Early corticosteroids are associated with lower mortality in critically ill patients with COVID-19: a cohort study.

BACKGROUND: Critically ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, although there are still some concerns regarding its use, timing, and dose. METHODS: This is a nationwide, prospective, multicenter, observational, cohort study in critically ill adult patients with COVID-19 admitted into Intensive Care Units (ICU) in Spain from 12th March to 29th June 2020. Using a multivariable Cox model with inverse probability weighting, we compared relevant outcomes between patients treated with early corticosteroids (before or within the first 48 h of ICU admission) with those who did not receive early corticosteroids (delayed group) or any corticosteroids at all (never group). Primary endpoint was ICU mortality. Secondary endpoints included 7-day mortality, ventilator-free days, and complications. RESULTS: A total of 691 patients out of 882 (78.3%) received corticosteroid during their hospital stay. Patients treated with early-corticosteroids (n = 485) had lower ICU mortality (30.3% vs. never 36.6% and delayed 44.2%) and lower 7-day mortality (7.2% vs. never 15.2%) compared to non-early treated patients. They also had higher number of ventilator-free days, less length of ICU stay, and less secondary infections than delayed treated patients. There were no differences in medical complications between groups. Of note, early use of moderate-to-high doses was associated with better outcomes than low dose regimens. CONCLUSION: Early use of corticosteroids in critically ill patients with COVID-19 is associated with lower mortality than no or delayed use, and fewer complications than delayed use.

Development of a microwave-assisted extraction method for the recovery of bioactive inositols from lettuce (Lactuca sativa) byproducts.

A microwave-assisted extraction (MAE) method was developed for the extraction of bioactive inositols (D-chiro- and myo-inositols) from lettuce (Lactuca sativa) leaves as a strategy for the revalorization of these agrofood residues. Gas chromatography-mass spectrometry was selected for the simultaneous determination of inositols and sugars (glucose, fructose, and sucrose) in these samples. A Box-Behnken experimental design was used to maximize the extraction of inositols based on the results of single factor tests. Optimal conditions of the extraction process were as follows: liquid-to-solid ratio of 100:1 v/w, 40°C, 30 min extraction time, 20:80 ethanol:water (v/v), and one extraction cycle. When compared with conventional solid-liquid extraction (SLE), MAE was found to be more effective for the extraction of target bioactive carbohydrates (MAE 5.42 mg/g dry sample versus SLE 4.01 mg/g dry sample). Then, MAE methodology was applied to the extraction of inositols from L. sativa leaves of different varieties (var. longifolia, var. capitata and var. crispa). D-chiro- and myo-inositol contents varied between 0.57-7.15 and 0.83-3.48 mg/g dry sample, respectively. Interfering sugars were removed from the extracts using a biotechnological procedure based on the use of Saccharomyces cerevisiae for 24 h. The developed methodology was a good alternative to classical procedures to obtain extracts enriched in inositols from lettuce residues, which could be of interest for the agrofood industry.

Awake prone positioning does not reduce the risk of intubation in COVID-19 treated with high-flow nasal oxygen therapy: a multicenter, adjusted cohort study.

BACKGROUND: Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. METHODS: Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. RESULTS: A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53-1.43), p = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0-2.5) vs 2 IQR 1.0-3.0] days (p = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40-2.72), p = 0.92]. CONCLUSION: In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Evaluation of different ionic liquid stationary phases for the analysis of carbohydrates by gas chromatography-mass spectrometry.

Five commercial ionic liquid (IL) columns have been evaluated for the first time for the gas chromatography-mass spectrometry (GC-MS) analysis of low molecular weight carbohydrate (LMWC) standards (mono-, di-, and trisaccharides, inositols, and iminosugars). A previous derivatization step was necessary to convert the LMWCs into their volatile and stable derivatives. Compared with conventional GC stationary phases, such as HP-1 and Supelcowax® 10, IL columns have shown a different selectivity in the separation of target compounds. Among the IL columns, only SLB™-IL82 allowed the elution of all the LMWCs studied. Its performance in terms of peak width and asymmetry, evaluated under different oven temperature conditions, was shown to be dependent on the carbohydrate class considered. As an example of application, a SLB™-IL82 column was successfully used to separate the complex mixtures of LMWCs in hyacinth and mulberry extracts. This column is an interesting alternative to the conventional stationary phases used in the GC analysis of LMWCs in real-world samples. Graphical abstract.

Pollensomes as Natural Vehicles for Pollen Allergens.

Olive (Olea europaea) pollen constitutes one of the most important allergen sources in the Mediterranean countries and some areas of the United States, South Africa, and Australia. Recently, we provided evidence that olive pollen releases nanovesicles of respirable size, named generically pollensomes, during in vitro germination. Olive pollensomes contain allergens, such as Ole e 1, Ole e 11, and Ole e 12, suggesting a possible role in allergy. The aim of this study was to assess the contribution of pollensomes to the allergic reaction. We show that pollensomes exhibit allergenic activity in terms of patients' IgE-binding capacity, human basophil activation, and positive skin reaction in sensitized patients. Furthermore, allergen-containing pollensomes have been isolated from three clinically relevant nonphylogenetically related species: birch (Betula verrucosa), pine (Pinus sylvestris), and ryegrass (Lolium perenne). Most interesting, pollensomes were isolated from aerobiological samples collected with an eight-stage cascade impactor collector, indicating that pollensomes secretion is a naturally occurring phenomenon. Our findings indicate that pollensomes may represent widespread vehicles for pollen allergens, with potential implications in the allergic reaction.

Is the Quantification of Antigen-Specific Basophil Activation a Useful Tool for Monitoring Oral Tolerance Induction in Children With Egg Allergy?

OBJECTIVES: To assess modifications in baseline specific IgE- and anti-IgE- and antigen-specific-mediated basophil activation in egg-allergic children. The values were compared before and after the children completed specific oral tolerance induction (SOTI) with egg. PATIENTS AND METHODS: We studied 28 egg-allergic children who completed SOTI with egg. The basophil activation test and specific IgE determinations with egg white, ovalbumin, and ovomucoid were performed in all 28 children. RESULTS: A decrease in antigen-specific activation with egg white, ovalbumin, and ovomucoid was observed only at the 2 lowest concentrations used (5 and 0.05 ng/mL). Baseline activation was higher in patients with multiple food allergies and in those who developed anaphylaxis during SOTI; this activation decreased in both groups after completion of SOTI. A significant decrease was also observed in specific IgE values for egg white, ovalbumin, and ovomucoid after tolerance induction. CONCLUSIONS: Food tolerance induction is a specific process for each food that can be mediated by immunologic changes such as a decrease in specific IgE values and in specific and spontaneous basophil activation.

Betalactam antibiotics affect human dendritic cells maturation through MAPK/NF-kB systems. Role in allergic reactions to drugs.

The mechanisms leading to drug allergy in predisposed patients, especially those related to T-cell-mediated drug hypersensitivity, are not well understood. A key event in allergic reactions to drugs is the maturation process undergone by dendritic cells (DCs). Although amoxicillin (AX) has been reported to interact and maturate DCs from patients with AX-induced delayed-type hypersensitivity, the cell signaling pathways related to AX-mediated DC maturation have not been elucidated. We sought to determine the role of the MAPK and NF-κΒ pathways on AX-induced DC maturation and functional status. For that purpose, in monocyte-derived-DCs from AX-delayed allergic patients and tolerant subjects, we analyzed the activation pattern of p38MAPK, JNK, and ERK signaling and the NF-κB, maturation markers as well as endocytosis and allostimulatory capacities driven by AX-stimulated-DCs. Our data reveal that AX induces an increase in the phosphorylation levels of the three MAPKs and activated NF-κB in DCs from allergic patients. Moreover, the inhibition of these pathways prevents the up-regulation of surface molecules induced by AX. Additionally, we observed that the allostimulatory capacity and the endocytosis down-regulation in AX-stimulated-DCs from allergic patients depend on JNK and NF-κB activities. Taken together, our data shed light for the first time on the main signaling pathways involved in DC maturation from AX-delayed allergic patient.

The incidence of perioperative hypersensitivity reactions: a single-center, prospective, cohort study.

BACKGROUND: The incidence of perioperative hypersensitivity reactions, which can be life-threatening, ranges from 1 in 20,000 to 1 in 1361. These reactions are usually classified as IgE or non-IgE mediated. The aim of this study was to determine the incidence of allergic reactions during general anesthesia in our hospital, to establish the incidence of the allergic reactions for each drug used, to assess the frequency of IgE-mediated reactions in even mild reactions, and to compare the degree of agreement between anesthesiologist suspicion and allergy diagnosis. METHODS: We included patients diagnosed with a clinical hypersensitivity reaction during a procedure under general anesthesia over a 30-month period (February 2008 to August 2010). Plasma histamine and serum tryptase concentrations were determined in these patients. We performed skin tests to diagnose the causative agent. Data from the hospital electronic prescribing system were collected to determine the ratio of reactions for each drug. RESULTS: During the study period, 16,946 anesthetic procedures were performed (53% involved males; mean age, 51.6 years). Forty-four perianesthetic reactions were recorded, and the ratio of reactions was 1 in 385 operations (95% confidence interval, 1/529-1/287). Twenty-five reactions (25/44; 57%) occurred during the induction of anesthesia. Twenty-one reactions (21/44; 48%) were mild, involving only skin, and 23 of 44 (52%) were anaphylactic reactions. Four of 10 patients who had only a rash experienced IgE-mediated reactions. Five surgeries (11%) were suspended because of the severity of the reactions. Fifteen reactions (15/30; 50%) were IgE mediated, and, in 2 of 30 (7%), a non-IgE agent was found (cold urticaria and nonsteroidal anti-inflammatory drug intolerance). The ratio of reactions for each drug was as follows: protamine, 1 in 468; cisatracurium, 1 in 1388; amoxicillin-clavulanate, 1 in 1968; atracurium, 1 in 2039; and dipyrone, 1 in 3159. CONCLUSIONS: Perioperative reactions are more common than previously reported. Mild hypersensitivity perioperative reactions-involving only skin-should be considered in evaluating patients because a substantial number of these reactions are IgE mediated.

Identification and determination of 3-deoxyglucosone and glucosone in carbohydrate-rich foods.

BACKGROUND: α-Dicarbonyl compounds (α-DCs) such as 3-deoxyglucosone (3-DG) and glucosone are markers of both Maillard and degradation reactions of sugars and also of certain enzymatic processes. However, quantitation of these compounds is not straightforward when more abundant carbohydrates are present in real samples. Therefore in this work a GC/MS method was developed to separate monosaccharides, 3-DG and glucosone and applied to analyze them in carbohydrate-rich food products. Difructose anhydrides (DFAs), known markers of sugar degradation, were also determined. The effect of time and temperature in the production and storage of these compounds was also evaluated. RESULTS: Under optimized conditions, good separation between monosaccharides and α-DCs was achieved. Must syrups showed the highest concentrations of 3-DG and glucosone (average values 9.2 and 5.8 mg g(-1) respectively). Coffee substitutes based on carob, chicory and blends showed the highest content of DFAs. Heating and storage assays proved that production of 3-DG was influenced by temperature, while glucosone was more affected by storage time. CONCLUSION: The proposed method allows the rapid quantitation of 3-DG and glucosone along with carbohydrates and DFAs in different food products, which is essential to determine their degradation level. Moreover, the α-DC content in several foods is reported for the first time.

Decrease in antigen-specific CD63 basophil expression is associated with the development of tolerance to egg by SOTI in children.

BACKGROUND: In the last decade, there have been an increasing number of studies on achieving tolerance to foods by specific oral tolerance induction (SOTI). Still, the underlying mechanism of SOTI is unknown. Our aim was to describe changes in CD63 expression on basophils following in vitro Ag-specific stimulation by basophil activation test (BAT), after SOTI with egg in a pediatric population. METHODS: Ten children with persistent allergy to egg were included. Skin prick tests (SPTs) and open food challenges (OFCs) were performed before SOTI. Specific IgE determination and BAT with egg white (EW), ovomucoid (OM), and ovalbumin (OVA) were performed before and after 1 month of the buildup phase of SOTI. RESULTS: Total tolerance to egg was achieved in 9 cases and partial in one. After SOTI, there was a significant decrease in mean specific IgE levels (p < 0.05). CD63 expression also decreased (p < 0.05) in all patients. CONCLUSION: Decrease in Ag-specific basophil responsiveness is associated with the development of clinical tolerance by SOTI.

Optimisation of a biotechnological procedure for selective fractionation of bioactive inositols in edible legume extracts.

BACKGROUND: Currently, disorders such as diabetes mellitus, obesity or atherosclerosis are recognised as major global health problems. The use of inositols for treating these illnesses has attracted considerable attention and their extraction from natural sources presents added value as they are considered bioactive ingredients in the food industry. Legumes are natural and rich sources of inositols; however, the co-existence of other low molecular weight carbohydrates (LMWCs) in their extracts, which interfere in their bioactivity, might constitute an important drawback, thereby making their removal essential. RESULTS: LMWCs, including inositols, methyl-inositols and glycosyl-inositols of different legume extracts, were determined by GC-MS; the presence of bornesitol (2.35 mg g(-1) ) and lathyritol (0.27 mg g(-1) ) were reported for the first time in grass peas. The use of Saccharomyces cerevisiae for the selective removal of interfering carbohydrates was optimised. Incubation time (3-40 h) was highly dependent on the composition of the legume considered; inositol contents were generally stable along the treatment. CONCLUSION: Removal of interfering LMWCs from inositol-enriched extracts was successfully achieved using a clean and easily scalable fractionation methodology. This biotechnological procedure not only represents high interest for the production of bioactive food ingredients but for applications in other research areas.

Optimization of a Green Microwave-Assisted Extraction Method to Obtain Multifunctional Extracts of Mentha sp.

A microwave-assisted extraction (MAE) procedure has been optimized to simultaneously provide multifunctional extracts of Mentha sp. leaves with improved antioxidant properties and, for the first time, with optimal antimicrobial activity. Among the solvents evaluated, water was selected as the extractant in order to develop a green procedure and also for its improved bioactive properties (higher TPC and Staphylococcus aureus inhibition halo). MAE operating conditions were optimized by means of a 3-level factorial experimental design (100 °C, 14.7 min, 1 g of dry leaves/12 mL of water and 1 extraction cycle), and further applied to the extraction of bioactives from 6 different Mentha species. A comparative LC-Q MS and LC-QToF MS analysis of these MAE extracts was carried out for the first time in a single study, allowing the characterization of up to 40 phenolics and the quantitation of the most abundant. Antioxidant, antimicrobial (Staphylococcus aureus, Escherichia coli and Salmonella typhimurium) and antifungal (Candida albicans) activities of MAE extracts depended on the Mentha species considered. In conclusion, the new MAE method developed here is shown as a green and efficient approach to provide multifunctional Mentha sp. extracts with an added value as natural food preservatives.

A Combined Gas and Liquid Chromatographic Approach for Quality Evaluation of Saffron-Based Food Supplements.

Considering the interest in the bioactive properties of saffron (Crocus sativus L.), as well as its limited production and high price, saffron-based food supplements (SFS) are highly susceptible to adulteration. However, their complex composition and the wide variety of potential fraudulent practices make the comprehensive assessment of SFS quality a challenging task that has been scarcely addressed. To that aim, a new multianalytical strategy based on gas chromatography coupled to mass spectrometry (GC-MS) and liquid chromatography with diode array detection coupled to mass spectrometry (HPLC-DAD-MS) was developed and validated in order to detect different frauds affecting SFS. Dried saffron stigmas and a commercial standardized saffron extract (affron®) were selected as reference samples (RS) to obtain an authenticity profile, which was further used to evaluate the quality of 17 SFS. Up to 17 crocins and crocetins, 5 kaempferol glycosides, picrocrocin (determined for the first time by GC-MS), safranal, furanone and isophorone-related compounds were determined in RS. Safranal and crocins were identified in all SFS except for one sample. However, discrepancies with the content declared were detected in 65% of the cases. Moreover, this multianalytical methodology also allowed identifying undeclared additives and the non-declared addition of vegetable sources other than saffron.

Fingerprint of Characteristic Saffron Compounds as Novel Standardization of Commercial Crocus sativus Extracts.

Food supplements based on saffron (Crocus sativus L.) dried stigma extracts are widely consumed due to their multiple bioactive properties. Saffron extract (SE) standardization is of crucial importance, as it determines the reproducibility of the product quality and is essential for the evaluation of its bioactive effect and safety. Although SEs are commonly standardized considering their safranal content, the lack of specificity of the official methods may give inaccurate measurements. In addition to the development of more precise methodologies, the evaluation of alternative saffron components, such as crocins and picrocrocin, for standardization purposes would also be of interest. Thus, in this study, qualitative and quantitative information regarding picrocrocin and crocin isomers of different commercial saffron extracts was first obtained by a validated methodology using liquid chromatography (HPLC) coupled to diode array (DAD) and mass spectrometer (MS) detectors. Principal component analysis (PCA) was applied to gain insight into the compositional variability and natural grouping of SE. These studies suggested the potential use of the relative content of crocin isomers and trans-/cis-crocins and trans-4 GG/picrocrocin ratios as novel criteria for SE standardization. Their reproducibility and stability under controlled storage conditions for 36 months was demonstrated in a commercial standardized SE (affron®).

Diagnosis and management of drug hypersensitivity reactions.

The present article addresses the advances in the diagnosis and management of drug hypersensitivity reactions that were discussed in the 4th Drug Hypersensitivity Meeting held in Rome in April 2010. Such reactions can be classified as immediate or nonimmediate according to the time interval between the last drug administration and onset. Immediate reactions occur within 1 hour, and nonimmediate reactions occur after more than 1 hour. Clinical and immunologic studies suggest that type-I (IgE-mediated) and type-IV (T cell-mediated) pathogenic mechanisms are involved in most immediate and nonimmediate reactions, respectively. In diagnosis prick, patch, and intradermal tests are the most readily available tools. Determination of specific IgE levels is still the most common in vitro method for diagnosing immediate reactions. New diagnostic tools, such as the basophil activation test, the lymphocyte activation test, and enzyme-linked immunospot assays for analysis of the frequency of antigen-specific, cytokine-producing cells, have been developed for evaluating either immediate or nonimmediate reactions. The sensitivity of allergologic tests is not 100%; therefore in selected cases provocation tests are necessary. In the diagnosis of nonallergic hypersensitivity reactions to nonsteroidal anti-inflammatory drugs, the provocation test with the suspected drug still represents the "gold standard." However, there was no consensus regarding the use of this test in subjects with histories of hypersensitivity reactions to 1 (single reactors) or more (multiple reactors) nonsteroidal anti-inflammatory drugs. With regard to management, desensitization allows patients to be treated with irreplaceable chemotherapy agents, such as taxanes, platinum salts, and mAbs, to which they have presented hypersensitivity reactions. Desensitization also permits the use of aspirin in aspirin-sensitive patients undergoing revascularization and in subjects with aspirin-exacerbated respiratory disease.

Gastrointestinal, nutritional, endocrine, and microbiota conditions in autism spectrum disorder. / Problemas gastrointestinales, nutricionales, endocrinológicos y de microbiota en el trastorno del espectro autista.

Gastrointestinal, nutritional, metabolic, endocrine, and microbiota medical problems in pediatric patients diagnosed with autism spectrum disorder (ASD) are some of the coexisting medical conditions in ASD diagnosis. Their prevalence reaches more than 91 % for gastrointestinal problems, up to 89 % for nutritional and metabolic disorders, more than 50 % for thyroid dysfunction, and up to 100 % for microbiota-related conditions. There is an urgency for medical practice to be updated and to include the assessment, testing, diagnosis, and treatment of these coexisting medical conditions in ASD diagnosis in the pediatric, adolescent, and adult population. A strict management of such conditions results in positive changes in the quality of life and symptoms based on which ASD is diagnosed many times. It should be based on high-quality scientific evidence with an adequate medical care and control.

Los problemas médicos gastrointestinales, nutricionales, metabólicos, endocrinológicos y de microbiota en los pacientes pediátricos con diagnóstico de trastorno del espectro autista (TEA) son parte de los problemas médicos concomitantes al diagnóstico. La prevalencia alcanza a más del 91 % en el caso de los problemas gastrointestinales, hasta el 89 % para los nutricionales y metabólicos, más del 50 % de disfunción tiroidea y hasta el 100 % para los relacionados con la microbiota. Es urgente actualizar la práctica médica para incluir la evaluación, testeo, diagnóstico y tratamiento de estos problemas médicos concomitantes al diagnóstico de TEA en la población pediátrica, adolescente y adulta. El tratamiento riguroso de dichos problemas genera cambios positivos en la calidad de vida y en la sintomatología bajo la cual el TEA se diagnostica en muchos casos. Debe basarse en evidencia científica de alta calidad, con control y cuidado médico adecuado.

Toxic epidermal necrolysis related to pemetrexed and carboplatin with vitamin B12 and folic acid supplementation for advanced non-small cell lung cancer.

BACKGROUND: Pemetrexed is a multitargeted antifolate initially approved as a single agent for the second-line treatment of locally advanced or metastatic non-small cell lung cancer and more recently in the first-line setting combined with cisplatin. The combination of pemetrexed with carboplatin has been tested in several phase II clinical trials showing interesting antitumour activity with mild toxicity. Supplementation with folic acid and vitamin B12 during treatment with pemetrexed is recommended to reduce potential haematological and gastrointestinal adverse events. CASE REPORT: A patient experienced cutaneous lesions including widespread erythema, epidermal detachment, and skin denudation, associated with deterioration of his general condition after the second cycle of this chemotherapy combination, which was clinically and histologically compatible with toxic epidermal necrolysis (Lyell's syndrome). Treatment with systemic steroids, antihistamines, and antibiotics led to resolution of the skin lesions and improvement of his general condition. CONCLUSION: To our knowledge, this is the second case reported in the literature of this type of suspected adverse drug reaction associated with a pemetrexed-based chemotherapy combination.