and its relationship with asthma control.

OBJECTIVE: Some evidences indicate that exposure to molds or their products can be relevant for the loss of asthma control. Thus, we measured the mold burden present inside houses of subjects with asthma, and evaluated its relationship with asthma control. METHODS: Markers of asthma control in adult patients residing in Mexico City were evaluated through questionnaires and spirometry. Dust was collected from the patients' houses and its fungal content was determined by mold specific quantitative PCR (MSQPCR) for 36 fungal species. RESULTS: Forty-two patients with asthma (12 males, 30 females) with a mean age of 45 years (18-76 years) were included in the study. The level of asthma control measured through the Asthma Control Test ranged from 9 to 25 (mean 20.9). The FEV1/FVC ratio fluctuated from 38 to 106 %predicted (mean, 87.4 %predicted). Associations between mold burden and asthma control differed between males and females. Thus, concentrations of some molds, particularly Aspergillus fumigatus, Aureobasidium pullulans, Stachybotrys chartarum, Alternaria alternata, Cladosporium cladosporioides 2, Cladosporium herbarum, and Epicoccum nigrum, were negatively associated with parameters of asthma control in male subjects, but not in female patients. CONCLUSION: Our results showed that potential indoor exposure to some molds is associated with less asthma control in male subjects.

Pediatric asthma treatment: What to do when international guideline recommendations do not agree.

BACKGROUND: There was a need for a solid asthma guideline in Mexico to update and unify asthma management. Because high-quality asthma guidelines exist worldwide, in which the latest evidence on asthma management is summarized, the ADAPTE approach allows for the development of a national asthma guideline based on evidence from already existing guidelines, adapted to national needs. OBJECTIVE: To fuse evidence from the best asthma guidelines and adapt it to local needs with the ADAPTE approach. METHODS: The Appraisal of Guidelines for Research and Evaluation (AGREE) II asthma guidelines were evaluated by a core group to select 3 primary guidelines. For each step of asthma management, clinical questions were formulated and replied according to (1) evidence in the primary guidelines, (2) safety, (3) Cost, and (4) patient preference. The Guidelines Development Group, composed of a broad range of experts from medical specialties, primary care physicians, and methodologists, adjusted the draft questions and replies in several rounds of a Delphi process and 3 face-to-face meetings, taking into account the reality of the situation in Mexico. We present the results of the pediatric asthma treatment part. RESULTS: Selected primary guidelines are from the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), Global Initiative for Asthma (GINA), and Spanish Guidelines on the Management of Asthma (GEMA) 2015, with 2016 updates. Recommendations or suggestions were made for asthma treatment in Mexico. In this article, the detailed analysis of the evidence present in the BTS/SIGN, GINA, and GEMA sections on the (non) pharmacologic treatment of pediatric asthma, education, and devices are presented for 2 age groups: children 5 years or younger and children 6 to 11 years old with asthma. CONCLUSION: For the pediatric treatment and patient education sections, applying the AGREE II and Delphi methods is useful to develop a scientifically sustained document, adjusted to the Mexican situation, as is the Mexican Guideline on Asthma.

[Mexican Asthma Guidelines: GUIMA 2017]. / Guía Mexicana del Asma: GUIMA 2017.

BACKGROUND: The need for a national guideline, with a broad basis among specialists and primary care physicians was felt in Mexico, to try unifying asthma management. As several high-quality asthma guidelines exist worldwide, it was decided to select the best three for transculturation. METHODS: Following the internationally recommended methodology for guideline transculturation, ADAPTE, a literature search for asthma guidelines, published 1-1-2007 through 31-12-2015 was conducted. AGREE-II evaluations yielded 3/40 most suitable for transculturation. Their compound evidence was fused with local reality, patient preference, cost and safety considerations to draft the guideline document. Subsequently, this was adjusted by physicians from 12 national medical societies in several rounds of a Delphi process and 3 face-to-face meetings to reach the final version. RESULTS: Evidence was fused from British Thoracic Society Asthma Guideline 2014, Global Initiative on Asthma 2015, and Guía Española del Manejo del Asma 2015 (2016 updates included). After 3 Delphi-rounds we developed an evidence-based document taking into account patient characteristics, including age, treatment costs and safety and best locally available medication. CONCLUSIONS: In cooperation pulmonologists, allergists, ENT physicians, paediatricians and GPs were able to develop an evidence-based document for the prevention, diagnosis and treatment of asthma and its exacerbations in Mexico.

Antecedentes: Con el objetivo de unificar el manejo del asma en México se estructuró una guía clínica que conjunta el conocimiento de diversas especialidades y la atención en el primer nivel de contacto. Se seleccionaron 3 guías publicadas en el ámbito internacional para su transculturación. Métodos: Conforme a la metodología ADAPTE se usó AGREE II después de la búsqueda bibliográfica de guías sobre asma publicadas entre 2007 y 2015. Se fusionó la realidad local con la evidencia de 3/40 mejores guías. El documento inicial fue sometido a la revisión de representantes de 12 sociedades médicas en varias rondas Delphi hasta llegar a la versión final. Resultados: Las guías base fueron la British Thoracic Society Asthma Guideline 2014, la Global Initiative on Asthma 2015 y la Guía Española del Manejo del Asma 2015. Después de 3 rondas Delphi se desarrolló un documento en el que se consideraron las características de los pacientes según edad, costos de los tratamientos y perfiles de seguridad de los fármacos disponibles en México. Conclusión: Con la cooperación de neumólogos, alergólogos, otorrinolaringólogos, pediatras y médicos generales se llegó a un consenso basado en evidencia, en el que se incluyeron recomendaciones sobre prevención, diagnóstico y tratamiento del asma y sus crisis.

Clinical Characteristics and Mortality of Influenza A H1N1 and Influenza-Like Illness in Mexico City in the 2013-2014 Winter Season.

BACKGROUND: The 2013-2014 influenza season in Mexico City was severe and mainly due to influenza A H1N1, as was the 2009 pandemic. OBJECTIVE: To describe features of the outbreak and to compare the characteristics of patients with and without viral identification. METHODS: We reviewed the medical charts of all individuals with influenza or influenza-like illness admitted to a referral hospital for respiratory diseases in Mexico City from January 2013 to March 2014, whether influenza virus was identified or not. RESULTS: We included 233 patients with influenza-like illness, 99 of whom had laboratory confirmed influenza; one-half of all patients required mechanical ventilation and 25% were admitted to the intensive care unit. Patients with confirmed influenza had a more severe disease than those without confirmation. A total of 52 (22.3%) patients died in hospital; survival was greater among patients hospitalized in the intensive care unit compared with those who remained in regular wards. CONCLUSIONS: Influenza A H1N1 continues to cause significant outbreaks in Mexico City. Patients with influenza-like illness had a similar clinical course regardless of laboratory confirmation of influenza, suggesting that their illness likely belonged to the same outbreak. Mechanical ventilation in regular hospital wards may be lifesaving, although the outcome is worse than at an intensive care unit.

EV-D68 infection in children with asthma exacerbation and pneumonia in Mexico City during 2014 autumn.

BACKGROUND: Human enterovirus D68 (EV-D68) recently caused an increase in mild-to-severe pediatric respiratory cases in North America and some European countries. Even though few of these children presented with acute paralytic disease, direct causal relationship cannot yet be assumed. OBJECTIVES: The purposes of this report were to describe the clinical findings of an outbreak of EV-D68 infection in Mexico City and identify the genetic relationship with previously reported strains. PATIENTS/METHODS: Between September and December 2014, 126 nasopharyngeal samples (NPS) of hospitalized children <15 years of age with ARI were tested for the presence of respiratory viruses using a multiplex RT-qPCR and EV-D68-specific RT-qPCR. Clinical, epidemiological, and demographic data were collected and associated with symptomatology and viral infections. Phylogenetic analyses were performed using VP1 region. RESULTS: Enterovirus/rhinovirus infection was detected in 40 patients (31·7%), of which 24 patients were EV-D68-positive. EV-D68 infection prevailed over September and October 2014 and was associated with neutrophilia and lymphopenia, and patients were more likely to develop hypoxemia. Phylogenetic analyses showed that Mexican EV-D68 belongs to the new B1 clade. CONCLUSIONS: This is the first EV-D68 outbreak described in Mexico and occurred few weeks after the United States reported similar infections. Although EV-D68 belongs to new B1 clade, no neurological affection was observed.

[ARIA Mexico 2014. Adaptation of the Clinical Practice Guide ARIA 2010 for Mexico. Methodology ADAPTE]. / ARIA México 2014. Adaptación de la Guía de Práctica Clínica ARIA 2010 para México. Metodología ADAPTE.

BACKGROUND: The global prevalence of allergic rhinitis is high. International Study of Asthma and Allergies in Childhood (ISAAC) Phase III reports a total estimated prevalence of 4.6% in Mexico. There is evidence based on allergic rhinitis Clinical Practice Guidelines (CPG), but its promotion, acceptance and application is not optimal or adequate in Mexico. OBJECTIVE: To generate a guideline for the treatment of allergic rhinitis and its impact on asthma by adaptating the 2010 ARIA Guideline to Mexican reality, through a transculturation process applying the ADAPTE methodology. PATIENTS AND METHOD: Using the ADAPTE Methodology, the original 2010 ARIA CPG recommendations were evaluated by the guideline development group (GDG) into which multiple medical specialities managing patients with allergic rhinitis were incoorporated. The GDG valorated the quality of 2010 ARIA, checked and translated key clinical questions. Moreover, the GDG adjusted recommendations, patient preferences and included comments in the context of the Mexican reality (safety, costs and cultural issues). To accomplish this, we ran Delphi panels with as many rounds as necessary to reach agreement. One extra question, not included in the original 2010 ARIA, on the use of Nasal Lavages for AR was created sustained by a systematic literature review. RESULTS: A total of 45 questions from the original 2010 ARIA were included and divided into six groups covering prevention, medical treatment, immunotherapy and alternative medicine to treat patients with allergic rhinitis with or without asthma. Most of the questions reached agreement in one or two rounds; one question required three rounds. CONCLUSIONS: An easy-to-use, adaptated, up-to-date and applicable allergic rhinitis guideline for Mexico is now available.

ANTECEDENTES: la prevalencia de rinitis alérgica en todo el mundo es alta. El Estudio Internacional de Asma y Alergias en la Niñez (ISAAC de International Study of Asthma and Allergies in Childhood) Fase III reporta una prevalencia estimada total en México de 4.6%. Existen guías de práctica clínica basadas en evidencia de rinitis alérgica, pero su promoción, aceptación y validez no son óptimas ni adecuadas para México. OBJETIVO: generar una guía de tratamiento de la rinitis alérgica y su repercusión en el asma adaptando la guía ARIA 2010 a la realidad mexicana mediante un proceso de transculturización, por medio de la metodología ADAPTE. MATERIAL Y MÉTODO: a través de la metodología ADAPTE un grupo de desarrollo de la guía, integrado por múltiples especialistas que tratan pacientes con rinitis alérgica, valoró la calidad de la guía ARIA 2010, revisó y tradujo las preguntas clínicas clave y ajustó las recomendaciones, preferencias del paciente y comentarios a la realidad mexicana (seguridad, costos y aspectos culturales). Para lograrlo se corrieron páneles Delphi, con tantas rondas como fuera necesario hasta lograr un acuerdo. Por medio de una revisión sistemática de la bibliografía se creó una pregunta especial no incluida en ARIA 2010 de la utilidad de realizar lavados nasales en pacientes con rinitis alérgica. RESULTADOS: se incluyeron 45 preguntas de la guía original ARIA 2010, divididas en seis bloques que abarcan prevención, tratamiento médico, inmunoterapia y terapias alternativas de pacientes con rinitis alérgica con o sin asma. La mayor parte de las preguntas alcanzaron acuerdo en una a dos rondas, sólo una requirió tres para ello. CONCLUSIONES: se cuenta ahora con una guía de rinitis alérgica de usosencillo, adaptada, actualizada y válida para México.

Respiratory health in Latin America: number of specialists and human resources training.

Latin America is made up of a number of developing countries. Demographic changes are occurring in the close to 600 million inhabitants, in whom a significant growth in population is combined with the progressive ageing of the population. This part of the world poses great challenges for general and respiratory health. Most of the countries have significant, or even greater, rates of chronic respiratory diseases or exposure to risk. Human resources in healthcare are not readily available, particularly in the area of respiratory disease specialists. Academic training centers are few and even non-existent in the majority of the countries. The detailed analysis of these conditions provides a basis for reflection on the main challenges and proposals for the management and training of better human resources in this specialist area.

Relaciones estructurales entre estrategias de afrontamiento y síndrome de Burnout en personal de salud: un estudio de validez externa y de constructo / Structural relations between coping strategies and Burnout syndrome on health workers: A study of external and construct validity

El objetivo del estudio fue validar relaciones estructurales y funcionales hipotetizadas entre estrategias de afrontamiento y factores asociados al síndrome de burnout en muestras independientes de trabajadores de la salud, de diferentes hospitales y contextos de atención hospitalaria. Se aplicó el Maslach Burnout Inventory y la escala de Afrontamiento ante Riesgos Extremos adaptados para población mexicana; se analizaron las respuestas de 354 trabajadores de la salud de un hospital de tercer nivel y 300 de un hospital de referencia. Las muestras fueron intencionales, no probabilísticas, por cuotas. Los grupos se conformaron con personal de enfermería, para-médicos, servicios auxiliares y diagnóstico, médicos y médicos residentes. Los resultados confirmaron la estructura factorial de los instrumentos en las dos muestras; mostraron que el uso de estrategias activas de afrontamiento (control, búsqueda de información, soporte social, entre otras) tiene efectos protectores sobre los factores asociados al síndrome (cansancio emocional, despersonalización y realización personal en el trabajo), independientemente de la muestra, del contexto y del tipo de atención hospitalaria. Se discuten los resultados y sus implicaciones en relación con la validez externa y hallazgos en otras investigaciones relacionadas.

The aim of this study was to validate hypothesized structural and functional relationships between coping strategies and factors associated with burnout syndrome in independent samples of health workers from different hospitals and hospital care settings. We applied the Maslach Burnout Inventory and the scale of Coping with Extreme Risks adapted to the Mexican population, we analyzed the responses of354 health workers in a tertiary hospital and 300 from a reference hospital. The samples were intentional, non-probability, quota. The group was formed by nurses, paramedics, diagnostics services, physicians and resident physicians. Results confirmed the factor structure of the instruments in the two samples and showed that the use of active coping strategies (control, information seeking, social support, among others) has protective effects on the factors associated with the syndrome (emotional exhaustion, depersonalization and personal fulfillment at work), regardless of the sample, context and type of hospital care. We discuss the results and their implications in relation to external validity and findings in other related research.

Prevalencia delssíndrome de burnout y estrategis de afrontamiento durante una epidemia de influenz aah1n1 / Prevaence of burrnout syndrome and coping strategies uring an epidemmiology because of ah1n1 influenza

El objetivo de este estudio fue evaluar el síndrome de Burnout en una muestra de 477 trabajadores de la salud durante una epidemia por influenza AH1N1 en la Ciudad de México, e identificar si el uso de estrategias de afrontamiento tenía efectos protectores al Burnout. Se realizó un estudio descriptivo transversal con una muestra no probabilística por cuotas, utilizando como instrumentos el Maslach Burnout Inventory versión Human Services y la Escala de Afrontamiento Frente a Riesgo Extremos. Se hizo una distribución de frecuencia y de normalidad para analizar las diferencias, un análisis de varianza en Burnout y regresión lineal múltiple para estrategias de afrontamiento. A partir del análisis, se encontró que el 24% presentó el síndrome de Burnout en grado moderado (cansancio emocional y despersonalización, con presencia de realización personal); asimismo, fueron empleadas estrategias activas y pasivas. Se constató que el uso de estrategias de afrontamiento fue selectivo y las estrategias activas tuvieron una función moderadora al Burnout, protectora a la escala de cansancio emocional, que aumentó cuando presentaban realización personal. El estudio propone el desarrollo de investigaciones cuantitativas y cualitativas, así como el uso de modelos mixtos de intervención: centradas en las personas.

The aim of this study was to assess the Burnout syndrome in health workers during a contingency in Mexico City because of epidemiology AH1N1 influenza, and identify if the use of coping strategies had protective effects for the Burnout. We had a sample of 477 health workers and was performed a transversal descriptive study with a nonrandom quote sample. The instruments used were Maslach Burnout Inventory Human Services version and scale measuring coping face to extreme risks. It was performed a frequency and normality distribution to analyze the differences, and also an analysis of variance in Burnout, and multiple lineal regression for coping strategies. We found that 24% had Burnout (in emotional exhaustion and a moderate degree depersonalization, with the presence of personal accomplishment). They were also employed active and passive strategies. We found that the use of coping strategies was selective, active strategies had a moderating role to Burnout and protective to the scale of emotional exhaustion, which seems to increase when there is personal realization. We propose the development of quantitative and qualitative research and the use of mixed models of intervention: focusing on people.