Use of Intravenous Immunoglobulins and Systemic Corticosteroids in Patients with Toxic Epidermal Necrolysis: Experience of a Hospital in Mexico City. / Tratamiento con inmunoglobulina intravenosa y esteroides sistémicos en pacientes con necrólisis epidérmica tóxica: Experiencia en un hospital en Ciudad de México.

Toxic epidermal necrolysis is the most serious mucocutaneous adverse drug reaction. Multidisciplinary treatment and withdrawal of the causative drug are key to reducing mortality. Few studies have analyzed the use of systemic corticosteroids and intravenous immunoglobulins (IVIG) in patients with toxic epidermal necrolysis in Latin America. We describe our experience with 6 cases treated at a dermatology referral hospital in Mexico City. None of the patients died or developed complications in the short or medium term. The most widely used regimen was a combination of IVIG 1 g/kg for 3 to 5 days and methylprednisolone 1 g for 3 to 5 days. Mean hospital stay was 14.8 days. The combined use of systemic corticosteroids and IVIG seems to be a safe treatment option for patients with toxic epidermal necrolysis.

A meta-analysis of efficacy of topical steroids in eosinophilic esophagitis: From the perspective of histologic, clinical, and endoscopic outcome.

BACKGROUND: Swallowed topical steroids are a mainstay drug therapy for eosinophilic esophagitis (EoE), studies have demonstrated good histologic response, but with enormous discrepancy in clinical and endoscopic improvement. We conducted this meta-analysis to investigate the efficacy of topical steroids in EoE in histological, clinical and endoscopic improvement. METHODS: Several databases were searched from inception to August 1, 2019 for randomized controlled trials (RCTs) comparing topical steroids with placebo for EoE in the short-term. The outcomes of interest mainly included basic characteristics of the studies, histologic, clinical, endoscopic response rate and adverse events. The results were pooled together using Reviewer Manager 5.3.5 software, and inconsistency was quantified using I2 statistics. RESULTS: Nine studies were eventually selected. The results showed that topical steroids were effective in inducing histologic response compared with placebo for both complete (OR 35.82, 95% CI 14.98-85.64, P<0.0001; I2=0, P=0.72) and partial response (OR 28.44, 95% CI 8.56-94.47, P<0.0001; I2=70%, P=0.0009). Moreover, topical steroids were useful in gaining clinical response (OR 2.53, 95% CI 1.14-5.60, P=0.02; I2=60%, P=0.02) and endoscopic response (OR 3.51, 95% CI 1.47-8.36, P=0.005; I2=0, P=0.57). Generally, topical steroids are well tolerated. The most common adverse events are infections and infestations (59 cases). CONCLUSION: Topical steroids were effective in inducing histological, clinical and endoscopic response in the short-term, and the adverse events were almost tolerable; however, we should interpret the result of clinical and endoscopic response with caution.

Isolation and characterization of a marine testosterone-degrading bacterium: Vibrio sp. N3.

Steroids, including testosterone, estrone, 17ß-estradiol, estriol and 17ß-ethinyl estradiol, are harmful not only to the population dynamics of aquatic life forms but also to public health. In this study, a marine testosterone-degrading bacterium (strain N3) was isolated from Nanao Island in the South China Sea. In addition, the strain could also use 17ß-estradiol (E2), 17ß-ethinyl estradiol (EE2), estriol (E3) or cholesterol as a sole carbon source. According to the 16S rRNA gene sequence analysis, strain N3 was identified as Vibrio sp. Further characterization showed that the strain is aerobic, gram-negative, and mobile and exhibits resistance to ampicillin, carbenicillin, penicillin and spectinomycin. For enhancing its capacity of testosterone degradation, the Plackett-Burman factorial design and the central composite design were used to optimize the culture condition. Under optimal conditions, 92% of testosterone was degraded by Vibrio sp. N3 in 48h.

Galactomannan enzyme immunoassay and quantitative Real Time PCR as tools to evaluate the exposure and response in a rat model of aspergillosis after posaconazole prophylaxis.

INTRODUCTION: A steroid-immunosuppressed rat model of invasive pulmonary aspergillosis was use to examine the usefulness of galactomannan enzyme immunoassay (GM) and quantitative real time PCR (RT-PCR) in evaluating the association between response and exposure after a high dose of prophylactic posaconazole. METHODS: Two different strains of Aspergillus fumigatus with different in vitro posaconazole susceptibility were used. RESULTS: Serum concentrations demonstrated similar posaconazole exposure for all treated animals. However, response to posaconazole relied on the in vitro susceptibility of the infecting strain. After prophylaxis, galactomannan index and fungal burden only decreased in those animals infected with the most susceptible strain. CONCLUSION: This study demonstrated that both biomarkers may be useful tools for predicting efficacy of antifungal compounds in prophylaxis.

Case report: A rare case of cyclodialysis after cataract surgery managed exclusively with medical therapy.

We present the case of a 68-year-old female who presented with a substantial cyclodialysis after phacoemulsification identified by anterior segment optical coherence tomography and ultrasound biomicroscopy. Gonioscopy is challenging because of its shallow anterior chamber. Due to lack of response to topical steroids and refusal by the patient for surgical treatment, topical steroids were tapered, and cycloplegic was initiated. After two weeks, the cyclodialysis cleft was closed on optical coherence tomography persisting residual subchoroidal fluid, topical treatment was mantained. Despite of this, visual acuity and hypotony were restored. Finally at 2 months visit subchoroidal fluid was reabsorbed and patient was discharged. Clinics should consider the possibility of cyclodialysis in cases of unjustified hypotony during postoperative period. In addition, we recommend performing anterior segment imaging which includes ultrasound biomicroscopy and optical coherence tomography, when the evaluation of angular structures is unfeasible. Finally, we propose medical management for severe cyclodialysis as the first option considering anti-inflammatory drugs could perpetrate the separation between scleral spur and ciliary muscle.

Recovery of spermatogenesis after androgenic anabolic steroids abuse in men. A systematic review of the literature.

OBJECTIVE: This systematic review aims to evaluate the optimal treatment for male infertility resulting from Anabolic Androgenic Steroids (AAS) abuse. METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies that compared different protocols for the recovery of spermatogenesis in patients after AAS use were included. RESULTS: 13 studies investigating different protocols to restore spermatogenesis in patients with AAS abuse met the inclusion criteria. The available agents that showed restoration of spermatogenesis include injectable gonadotropins, selective estrogen receptor modulators, and aromatase inhibitors, but their use is still poorly described in the literature. CONCLUSIONS: Clinicians need to be aware of the detrimental effects of AAS on spermatogenesis. AAS-associated infertility may be reversible, but sperm production may take over a year to normalize. Both conservative and aggressive treatment can boost spermatogenesis with positive results. Further understanding of male reproductive endocrinology and high-quality data on the field of restoration of spermatogenesis after AAS abuse are warranted.

How can we optimize the diagnostic and therapeutic approach to pneumonia? Expert opinion-based recommendations.

Pneumonia continues to be one of the most frequent infectious syndromes and a relevant cause of death and health resources utilization. The OPENIN ("Optimización de procesos clínicos para el diagnóstico y tratamiento de infecciones") Group is composed of Infectious Diseases specialists and Microbiologists and aims at generating recommendations that can contribute to improve the approach to processes with high impact on the health system. Such task relies on a critical review of the available scientific evidence. The first Group meeting (held in October 2023) aimed at answering the following questions: Can we optimize the syndromic and microbiological diagnosis of pneumonia? Is it feasible to safely shorten the length of antibiotic therapy? And, is there any role for the immunomodulatory strategies based on the adjuvant use of steroids, macrolides or immunoglobulins? The present review summarizes the literature reviewed for that meeting and offers a series of expert recommendations.

Executive summary of the position statement of the Spanish Societies SEQCML/SEEN/SEEP. Recommendations for the measurement of sex steroids in clinical practice.

Accurate measurement of sex steroids, particularly testosterone and estradiol, is relevant for the diagnosis and treatment of a wide range of conditions. Unfortunately, current chemiluminescent immunoassays have analytical limitations with important clinical consequences. This document reviews the current state of clinical assays for estradiol and testosterone measurements and their potential impact in different clinical situations. It also includes a series of recommendations and necessary steps to introduce steroid analysis by mass spectrometry into national health systems, a methodology recommended for more than a decade by international societies.

[Are inhaled corticosteroids effective in asthma exacerbations? Evidentia praxis]. / ¿Son eficaces los corticoides inhalados en las exacerbaciones asmáticas? Evidentia praxis.

A clinical scenario is presented, from which a structured clinical question arises: In asthmatic children or adolescents with exacerbation symptoms, does the use of inhaled corticosteroids (newly instituted or base dose increased) reduce the risk of exacerbations that require systemic steroids and/or hospitalization? To answer it, we carried out a bibliographic search, with selection, evaluation and graduation of the evidence, following GRADE criteria. We did not find sufficient evidence to consider intermittent inhaled steroids as an alternative to maintenance inhaled steroids to avoid exacerbations that require the use of systemic steroids. The use of a combination of inhaled steroids with formoterol, as a rescue treatment at the onset of symptoms, is only effective when used by patients with this maintenance treatment, compared to those who only have inhaled steroids and rescue with beta2-agonists of short action; when patients already take maintenance combined therapy, combined rescue does not reduce the risk. In patients with asthma attacks attended in the emergency department, inhaled steroids compared to placebo reduce the risk of admission, but not when compared to systemic corticosteroids.

Practical recommendations for the management of the patient with chronic pain during the pandemic of COVID-19.

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Management of primary immune thrombocytopenia. A comparison between two historical cohorts.

INTRODUCTION: In recent years, there have been changes in the management of patients with primary immune thrombocytopenia. In this study, a review is presented of the characteristics and outcomes of children with primary immune thrombocytopenia in a children's hospital (Hospital Infantil Niño Jesús). Moreover, an analysis is made of the changes in the care of these patients diagnosed before and after 2011, when new guidelines were published by the Spanish Society of Paediatric Haematology Oncology (SEHOP). MATERIAL AND METHODS: Data from a cohort of primary immune thrombocytopenia patients followed up in this hospital have been retrospectively reviewed. The statistical package used for the analysis was SPSS Statistics 22.0 (IBM Corp., Chicago, IL, USA). RESULTS: A review is presented on the clinical data from 235 paediatric patients diagnosed with primary immune thrombocytopenia. It was observed that some features at diagnosis, such as age younger than five years and a previous history of infection, influenced the probability of cure. Regarding the changes in the management of patients since 2011, the steroid doses received during the first month and the first year, and the number of days corresponding to the patient's first admission have both significantly decreased. Splenectomies were also significantly reduced. CONCLUSIONS: Since 2011, there have been changes in the medical care of our primary immune thrombocytopenia patients: they receive lower doses of steroids, they stay fewer days in the hospital, and the number of splenectomies has decreased without increasing bleeding or worsening the clinical evolution. Furthermore, it was observed that age younger than 5 years and a history of infection prior to diagnosis were related to higher chances of recovery.

[Update on Duchenne muscular dystrophy]. / Puesta al día en distrofia muscular de Duchenne.

Duchenne muscular dystrophy, DMD*(ICD-9-C: 359.1; ICD-10-ES: G71.01, ORPHA: 98896) is a dystrophic type, autosomal recessive myopathy linked to the X chromosome, low incidence 1/3300, with full penetrance and multi-organ involvement (neuro-muscular, respiratory, digestive and metabolic). It has great clinical variability. Symptoms begin in pediatric age (mobility limitation and early respiratory complications). Respiratory complications reduce the life expectancy of those affected. There is no treatment that modifies its evolution, although corticosteroids and new gene therapies are increasing the half-life of this disease. The role of the Primary Care Physician (PCP) is decisive in the monitoring and control of the complications of DMD, either coordinating the different specialties involved in it.

Current use and abuse of anabolic steroids. / Uso y abuso de agentes anabolizantes en la actualidad.

Common abuse of anabolic androgenic steroids (AAS) is no longer confined to high performance athletes, as it has spread among the general population. Epidemiological data about the abuse of these substances show that it is a common practice in young populations. Its use is based on the desire to increase muscle mass and strength, as well as improving physical performance. The ease of acquisition of this type of substances has developed a "sophisticated" knowledge of steroid pharmacology based on subjective and anecdotal analysis with no adverse event information, which translates into a public health crisis. Unfortunately, athletes seem to be more influenced by these experiences than by their physician's advice. The abuse of AAS by the athlete and non-athlete population and its adverse events ought to be evaluated in order to improve routine clinical practice on this regard.

The Mexican consensus on alcoholic hepatitis. / Consenso Mexicano de hepatitis alcohólica.

Alcoholic hepatitis is a frequent condition in the Mexican population. It is characterized by acute-on-chronic liver failure, important systemic inflammatory response, and multiple organ failure. The severe variant of the disease implies elevated mortality. Therefore, the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Hepatología brought together a multidisciplinary team of health professionals to formulate the first Mexican consensus on alcoholic hepatitis, carried out utilizing the Delphi method and resulting in 37 recommendations. Alcohol-related liver disease covers a broad spectrum of pathologies that includes steatosis, steatohepatitis, different grades of fibrosis, and cirrhosis and its complications. Severe alcoholic hepatitis is defined by a modified Maddrey's discriminant function score ≥ 32 or by a Model for End-Stage Liver Disease (MELD) score equal to or above 21. There is currently no specific biomarker for its diagnosis. Leukocytosis with neutrophilia, hyperbilirubinemia (> 3 mg/dL), AST > 50 U/l (< 400 U/l), and an AST/ALT ratio > 1.5-2 can guide the diagnosis. Abstinence from alcohol, together with nutritional support, is the cornerstone of treatment. Steroids are indicated for severe disease and have been effective in reducing the 28-day mortality rate. At present, liver transplantation is the only life-saving option for patients that are nonresponders to steroids. Certain drugs, such as N-acetylcysteine, granulocyte-colony stimulating factor, and metadoxine, can be adjuvant therapies with a positive impact on patient survival.

Primary trochlear headache. A periorbital pain with a specific diagnosis and treatment. / Cefalea troclear primaria. Un dolor periorbitario con diagnóstico y tratamiento específicos.

Primary trochlear headache is a little-known cause of periorbital headache described in adults. It can involve very disabling pain. In addition, it can be associated with other types of headaches, making them even more difficult to identify. To diagnose this pathology, it is necessary that the examination of the trochlea be incorporated into the usual clinical practice of the patient with headache, which will allow the establishment of an adequate treatment. The case is presented of an adolescent patient with a diagnosis of migraine, who was admitted with a disabling headache secondary to a primary trochlear headache.

Practical recommendations for the management of the patient with chronic pain during the pandemic of COVID-19. / Recomendaciones prácticas para el manejo del paciente con dolor crónico durante la pandemia de COVID-19.

SARS-CoV-2 infection has evolved into a pandemic and a Public Health Emergency of International Importance that has forced health organizations at the global, regional and local levels to adopt a series of measures to address to COVID-19 and try to reduce its impact, not only in the social sphere but also in the health sphere, modifying the guidelines for action in the health services. Within these recommendations that include the Pain Treatment Units, patients with suspected or confirmed SARS-CoV-2 infection may be waiting for medical consult or interventional procedures for the management of chronic pain refractory to other therapies. A series of guidelines aimed at reducing the risk of infection of health personnel, other patients and the community are included in this manuscript.

Kidney disease associated with androgenic-anabolic steroids and vitamin supplements abuse: Be aware!

The excessive chase for beauty standards and the rise of muscle dysmorphia have ultimately led to an increase in androgenic-anabolic steroids (AAS) and intramuscular injections of vitamins A, D and E (ADE) abuse, which is associated with several adverse effects and has become a public health issue. This review of literature discusses kidney injury associated with the use of AAS and ADE, highlighting the mechanisms of acute and chronic renal lesion, such as direct renal toxicity, glomerular hyperfiltration and hypercalcemia. Future perspectives regarding evaluation and early diagnosis of kidney injury in these patients are also discussed.

COVID-19 pandemic: challenges ahead.

Since December 2019, health systems worldwide have faced the pandemic caused by the new severe acute respiratory syndrome coronavirus 2. The pandemic began in China and has spread throughout the world. This new coronavirus has a high transmission capacity and elevated lethality in people over 60 years old and in those with risk factors (obesity, diabetes, and systemic arterial hypertension); those characteristics have a different proportion in each country. At present, there is no specific, effective, and safe treatment to treat this virus. In this review, an analysis is made on the differences in epidemiological aspects of the disease and its presentation in pediatric patients; the poorly-based recommendation for using an empirical combination of antimalarials plus antimicrobials as antiviral treatment; the indication of intravenous steroids; and the possible influence of antihypertensive drugs on the course of the disease.

A partir de diciembre de 2019, los sistemas de salud de todos los países se han enfrentado a la pandemia causada por un nuevo coronavirus (SARS-CoV-2), el cual fue notificado por primera vez en China y se ha esparcido por todo el mundo. Este nuevo coronavirus posee una alta capacidad para transmitirse. A escala mundial la letalidad ha sido más alta en la población mayor de 60 años y en aquellos que tienen factores de riesgo (obesidad, diabetes e hipertensión arterial sistémica). Sin embargo, estas características varían en proporción en cada país. Hasta el momento no hay un tratamiento específico, eficaz y seguro para combatir este virus. En este artículo se realiza un análisis sobre las diferencias globales en los aspectos ­epidemiológicos y con relación a su presentación en pacientes pediátricos, así como de la recomendación, con pobre fundamento, del uso de la combinación de antimaláricos y antimicrobianos empíricos como antivirales. También se analizan la indicación de esteroides intravenosos y la posible influencia de los fármacos antihipertensivos en el curso de la enfermedad.

Caracterización clínica y epidemiológica de la enfermedad pulmonar obstructiva crónica / Clinical and epidemiological characterization of chronic obstructive pulmonary disease

Objetivo: caracterizar clínica y epidemiológicamente a los pacientes con enfermedad pulmonar obstructiva crónica. Métodos: estudio descriptivo retrospectivo trasversal, que incluyó pacientes adultos con diagnóstico de enfermedad pulmonar obstructiva crónica en un hospital universitario de Medellín. Material y métodos: la fuente de información fue secundaria a través de historias clínicas, el análisis se realizó en el programa Jamovi, empleando un análisis univariado. Resultados y discusión: se incluyeron 552 pacientes, la edad mediana fue 76 años con predominio del sexo femenino (56.7%). Respecto a la exposición a sustancias tóxicas respiratorias importantes en el desarrollo de la enfermedad, 24.1% consumían cigarrillo y 23% exposición a biomasa. Al momento del ingreso hospitalario 17.9% fueron clasificados con disnea grado IV; 74.1% recibió beta-agonistas de corta acción y antimuscarínicos de corta acción 60%; 11.6% requirió ingreso a las unidades de cuidados intensivos o especiales y 7.8% fallecieron durante la hospitalización. Conclusiones: se evidencia subdiagnóstico espirométrico de la enfermedad que puede estar relacionado con las limitaciones económicas, tecnológicas y de recurso humano capacitado, lo cual afecta el adecuado diagnóstico y manejo de la enfermedad, así como impacta la calidad de vida de los pacientes.

Objective: clinical and epidemiological characterization of patients with chronic obstructive pulmonary disease (COPD). Methods: a retrospective, cross-sectional, descriptive study, which included adult patients with a diagnosis of COPD in a university hospital in Medellín. Data sources were secondary, based on medical records. The Jamovi program was used to perform a univariate analysis. Results and discussion: 552 patients were included. Median age was 76 years with a female predominance (56.7%). Regarding exposure to major respiratory toxic substances implicated in the development of the disease, 24.1% were tobacco smokers and 23% were exposed to biomass smoke. At the time of hospital admission,17.9% were classified as having grade 4 dyspnea; 74.1% received short acting beta-agonists and 60% short-acting antimuscarinics,11.6% required intensive care unit or special care unit admission, and 7.8% died in hospital. Conclusions: under-diagnosis of COPD by spirometry may be related to economic, technological, and trained human resource limitations, which affect adequate diagnosis and management of the disease, as well as patient ́s quality of life.

Circulating sex hormones in women with severe anxiety during pregnancy / Hormonas sexuales circulantes en mujeres con ansiedad severa durante el embarazo

Abstract Introduction Anxiety, mood- and stress-related behaviors are regulated by sex hormones in pregnant and non-pregnant women. Very scarce information exists about the role of sex steroids in pregnant women displaying high levels of anxiety. Objective To determine sex hormones serum levels in pregnant women exhibiting high levels of anxiety symptoms. Method The Hamilton Anxiety Rating Scale (HARS/ HAM-A) was used to assess the intensity of anxiety symptoms in third-trimester pregnant women. Two groups were included in the study, pregnant women exhibiting severe anxiety (ANX; HARS scores ≥ 25; n = 101) and healthy control subjects (CTRL; n = 40) displaying lower scores for anxiety (HARS scores ≤ 7). Estradiol (E2), progesterone (P4), and testosterone (T) serum levels were measured using a standard chemiluminescent immunoassay. Bivariate and partial correlations were performed to detect significant associations between groups, clinical measures, biochemical data, and HARS scores. Results The anxiety group (ANX) showed an increase in E2 and T serum levels (p < .001) compared to CTRL. Conversely, significantly lower P4 levels were found in the symptomatic group (p < .001) as compared to the CTRL hormone values. The P4:E2 index was significantly reduced in pregnant women with high levels of anxiety (p < .001). Negative correlations between anxiety (HARS) scores, P4 serum levels (p = .02), and P4:E2 ratio (p = .04) were found in the symptomatic group. Conversely, T serum levels displayed a positive association (p = .001) with high levels of anxiety symptoms in the same group, after adjusting our data by clinical confounders. Discussion and conclusion Serum levels of sex-steroid hormones are altered in pregnant women exhibiting severe anxiety.

Resumen Introducción La ansiedad, el estado de ánimo y el estrés están regulados por diversos esteroides sexuales. Existe poca información sobre el papel que juegan estos esteroides en mujeres embarazadas con niveles elevados de ansiedad. Objetivo Determinar los niveles séricos de hormonas sexuales en mujeres embarazadas con altos índices de síntomas de ansiedad con respecto a mujeres gestantes sanas. Método Determinación de la intensidad de síntomas ansiosos empleando la escala de Hamilton de Ansiedad (HAM-A) en 141 mujeres embarazadas en el tercer trimestre de gestación. Cuantificación de los niveles séricos de estradiol (E2), progesterona (P4) y testosterona (T) por inmunoensayo estándar. Aplicación de las correlaciones de Pearson para detectar asociaciones entre parámetros clínicos y valores hormonales entre los grupos de estudio. Resultados Las mujeres con ansiedad severa (ANX; n = 101; HAM-A ≥ 25) mostraron niveles séricos más altos de E2 y T (p < .001), así como niveles más bajos de P4 (p < .001) en relación con el grupo control (CTRL, n = 40, HAM-A < 7). Se detectó una disminución significativa en el índice P4:E2 en el grupo de ANX (p < .001) y se observaron correlaciones negativas y positivas entre los puntajes elevados de ansiedad con los niveles circulantes de P4 (p = .02), en la taza P4:E2 (p = .04) y en los niveles séricos de T (p = .001) respectivamente, al ajustar nuestros datos con variables confusoras. Discusión y conclusión Los niveles circulantes de los esteroides sexuales se encontraron alterados en mujeres con ansiedad severa.