Transplantation in the Context of Migration and Refugees: A Summary of the DICG and TTS Ethics Committee Workshop, Buenos Aires, Argentina, September 2022.

Global conflicts and humanitarian crises have resulted in an unprecedented number of refugees and migrants. This challenges the limited resources of health care systems and jeopardizes the availability of transplant care for these deserving migrants and refugees. This was the basis for a workshop held during the Congress of the Transplantation Society (Buenos Aires, 2022). We elaborate on the proceedings of the workshop entitled "Transplantation in the Context of Migration and Refugees," organized by the Ethics Committee of The Transplantation Society and Declaration of Istanbul Custodian Group. Transplant providers from around the world shared strategies of how each region has responded to providing access to care for refugees and migrants in need of transplant services. The potential exploitation of this vulnerable group leading to illicit organ removal was addressed for each region. The Transplantation Society, Declaration of Istanbul Custodian Group, and global transplant community should continue to focus on the status of refugees and migrants and collaborate on strategies to provide access to transplant care for this deserving population. Global cooperation will be essential to provide vigilant oversight to prevent exploitation of this vulnerable population.

Prevalence of Attempted Suicide by Exogenous Poisoning with Medication in the City of Salvador, Bahia, in the Period of 2015-2019 / Prevalência de Tentativa de Suicídio por Intoxicação Exógena com Medicamentos na Cidade de Salvador, Bahia, no Período de 2015-2019

Exogenous intoxication is one of the main mechanisms used in suicide attempts in Brazil, making it a condition of weekly, compulsory notification. The aim of this study is to analyze the prevalence of suicide attempts induced by medication in the city of Salvador, Bahia from 2015 to 2019. This is an ecological study following a time-trend analysis. People who used pharmacological drugs that led to exogenous intoxication for the purpose of committing suicide were included and cases in which the attempt was successful were excluded. The data search was made on DATASUS and SUVISA, and the following data were collected: race, sex, suicide attempt, detailed age, occupation, medication and city. 1418 victims of suicide attempts due to exogenous drug intoxication were reported in the years 2015 to 2019. Of this total, the prevalent demographic characteristics for victims of suicide attempt due to exogenous pharmacological intoxication were the female sex, brown race, age group from 20 to 34 years old, complete high school education, and students. With these findings, the present study aims to emphasize this condition of compulsory notification, since the reversal of these growing data requires the implementation of public policies and health programs that provide a greater awareness of the topic and access to trained professionals, in addition to the dissemination of information.(AU)

A intoxicação exógena é um dos principais mecanismos utilizados nas tentativas de suicídio no Brasil, tornando-se condição de notificação compulsória semanal. O objetivo deste estudo é analisar a prevalência de tentativas de suicídio induzidas por medicamentos na cidade de Salvador, Bahia, no período de 2015 a 2019. Trata-se de um estudo ecológico seguindo uma análise de tendência temporal. Foram incluídas pessoas que utilizaram medicamentos farmacológicos que levaram à intoxicação exógena com o objetivo de cometer suicídio e excluídos os casos em que a tentativa foi bem-sucedida. A busca de dados foi feita no DATASUS e SUVISA, e foram coletados os seguintes dados: raça, sexo, tentativa de suicídio, idade detalhada, ocupação, medicamento e cidade. Foram notificadas 1.418 vítimas de tentativas de suicídio por intoxicação medicamentosa exógena nos anos de 2015 a 2019. Desse total, as características demográficas prevalentes para vítimas de tentativa de suicídio por intoxicação farmacológica exógena foram o sexo feminino, a raça parda, a faixa etária de 20 a 34 anos, ensino médio completo, e estudantes. Com esses achados, o presente estudo visa enfatizar essa condição de notificação compulsória, uma vez que a reversão desses dados crescentes exige a implantação de políticas públicas e programas de saúde que proporcionem maior conscientização sobre o tema e acesso a profissionais capacitados, além do disseminação de informação. (AU)

The economic impact of machine perfusion technology in liver transplantation.

INTRODUCTION: Several clinical studies have demonstrated the safety, feasibility, and efficacy of machine perfusion in liver transplantation, although its economic outcomes are still underexplored. This review aimed to examine the costs related to machine perfusion and its associated outcomes. METHODS: Expert opinion of several groups representing different machine perfusion modalities. Critical analysis of the published literature reporting the economic outcomes of the most used techniques of machine perfusion in liver transplantation (normothermic and hypothermic ex situ machine perfusion and in situ normothermic regional perfusion). RESULTS: Machine perfusion costs include disposable components of the perfusion device, perfusate components, personnel and facility fees, and depreciation of the perfusion device or device lease fee. The limited current literature suggests that although this upfront cost varies between perfusion modalities, its use is highly likely to be cost-effective. Optimization of the donor liver utilization rate, local conditions of transplant programs (long waiting list times and higher MELD scores), a decreased rate of complications, changes in logistics, and length of hospital stay are potential cost savings points that must highlight the expected benefits of this intervention. An additional unaccounted factor is that machine perfusion optimizing donor organ utilization allows patients to be transplanted earlier, avoiding clinical deterioration while on the waiting list and the costs associated with hospital admissions and other required procedures. CONCLUSION: So far, the clinical benefits have guided machine perfusion implementation in liver transplantation. Albeit there is data suggesting the economic benefit of the technique, further investigation of its costs to healthcare systems and society and associated outcomes is needed.

Nova mutação no gene STAT1 associada com candidíase mucocutânea crônica / New STAT1 gene mutation associated with chronic mucocutaneous candidiasis

Mutações no gene STAT1 (signal transducer and activator of transcription 1) têm sido identificadas como responsáveis pela maioria dos casos sindrômicos da candidíase mucocutânea crônica com herança autossômica dominante (AD). Nesse artigo, descrevemos uma menina de 7 anos que apresentou candidíase da mucosa oral e unhas, além de infecção disseminada da pele e couro cabeludo por Microspora gipseum. Recentemente, a paciente foi diagnosticada e tratada de meningite por Cryptococcus neoformans. Na família não existem outros casos de candidíase. A avaliação imunológica incluiu a detecção de subpopulações de linfócitos (CD3, CD4, CD8, CD20 e células NK), assim como a dosagem de IgG, IgA, IgM e IgE, subclasses de IgG e autoanticorpos. Excluindo-se discreta diminuição de CD3, CD4, CD8, NK e leve aumento de IgG1, os demais exames estiveram dentro da normalidade. O sequenciamento do exoma detectou uma rara mutação em heterozigose no exon 14 do domínio de ligação do DNA (DNA-binding domain) do gene STAT1, ocasionando um provável ganho de função (GOF) responsável pela doença (Gly384Asp). Essa variação foi também identificada pelo sequenciamento de Sanger, não estando reportada nos bancos de dados públicos e apresentando elevado potencial de dano (índice CADD=32). Será interessante contarmos com informações clínicas e estudos com outros pacientes para conhecermos mais essa mutação patológica. Além da apresentação do caso, discutiremos as formas de tratamento existentes.

STAT1 (signal transducer and activator of transcription 1) gene mutations have been identified as responsible for most syndromic cases of chronic mucocutaneous candidiasis with autosomal dominant (AD) inheritance. In this article, we described a 7-year-old girl who presented with candidiasis of the oral mucosa and nails, as well as disseminated infection of the skin and scalp caused by Microsporum gypseum. Recently, the patient was diagnosed and treated for Cryptococcus neoformans meningitis. There are no other cases of candidiasis in the family. The immunological evaluation consisted of detection of subpopulations of lymphocytes (CD3, CD4, CD8, CD20, and NK cells), as well as measurement of IgG, IgA, IgM, and IgE, IgG subclasses, and autoantibodies. Excluding a slight decrease in CD3, CD4, CD8, NK and a minimal increase in IgG1, the others were within normal limits. Exome sequencing detected a rare heterozygous variation in exon 14 of the DNA-binding domain of the STAT1 gene, causing a probable gain of function (GOF) responsible for the disease (Gly384Asp). This variation was also identified by Sanger sequencing, but it was not reported in public databases and had a high potential for damage (Combined Annotation-Dependent Depletion [CADD] score = 32). Having clinical information and conducting studies of other patients will be helpful to learn more about this pathological mutation. In addition to the presentation of the case, we will discuss the existing forms of treatment.

Neutropenia aloimune neonatal em gêmeas idênticas / Neonatal alloimmune neutropenia in identical twins

A neutropenia aloimune neonatal (NAN) é uma patologia causada pelo antagonismo imunológico, como a doença hemolítica do recém-nascido ou a trombocitopenia aloimune neonatal, mas relacionada aos neutrófilos, em vez de glóbulos vermelhos ou plaquetas. Descreveremos um caso clínico de duas gêmeas idênticas nascidas a termo, com Apgar de 8 e 9, sendo que após algumas horas do nascimento apresentaram febre. Um exame de sangue revelou neutropenia grave que resultou em sepse. O diagnóstico da NAN foi realizado clinicamente e por testes de histocompatibilidade. A prova cruzada por citometria de fluxo foi positiva, usando soro da mãe e suspensões celulares (granulócitos e linfócitos) das gêmeas e do pai. Este teste não fornece informações sobre para qual sistema genético os anticorpos foram positivos, se contra os antígenos específicos de neutrófilos humanos (HNA) ou contra os antígenos leucocitários humanos (HLA). Para o esclarecimento, realizamos o teste de aglutinação de granulócitos (GAT) com um painel de doadores fidelizados e com antígenos HNA1-5 conhecidos, utilizando o soro materno como reagente. Foi também realizada a pesquisa de anticorpos anti-HLA e anti-HNA no soro materno. Os genótipos HLA e HNA foram identificados, permitindo conhecer as especificidades dos anticorpos maternos contra os antígenos dos neutrófilos do marido e das filhas. O diagnóstico de NAN não é realizado na maioria dos hospitais de nosso país e do exterior, devido à dificuldade de execução dos testes de histocompatibilidade, no entanto a prova cruzada por citometria de fluxo pode facilmente ser implantada nos laboratórios clínicos, sendo que está descrita detalhadamente nesse caso clínico.

Neonatal alloimmune neutropenia (NAN) is a disease caused by immunological antagonism, such as hemolytic disease of the newborn or neonatal alloimmune thrombocytopenia, but related to neutrophils rather than to red blood cells or platelets. We will describe a clinical case of two identical twins born with Apgar 8 and 9 that started with fever few hours after delivery. A blood test revealed severe neutropenia, which was followed by sepsis. The diagnosis of NAN was done clinically and by histocompatibility testing. Flow cytometry crossmatch was positive, using mother serum and cell suspensions (granulocytes and lymphocytes) from the twin girls and from the father. This test did not provide information about the genetic system for which the antibodies are positive, if against human neutrophil antigens (HNA) or human leucocyte antigens (HLA). To clear this, the granulocyte agglutination test (GAT) was performed with a panel of control donors with known HNA1-5 antigens, using the maternal serum as a reagent. We did also a Luminex screening assay for detection of anti-HLA and anti-HNA antibodies in the mother serum. The HLA and HNA genotypes were identified, which allowed to define specificities in mother's antibodies against the neutrophil surface antigens from her husband and from the twins. The diagnosis of NAN diagnose is not done in most hospitals worldwide, mainly by the difficulty in executing the histocompatibility test. However, the crossmatch by flow cytometry could be easily done in clinical laboratories following the method described in this article.

Diagnosis and treatment of immunological platelet refractoriness by histocompatibility.

Immunological platelet refractoriness occurs when polytransfused patients develop antibodies against donors' HLA class I antigens, HPA (human platelet antigens) and few cases against both systems. Flow cytometry crossmatch with the patient serum against platelets from several donors can determine whether the refractoriness is or is not of immunological origin. Patients with moderate sensitization will be given transfusions from donors with a negative platelets crossmatch; those who are hypersensitized will need to have antibodies assessed against a reactivity panel (RP) for HLA class I and HPA. The patient must be typed for HLA and HPA in order to identify best donors. We have compiled a list of 500 donors registered at our blood bank with known HLA and HPA profiles. Pre-transfusion crossmatch is performed against donors selected virtually, transfusing those who are negative. We analyzed 75 patients with refractoriness, 67% (50/75) of whom had anti-HLA or anti-HPA antibodies and 56% (28/50) were hypersensitized, with RP ≥ 80%. The diagnosis of the immunological refractoriness and the compatibility between donor and recipient allowed efficient transfusions for all patients.

Alimentación y uso del complemento alimentario en hogares de beneficiarios de la Corporación Educativa Combos / Diet and Use of a Nutrition Supplement in Household Beneficiares of the Corporación Educativa Combos Program

Resumen Antecedentes: es importante que al indagar sobre temas de alimentación y hambre se haga desde la perspectiva de los sujetos que experimentan y vivencian dichas situaciones, para comprender de forma integral dicho asunto. Objetivo: describir la alimentación en los hogares de niñas y niños beneficiarios del Programa de Atención Integral a la Niñez Trabajadora de la Corporación Educativa Combos y la percepción que tienen del complemento alimentario. Materiales y métodos: investigación con enfoque cualitativo, metodología de etnografía focalizada, técnicas de entrevista a profundidad y grupos focales. Resultados: las familias participantes viven situaciones de hambre; omiten comidas principales por falta de recursos económicos; sus gustos alimentarios en el hogar tienden a ser tradicionales; prefieren alimentos rendidores, saciadores y económicos, ricos en grasas y carbohidratos. Fuera del hogar prefieren comidas rápidas porque están disponibles y son más económicas. Las y los participantes perciben el complemento alimentario como un protector del hambre de las y los menores, y el paquete de alimentos como una manera de disponer de alimentos para compartirlos en familia. Conclusiones: en poblaciones empobrecidas se prefieren alimentos rendidores, saciadores y económicos que les permita sentirse llenos por más tiempo. Los servicios que brinda la Corporación fueron apreciados y valorados por las y los beneficiarios, pues estos han contribuido a mejorar su calidad de vida, a configurar el comensalismo familiar y a restituir el derecho a la alimentación en los hogares.

Abstract Background: The theme of food and nutrition security, hunger and the meaning of food programs for vulnerable population has been investigated, however, from a qualitative and comprehensive perspective, trying to identify from the perspective of the subjects who experience the phenomenon. Objective: To describe the in-home diet of children who are beneficiaries of the Programa de Atención Integral a la Niñez Trabajadora (PAINIT) of the Corporación Educativa COMBOS and their perceptions of a nutrition supplement. Materials and Methods: Research was conducted using a qualitative approach, focused ethnography studies, in-depth interviews, and focus groups. Results: Participating families live in situations of hunger and often omit main meals for lack of economic resources. At-home food tends to be traditional, with preference for satiating and inexpensive foods rich in fats and carbohydrates. Outside the home they prefer fast foods due to accesability and affordability. Participants perceive the nutrition supplement as a protector against child hunger, and the food basket as a way to share meals with family on weekends. Conclusions: Impoverished populations prefer foods that are accesible, satiating and economic that allow them to feel full for longer, and tend towards collective or family meals. The services provided by the Corporation were appreciated and valued by the beneficiaries as they have contributed to improving quality of life, family togetherness, and restoration to food security in homes.

Diferencias en el gasto alimentario según características socioeconómicas y de seguridad alimentaria y nutricional en hogares de Medellín / Differences in Food Expenditure According to Socioeconomic Characteristics and Households Food Security in Medellin

Resumen Antecedentes: la proporción de gasto alimentario en el hogar con respecto al gasto total es un indicador inverso del bienestar. Objetivo: analizar las diferencias en la proporción de gasto alimentario en los hogares de Medellín según características socioeconómicas y clasificación de seguridad alimentaria y nutricional. Materiales y métodos: estudio transversal, en 3008 hogares de Medellín participantes en el Perfil de Seguridad Alimentaria y Nutricional de Medellín-2015. Se analizó el gasto alimentario según seguridad alimentaria, características del jefe del hogar, ubicación de la vivienda, estrato socioeconómico y lugar de compra. Se aplicaron las pruebas estadísticas ji al cuadrado, Spearman y regresión logística ordinal. Resultados: los hogares clasificados con inseguridad alimentaria presentaron alta proporción de gasto alimentario (p=0,000). Se encontró una relación inversa entre la proporción de gasto alimentario e ingreso y nivel educativo del jefe del hogar (p=0,00). También, mayor probabilidad de alta proporción de gasto alimentario en los hogares de estrato socioeconómico bajo (p=0,00) y localizados en el área rural (p=0,00). Hogares con mayor proporción de gasto alimentario hacen mayor uso de tiendas locales para com- prar alimentos (p=0,00). Conclusión: hay mayor proporción de gasto alimentario en los hogares de Medellín con estrato socioeconómico bajo, ubicados en zona rural, con bajo nivel educativo del jefe del hogar y que compran en tiendas locales.

Abstract Background: The proportion of food expenditure in the home with respect to total household expenditure is an inverse indicator to wellbeing. Objective: To analyze the differences in the proportion of food expenditure in Medellin households according to socioeconomic characteristics and food security classifications. Materials and Methods: A cross-sectional study in 3008 households in Medellin that participated in the 2015 Food and Nutrition Security Profile in Medellin. Food expenditure was analyzed according to food security, characteristics of the head of household, location of living space, socioeconomic strata, and places where purchases are made. The statistical tests chi-square, Spearman and ordinal logistic regression were applied. Results: Households classified as food-insecure presented with a higher proportion of food expenditure (p=0.000). An inverse relationship was found between the proportion of household expenditure and income and education level of the head of household (p=0.00). Also, a higher probability was found between high proportion of food expenditure and households of low socioeconomic status (p=0.00), and households located in rural areas. Households with a higher proportion of food expenditure are more likely to purchase foods at local stores and shops (p=0.00). Conclusion: There is a greater proportion of food expenditure in Medellin households of low socioeconomic status, located in rural areas, with low educational level of the head of household, and who make purchases in local stores.

Melatonin enhances neural stem cell differentiation and engraftment by increasing mitochondrial function.

Neural stem cells (NSCs) are regarded as a promising therapeutic approach to protecting and restoring damaged neurons in neurodegenerative diseases (NDs) such as Parkinson's disease and Alzheimer's disease (PD and AD, respectively). However, new research suggests that NSC differentiation is required to make this strategy effective. Several studies have demonstrated that melatonin increases mature neuronal markers, which reflects NSC differentiation into neurons. Nevertheless, the possible involvement of mitochondria in the effects of melatonin during NSC differentiation has not yet been fully established. We therefore tested the impact of melatonin on NSC proliferation and differentiation in an attempt to determine whether these actions depend on modulating mitochondrial activity. We measured proliferation and differentiation markers, mitochondrial structural and functional parameters as well as oxidative stress indicators and also evaluated cell transplant engraftment. This enabled us to show that melatonin (25 µM) induces NSC differentiation into oligodendrocytes and neurons. These effects depend on increased mitochondrial mass/DNA/complexes, mitochondrial respiration, and membrane potential as well as ATP synthesis in NSCs. It is also interesting to note that melatonin prevented oxidative stress caused by high levels of mitochondrial activity. Finally, we found that melatonin enriches NSC engraftment in the ND mouse model following transplantation. We concluded that a combined therapy involving transplantation of NSCs pretreated with pharmacological doses of melatonin could efficiently restore neuronal cell populations in PD and AD mouse models depending on mitochondrial activity promotion.

Oxigenoterapia Crónica Domiciliaria en el Noroeste Argentino, situación actual y propuestas de solución / Chronic Domiciliary Oxygen Therapy in Argentina's Northwest, Current Situation and Possible Solutions

Introducción: La Oxigenoterapia Crónica Domiciliaria (OCD) es una modalidad terapéutica con efectos beneficiosos conocidos y avalados por evidencia científica en pacientes con insuficiencia respiratoria crónica en estado estable. En nuestro medio existen controversias relacionadas con su "uso incorrecto" atribuible quizás a la falta de un marco regulatorio actualizado y un sistema de registro nacional, tal como fue recomendado por el consenso argentino de OCD. Se consideró hacer un diagnóstico de situación en la Región Noroeste Argentino (NOA) de la AAMR para elaborar propuestas concretas a futuro. Material y Métodos: Se realizó una investigación descriptiva en la Región NOA. Se determinó como población de referencia los tres sectores involucrados en la prestación de OCD: neumonólogos de la Región, delegados locales de las principales empresas proveedoras de oxígeno medicinal y representantes de los tres subsistemas de salud. Se aplicaron encuestas y entrevistas especialmente diseñadas. Resultados: 65 neumonólogos del NOA respondieron la encuesta, un 71% del total de los especialistas registrados en la AAMR. 91% prescribe OCD con un promedio de 11 pacientes por cada profesional, siendo la insuficiencia respiratoria por EPOC el diagnóstico más frecuente como indicación de oxigenoterapia. 54% considera que el equipo adjudicado al paciente no se ajusta al que prescribió. En una de las provincias se autoriza la prescripción a médicos no neumonólogos. Los representantes de las empresas proveedoras de oxígeno respondieron que trabajan según normativas de ANMAT y acorde a legislación nacional vigente. Se entrevistó a 52 obras sociales y prepagas y a tres sistemas de gestión estatal. En los subsistemas de salud la posición ante la cobertura de OCD es desigual y no poseen base de datos de pacientes con oxigenoterapia. Todos coincidieron en la necesidad de unificar las normativas y proponer un marco regulatorio único. Conclusión: El diagnóstico de situación sobre la prescripción y prestación de la oxigenoterapia en el NOA señala la falta de un marco regulatorio que contemple todos los aspectos de la OCD. Las normativas existentes no son suficientes para la correcta utilización de la terapéutica y la implementación de las recomendaciones del consenso argentino no fueron las esperadas. El grupo de trabajo elaboró propuestas como actualización del Consenso Nacional de OCD, creación de un Sistema Nacional de Registro y confección de un "Instrumento Legal" que respalde el tratamiento con oxígeno, medidas destinadas a una distribución más equitativa de los gastos en Salud.

Introduction: Chronic Domiciliary Oxygen Therapy (OCD) is a therapeutic modality with beneficial effects known and supported by scientifc evidence in patients with chronic respiratory failure in stable condition. In our area there are controversies related to their "misuse" perhaps attributable to the lack of an updated regulatory framework and a national registration system, as was recommended by the Argentine consensus of OCD. It was performed a diagnosis of the current situation in Northwest Argentina (NOA)-AAMR Region to develop concrete future proposals. Material and Methods: A descriptive research was carried out in the NOA Region. The reference population was determined by the three sectors involved in the provision of OCD: pulmonologists in the region, the main suppliers of medical oxygen and the three health subsystems. Surveys and interviews especially designed were applied. Results: 65 pulmonologists of NOA responded (71% of the overall of specialists in NOA): 91% prescribed OCD, with an average of 11 patients per professional. Respiratory failure due to COPD was the most common indication of oxygen therapy. 54% believe that the equipment awarded to the patient does not conform to that prescribe. In one of the provinces, not pulmonologists physicians were authorized to prescribing OCD. Representatives of oxygen suppliers responded working under the ANMAT regulations and national legislation. Data of 52 Social Work and Private Medicine and also information of three system of state management were obtained. Health subsystems coverage is uneven and reported not having database. All agreed on the need to unify regulations and propose a single regulatory framework. Conclusion: The diagnosis of the situation on the prescription and delivery of oxygen therapy in the NOA notes the lack of a regulatory framework in Argentina that covers all aspects of OCD. Existing regulations are not sufficient for the proper use of the OCD and the implementations of the recommendations of the Argentine consensus were not expected. The working group developed proposals as updating the National OCD Consensus, the creation of a National Registration System and the construction of a "legal instrument" to support oxygen treatment, all measures aimed at a more equitable distribution of expenses Health.

Recomendaciones prácticas para el manejo de la crisis asmática en pacientes adultos / Practical Recommendations for the Management of Acute Asthma in Adult Patients

Las exacerbaciones de asma pueden ser graves y ponen en riesgo la vida de los pacientes. En estos casos es fundamental reconocer signos y síntomas de riesgo, incluyendo la medición de la obstrucción al flujo aéreo y la oximetría de pulso, con la finalidad de objetivar la gravedad de la crisis. La administración adecuada del tratamiento incluyendo broncodilatadores, corticoesteroides y oxigenoterapia permite revertir la obstrucción bronquial y preservar la vida del paciente. A pesar de estas premisas básicas en el manejo de la crisis asmática, en nuestro medio se ha detectado recurrentemente una atención defciente de estos eventos. El contar con recomendaciones de fácil implementación, adecuadas a las necesidades locales y desarrolladas por médicos especialistas en medicina respiratoria podría mejorar la calidad de atención de estos pacientes. Con este objetivo se realizó una revisión bibliográfica clasificando la información según el grado de evidencia. Los resultados fueron evaluados por un panel de expertos y se desarrolló un algoritmo de manejo del asma aguda. El algoritmo propone una evaluación inicial en base a signos de severidad, datos de medición del flujo aéreo (FEV1 y/o FPE) y oximetría de pulso que permitirán clasificar las exacerbaciones según su grado de severidad e indicar detalladamente los pasos terapéuticos a seguir en cada caso, como así también los criterios de internación y alta. El uso de estas recomendaciones permitirá una mejor distribución de recursos y optimización del tratamiento de los pacientes atendidos por exacerbaciones de asma.

Asthma exacerbations can be severe and life threatening. In order to assess in a correct and objective way the severity of the exacerbation, it is essential to recognize risk signs and symptoms, including the measurement of airflow obstruction and pulse oximetry. Proper treatment including bronchodilators, corticosteroids, and oxygen can reverse bronchial obstruction and preserve patient's life. Despite these basic facts, inappropriate care in the management of acute asthma events is frequent in Argentina. Recommendations developed by specialists in respiratory medicine, which are easy to implement and adapted to local needs, could improve the quality of care of these patients. In order to accomplish these goals, an exhaustive review of the literature was conducted and the information was classified according to the degree of evidence. The results were evaluated by a panel of experts and an algorithm for the management of acute asthma was designed. This algorithm proposes an initial assessment based on asthma severity including measurement of airflow obstruction (FEV1 and/or PF) and pulse oximetry. Thus, it allows classifying exacerbations by degree of severity, leading to appropriate sequential therapeutic options as well as criteria for admission and discharge. The use of these recommendations is intended to allow a correct management of asthma exacerbations in Argentina and an optimized use of medical resources.

Expression patterns of B cells in acute kidney transplant rejection.

OBJECTIVES: To evaluate B-cell expression patterns and association with function and survival in dysfunctional kidney allografts. MATERIALS AND METHODS: There were 110 kidney transplant recipients included who had for-cause biopsies. Demographic and transplant data were collected. Immunostaining for B cells, plasma cells, and C4d was performed by the immunoperoxidase technique in paraffin-embedded samples. Circulating antihuman leukocyte antigen donor-specific antibodies were detected in a single-antigen assay at biopsy. The main outcomes were kidney graft survival and function. The patients were evaluated in 3 groups according to the Banff classification: no rejection (40 patients), T-cell-mediated rejection (50 patients), and antibody-mediated rejection (20 patients). RESULTS: The CD138-positive plasma cell-rich infiltrates predominated in antibody-mediated rejection and were associated with stronger reactivity against panel antibodies (r = 0.41; P ≤ .001) and positive donor-specific antibodies (r = 0.32; P ≤ .006). The CD20-positive lymphocytes were associated with T-cell-mediated rejection, increased human leukocyte antigen mismatch, and frequency of retransplant. The CD138-positive cell infiltrates also were significantly greater in patients who had late than early rejection. There was no correlation between cellular CD20 and CD138 expression, and neither CD20 nor CD138 predicted worse graft function or survival. Other markers of antibody-mediated rejection such as C4d and donor-specific antibodies were associated with worse graft function and survival at 4 years after transplant. In multivariate analysis, C4d was the only risk factor associated with graft loss. CONCLUSIONS: After kidney transplant, CD20-positive B-cell infiltrates were associated with T-cell-mediated rejection, and CD138-positive plasma cells were associated with antibody-mediated rejection. Graft loss was associated with the presence of C4d.

[Evaluation of fetal lung maturity by lamellar bodies counting in amniotic fluid]. / Avaliação da maturidade pulmonar fetal pela contagem dos corpos lamelares no líquido amniótico.

PURPOSE: To compare the lamellar body number density (LBND) count in amniotic fluid using the fluorescent polarization (FP) test as a diagnostic parameter for the assessment of fetal pulmonary maturity. METHOD: This was an analytical, controlled cross-sectional study conducted on 60 pregnant women from March 2002 to December 2007. Amniotic fluid specimens were obtained by amniocentesis or at the time of caesarean section, and submitted to the LBND and FP tests (TDxFLM, Abbott Laboratories), the latter considered to be a reference test, and compared in terms of the presence or absence of respiratory distress syndrome (RDS). Cut-off values for maturity were established at 30,000 lamellar bodies/microL for the LBND test and 55 mg/g albumin for the FP test. Maternal and perinatal characteristics and neonatal evolution were evaluated, and the performance of the diagnostic tests regarding fetal pulmonary maturity was determined. In the statistical analysis, descriptive measures were used and the sensitivity, specificity and positive and predictive values of the tests were determined with the level of significance set at p<0.05. RESULTS: Maternal age ranged from 15 to 34 years (mean: 26.6 years) and gestational age ranged from 24.3 to 41.6 weeks (mean: 35.1 weeks). RDS was diagnosed in 35.1% of neonates. Perinatal characteristics such as weight, Apgar score, and RDS incidence were compared to the results of the LBND and FP tests and a significant correspondence (p<0.05) was observed between the groups of neonates clinically classified as mature and immature in both tests. The tests were concordant in 68.3% of the cases. Comparison of the PF and LBND tests revealed 100% specificity for both and a higher specificity for the LBND test (73.1% as opposed to 51.9% for the PF test). The gold standard for the determination of fetal maturity is the occurrence of RDS. The positive predictive value of the LBND test was higher (36.4%) than that of the FP test (24.2%) (p<0.05) and the negative predictive value was 100% for both tests. CONCLUSIONS: The present study demonstrated that the LBND test has 100% sensitivity and higher specificity than the reference test (FP). In addition, the LBND test is considered to be rapid, accessible, inexpensive and feasible for the Brazilian reality, and it can be used as a reliable test for the prediction of fetal pulmonary maturity.

Avaliação da maturidade pulmonar fetal pela contagem dos corpos lamelares no líquido amniótico / Evaluation of fetal lung maturity by lamellar bodies counting in amniotic fluid

Objetivo: comparar o teste de contagem de corpos lamelares (CCL) no líquido amniótico com o teste da polarização fluorescente (PF) como parâmetro diagnóstico para avaliação da maturidade pulmonar fetal. Método: estudo transversal, analítico e controlado realizado com 60 gestantes atendidas no período de março de 2002 a dezembro de 2007. Foram colhidas amostras de líquido amniótico e realizados os testes de CCL e PF (TDxFLM II), considerados de referência, e comparados à presença ou ausência da Síndrome do Desconforto Respiratório (SDR). Foram estabelecidos valores de corte para maturidade de 30 mil corpos lamelares/µL para o teste da CCL e 55 mg/g de albumina para o PF. Foram avaliadas as características maternas e perinatais, a evolução neonatal e o desempenho dos testes diagnósticos para predição da maturidade pulmonar fetal. Na análise estatística, foram utilizadas medidas descritivas e calculados os valores referentes à sensibilidade, especificidade, valor preditivo positivo e negativo dos testes, considerando-se significativos valores de p<0,05. Resultados: a idade materna variou entre 15 e 43 anos, com média de 26,6 anos. A idade gestacional variou entre 24,3 e 41,6 semanas, com média de 35,1 semanas. A Síndrome do Desconforto Respiratório foi diagnosticada em 13,3 por cento dos neonatos. As características perinatais, como peso, índice de Apgar, incidência de SDR, foram comparadas aos resultados dos testes de CCL e PF, sendo observada uma correspondência, estatisticamente significativa (p<0,05), entre os grupos de neonatos clinicamente classificados como imaturos e maduros em ambos os testes. Os testes foram concordantes em 68,3 por cento dos casos. Quando se comparou o teste da PF com o teste da CCL, a sensibilidade foi de 100 por cento para ambos, e a especificidade do teste da CCL foi superior (73,1 por cento), quando comparado com o teste de PF (51,9 por cento). O padrão-ouro para determinação da maturidade fetal é a ocorrência da SDR. O valor...

Purpose: to compare the lamellar body number density (LBND) count in amniotic fluid using the fluorescent polarization (FP) test as a diagnostic parameter for the assessment of fetal pulmonary maturity. Method: this was an analytical, controlled cross-sectional study conducted on 60 pregnant women from March 2002 to December 2007. Amniotic fluid specimens were obtained by amniocentesis or at the time of caesarean section, and submitted to the LBND and FP tests (TDxFLM®, Abbott Laboratories), the latter considered to be a reference test, and compared in terms of the presence or absence of respiratory distress syndrome (RDS). Cut-off values for maturity were established at 30,000 lamellar bodies/µL for the LBND test and 55 mg/g albumin for the FP test. Maternal and perinatal characteristics and neonatal evolution were evaluated, and the performance of the diagnostic tests regarding fetal pulmonary maturity was determined. In the statistical analysis, descriptive measures were used and the sensitivity, specificity and positive and predictive values of the tests were determined with the level of significance set at p<0.05. Results: maternal age ranged from 15 to 34 years (mean: 26.6 years) and gestational age ranged from 24.3 to 41.6 weeks (mean: 35.1 weeks). RDS was diagnosed in 35.1 percent of neonates. Perinatal characteristics such as weight, Apgar score, and RDS incidence were compared to the results of the LBND and FP tests and a significant correspondence (p<0.05) was observed between the groups of neonates clinically classified as mature and immature in both tests. The tests were concordant in 68.3 percent of the cases. Comparison of the PF and LBND tests revealed 100 percent specificity for both and a higher specificity for the LBND test (73.1 percent as opposed to 51.9 percent for the PF test). The gold standard for the determination of fetal maturity is the occurrence of RDS. The positive predictive value of the LBND test was higher (36.4%) than that...

Análise molecular de patógenos pela reação em cadeia da polimerase no líquido cefalorraquiano de pacientes infectados com HIV / Molecular analysis of pathogens in cerebrospinal fluid by the polymerase chain reaction in HIV-infected patients

Introdução: A reação em cadeia da polimerase (PCR) foi teste de grande impacto no diagnóstico das meningites e encefalites linfocíticas durante a última década. Esse método foi extensivamente usado no diagnóstico das infecções do sistema nervoso central (SNC), devido a sua habilidade em detectar amostras mínimas de DNA-alvo no líquido cefalorraquiano. Objetivo: O objetivo deste estudo foi identificar a prevalência dos patógenos oportunistas responsáveis por causar problemas neurológicos em pacientes infectados com o vírus da imunodeficiência humana (HIV) e avaliar sua associação com os achados clínicos, laboratoriais e da tomografia computadorizada cerebral (TCC). Pacientes e métodos: Um estudo transversal foi realizado em 203 amostras de líquido cefalorraquiano (LCR) de pacientes do sul do Brasil infectados com HIV e com aparente encefalite e meningite linfocíticas. As amostras foram analisadas para os seguintes agentes pelo método da reação em cadeia da polimerase "nested" ou dupla (N-PCR): citomegalovírus, vírus do Epstein-Barr, vírus do herpes simplex tipos 1 e 2, vírus da varicella zoster, vírus do herpes humano tipo 6, vírus JC, Toxoplasma gondii e micobactérias. Resultado: Pelo menos um patógeno foi encontrado em 77 (38%) dos indivíduos. O Epstein-Barr foi o mais prevalente, com 40 casos (19,7%), seguido pelo citomegalovívus, com 12 casos (15%) e pelo vírus JC, em 9 casos (4,4%). Um N-PCR positivo mostrou associação com aumento de proteínas e de celularidade (P=0,001), meningismo (P=0,017) e tomografia computadorizada anormal (P=0,006). Conclusão: O painel de PCR empregado foi efetivo na identificação de infecções neurológicas severas em pacientes HIV positivos (AU)

Introduction: Polymerase chain reaction (PCR) has had great impact on the diagnosis of lymphocytic meningitis and encephalitis over the last decade. It has been extensively used in the diagnosis of central nervous system (CNS) infections for its ability to detect small amounts of target DNA in the cerebrospinal fluid (CSF). Objective: The aim of this study was to identify the prevalence of opportunistic pathogens responsible for neurological disorders in patients infected with human immunodeficiency virus (HIV) and to evaluate its association with clinical, laboratory and cerebral computed tomography (CCT) findings. Patients and methods: A cross-sectional study was performed on 203 cerebrospinal fluids (CSF) from HIV-infected patients from Southern Brazil, with apparent lymphocytic meningitis and encephalitis. CSF samples were analyzed with probes for cytomegalovirus, Epstein-Barr virus, herpes simplex virus types 1 and 2, varicella zoster virus, human herpes virus type 6, JC virus, Toxoplasma gondii and mycobacterium in nested polymerase chain reaction (N-PCR). Results: At least one pathogen was found in 77 (38.0%) individuals. Epstein-Barr virus was the most prevalent with 40 cases (19.7%), followed by cytomegalovirus with 12 cases (5.9%) and JC virus with 9 cases (4.4%). Positive NPCR showed association with high spinal fluid protein and cell count (P=0.001), meningism (P=0.017) and abnormal CCT (P=0.006). Conclusion: The PCR panel used was effective in screening several neurological infections in HIV positive patients (AU)

Educação sexual e contracepção de adolescentes das áreas rural e urbana: estudo comparativo / Sexual education and teenagers contraceptive methods at rural and city areas: a comparative study

Foram avaliadas 149 adolescentes, subdivididas em dois grupos (46,31 por cento procedentes da área rural e 53,70 por cento da área urbana), com o objetivo de compararmos o conhecimento quanto aos métodos contraceptivos, bem como a influência desse conhecimento na sexualidade e perfil reprodutivo das mesmas. Na maioria das variáveis analisadas não houve diferenças estatisticamente significativas entre os grupos estudados...