Anaphylaxis to SARS-CoV-2 Vaccines in the Setting of a Nationwide Passive Epidemiological Surveillance Program.

BACKGROUND: Information on anaphylaxis among recipients of vaccines against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains scarce. OBJECTIVE: To identify the observed incidence of anaphylaxis in recipients of different anti-SARS-CoV-2 vaccines. METHODS: A nationwide observational study among recipients of 61,414,803 doses of seven different anti-SARS-CoV-2 vaccines, describing the incidence and characteristics of adult patients (age ≥ 18 years) who developed anaphylaxis as an adverse event following immunization (AEFI) against SARS-CoV-2 vaccines between December 24, 2020, and October 15, 2021, in Mexico. RESULTS: Sixty-six patients developed anaphylaxis as an AEFI, for an overall observed incidence of 1.07 cases per 1,000,000 (95% CI 0.84-1.37) administered doses. Eighty-six percent of the patients were female, consistent with previous reports of AEFI to COVID-19 vaccines. mRNA-based vaccine recipients had the highest frequency of anaphylaxis, followed by adenovirus-vectored vaccines and inactivated virus recipients, with an observed incidence of 2.5, 0.7, and 0.2 cases per 1,000,000 doses administered, respectively. Only 46% of the patients received correct treatment with epinephrine as the first-line treatment through the appropriate route and dose. We detected one case of anaphylactic reaction-related death occurring 5 min following immunization with ChAdOx1 nCov-19 for a mortality rate of 1.5% among those who developed this AEFI. CONCLUSIONS: In our population, anaphylactic reactions were infrequent. Our study provides further evidence supporting the security of these newly developed vaccines.

Harmonizing allergy care-integrated care pathways and multidisciplinary approaches.

There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care. We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers. The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.

Allergy education and training for physicians.

The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence  to manage  mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.

Prevention of recurrent urinary tract infections: bridging the gap between clinical practice and guidelines in Latin America.

The branches of the immune system work in concert to defend against pathogens and prevent tissue damage due to excessive inflammation. Uropathogens in general, and uropathogenic Escherichia coli (UPEC) in particular, have evolved a diverse range of virulence mechanisms to avoid detection and destruction by the mucosal immune system of the urinary tract. Research towards a vaccine active against UPEC continues but has yet to be successful. Orally administered immunomodulatory bacterial lysates both stimulate and modulate the immune response in the urinary tract via the integrated mucosal immune system. The 2018 European Association of Urology (EAU) guidelines on treating acute uncomplicated cystitis recommend aiming for rapid resolution of symptoms, reduction of morbidity, and prophylaxis against reinfection. Recommended short-term antibiotic therapy has the advantage of good compliance, low cost, few adverse events, and low impact on bacterial flora. Antibiotic treatment of asymptomatic bacteriuria is only indicated during pregnancy and before invasive interventions. For recurrent infection, prophylaxis using behavioral modification and counseling should be employed first, then nonantibiotic prophylaxis, and, finally, low-dose continuous or postcoital antibiotic prophylaxis. The 2018 EAU guidelines give a strong recommendation for the oral bacterial lysate immunomodulator OM-89. All other nonantibiotic prophylactic strategies require more data, except for topical estrogen for postmenopausal women. For last-resort antibiotic prophylaxis, nitrofurantoin or fosfomycin trometamol are recommended. Guidelines for Latin America are currently being drafted, taking into account the unique ethnicity, availability of medicines, prevalence of antibiotic resistance, and healthcare practices found throughout the region.

Transfer factor and allergy.

Although various mechanisms involving antibodies and various cell types participate, a Thl and Th2 cells imbalance seems to play a central role for allergy development. Other lymphocyte subpopulations, such as Th17, CD4 FOXP3, and Th9 positive regulatory T lymphocytes may also be involved in the allergic response. Regulatory processes are an appealing target for therapeutic approaches aiming to solve allergic reactions by restoring the delicate balance within the immune system. Transfer factor (TF) or dialyzable leukocyte extract is meant to transfer cell-mediated immunity from immune competent donors to unsensitized or deficient recipients. A PubMed search on the current knowledge on TF indicates that TF may restore the Th1/Th2 balance and improve immune regulatory mechanisms of patients receiving it. Our preliminary results demonstrate that TF induces mRNA expression of IFN-g, osteopontin, RANTES, and hBD-2 in human healthy subjects. TF has been used to treat a variety of immune dysfunction related-pathologies, such as allergy, autoimmunity, immunodeficiencies, infectious diseases and tumors. Patients receiving TF together with their conventional treatment often have better clinical evolution than without it, as we have witnessed, adding TF to the usual medical treatment of allergic diseases as an attempt to provide allergic patients with those regulatory elements that they apparently lack but require to achieve properly regulated immune responses and thus obtain a faster and better resolution of allergic reactions.

[Special situations in asthma]. / Situaciones especiales en asma.

In this chapter, we discuss some of the situations in which an asthmatic patient may require different management to usual treatment has been discussed in previous chapters. It is important to recognize these special situations in the asthmatic patient, because if we do so may be serious complications and unnecessary in its evolution. Although the list can be quite extensive, this section will refer to asthma during natural hormonal changes like pregnancy or the menstrual cycle, the relationship with intolerance to NSAIDs, care needs asthmatic patients before and after surgery, and ultimately the patient who is facing an event of anaphylaxis.

Dermatomiositis juvenil: perfil clínico en niños mexicanos / Juvenile dermatomyositis. Clinical profile in Mexican children

Objetivo. Conocer el perfil clínico de pacientes pediátricos con dermatomiositis juvenil (DMJ), en función del tiempo de evolución de la enfermedad al momento del diagnóstico. Diseño. Retrospectivo, longitudinal, descriptivo y observacional. Contexto. Servicio de Inmunología, Instituto Nacional de Pediatría, Ciudad de México. Hospital pediátrico de tercer nivel. Pacientes. Todos los expedientes de pacientes entre 0 y 17 años de edad que fueron diagnosticado con DMJ, que cumplieron con dos o más criterios diagnósticos de Bohan y Peter. Se dividió a la población en dos grupos según tiempo de evolución al momento del diagnóstico: en el grupo 1 (G1) los pacientes con 6 meses o menos y en el grupo 2 (G2), aquellos que tenían más de 6 meses. Material y Métodos. Se investigó sexo, edad, antecedentes de importancia, signos y síntomas, enzimas musculares, estudios inmunológicos, serología para hepatitis A, B, y C y Toxoplasma gondii, electromiografía (EMG), biopsia muscular, serie esofagogástrica (SEG), radiografía de tórax, pruebas de función respiratoria (PFR), electrocardiograma (ECG), electroencefalograma (EEG), valoración oftálmica y renal. Resultados. Se encontraron 102 pacientes, 57 en el G1 y 45 en el G2, la edad promedio fue de 9 años 2 meses con desviación estándar (DE) de 3 años 7 meses. Predominó el sexo femenino en relación 2.3:1. La evoluación del padecimiento tuvo un promedio de 9 meses 10 días con DE de 10 meses 15 días. Los síntomas y signos más frecuentes en ambos grupos fueron el exantema en heliotropo y la debilidad muscular. En el G2 fueron más fecuentes la artritis (p=0.04), hipertricosis (p=0.05) y calcinosis (p=0.03). La ALT (alanin transferasa) fue mayor (p=0.05) y la PCR (proteína C reactiva) positiva con mayor frecuencia (p=0.03) en el G1. Los anticuerpos aCL (anticardiolipina) fueron positivos en cuatro pacientes del G1. Los anticuerpos antitoxoplasma fueron positivos en cuatro pacientes del G1 y uno del G2. No se observaron diferencias significativas entre los grupos al comparar los resultados de EMG, biopsia muscular, SEG, Rx de tórax, PFR, ECG, EEG y valoraciones oftálmica y renal. Discusión. El hecho de que no se detectaran diferencias significativas entre los grupos en la mayor parte de los parámetros estudiados, sugiere que el tiempo de evolución no afecta la expresión clínica de la enfermedad. La artritis, calcinosis e hipertricosis se relacionan con cronicidad. La PCR es un marcador de inflamación del G1 y puede estar en relación al grado de inflamación muscular. Es posible que los anticuerpos aCL y antitoxoplasma fueran positivos con mayor frecuencia en el G1, en relación con el grado de vasculitis; sin embargo, se necesitará evaluar prospectivamente un mayor número de casos para hacer conclusiones válidas