ABSTRACT
BACKGROUND: Allergen immunotherapy (AIT) has a longstanding history and still remains the only disease-changing treatment for allergic rhinitis and asthma. Over the years 2 different schools have developed their strategies: the United States (US) and the European. Allergen extracts available in these regions are adapted to local practice. In other parts of the world, extracts from both regions and local ones are commercialized, as in Mexico. Here, local experts developed a national AIT guideline (GUIMIT 2019) searching for compromises between both schools. METHODS: Using ADAPTE methodology for transculturizing guidelines and AGREE-II for evaluating guideline quality, GUIMIT selected 3 high-quality Main Reference Guidelines (MRGs): the European Academy of Allergy, Asthma and Immunology (EAACI) guideines, the S2k guideline of various German-speaking medical societies (2014), and the US Practice Parameters on Allergen Immunotherapy 2011. We formulated clinical questions and based responses on the fused evidence available in the MRGs, combined with local possibilities, patient's preference, and costs. We came across several issues on which the MRGs disagreed. These are presented here along with arguments of GUIMIT members to resolve them. GUIMIT (for a complete English version, Supplementary data) concluded the following. RESULTS: Related to the diagnosis of IgE-mediated respiratory allergy, apart from skin prick testing complementary tests (challenges, in vitro testing and molecular such as species-specific allergens) might be useful in selected cases to inform AIT composition. AIT is indicated in allergic rhinitis and suggested in allergic asthma (once controlled) and IgE-mediated atopic dermatitis. Concerning the correct subcutaneous AIT dose for compounding vials according to the US school: dosing tables and formula are given; up to 4 non-related allergens can be mixed, refraining from mixing high with low protease extracts. When using European extracts: the manufacturer's indications should be followed; in multi-allergic patients 2 simultaneous injections can be given (100% consensus); mixing is discouraged. In Mexico only allergoid tablets are available; based on doses used in all sublingual immunotherapy (SLIT) publications referenced in MRGs, GUIMIT suggests a probable effective dose related to subcutaneous immunotherapy (SCIT) might be: 50-200% of the monthly SCIT dose given daily, maximum mixing 4 allergens. Also, a table with practical suggestions on non-evidence-existing issues, developed with a simplified Delphi method, is added. Finally, dissemination and implementation of guidelines is briefly discussed, explaining how we used online tools for this in Mexico. CONCLUSIONS: Countries where European and American AIT extracts are available should adjust AIT according to which school is followed.
ABSTRACT
BACKGROUND: There are different guidelines for the diagnosis of allergic diseases and the application of allergen immunotherapy (AIT). OBJECTIVE: To describe how Mexican allergists diagnose and treat respiratory and food allergies with AIT. METHODS: 227 allergists who attended an immunotherapy symposium were surveyed; the topics investigated were the daily practices in the diagnosis of respiratory and food allergies, as well as ways to apply AIT. RESULTS: The surveyed allergists use skin prick tests for the diagnosis of both respiratory and food allergies in 100 % and 87.7 % of their cases respectively; in vitro diagnosis through serum specific IgE in 55.5 % and 63 %, and molecular diagnostics in 14.1% and 13.2 %. For aeroallergens, 81 % prescribe subcutaneous AIT, 77.9 % use liquid sublingual AIT, and 1.8 % prefer SLIT in tablets; however, 45 % indicated that they would use tablets in the future. Regarding food allergens, most respondents did not prescribe AIT; however, 55% of them are interested in oral AIT and 59% of them are interested in sublingual AIT. CONCLUSIONS: Generally, the diagnosis and treatment of allergic diseases are carried out according to international guidelines; besides, the interviewed allergists expressed flexibility to adopt new schemes.
Antecedentes: Existen lineamientos para el diagnóstico de las enfermedades alérgicas y la aplicación de inmunoterapia con alérgenos (ITA). Objetivo: Describir cómo los alergólogos mexicanos diagnostican y tratan con ITA las alergias alimentaria y respiratoria. Métodos: Se encuestó a 227 alergólogos que acudieron a un simposio de inmunoterapia; se indagaron prácticas cotidianas en el diagnóstico de las alergias respiratoria y alimentaria, así como en la forma de aplicar la ITA. Resultados: Los alergólogos utilizan las pruebas cutáneas por punción para el diagnóstico de las alergias respiratorias y alimentarias en 100 y 87.7 % de los casos de una y otra; diagnóstico in vitro mediante determinación de IgE alérgeno-específica en 55.5 y 63 %; y diagnóstico molecular por componentes en 14.1 y 13.2 %. Para los aeroalérgenos, 81 % emplea ITA subcutánea; 77.9 %, ITA sublingual líquida; 1.8 %, ITA sublingual en tabletas; 45 % indicó que estaba dispuesto a emplear tabletas en el futuro. Para los alérgenos de alimentos, la mayoría no utilizaba ITA, aunque 55 % se interesa en la ITA oral y 59 %, en la ITA sublingual. Conclusiones: En términos generales, el diagnóstico y tratamiento de las enfermedades alérgicas se realizan conforme los lineamientos internacionales, además, los alergólogos encuestados mostraron flexibilidad para adoptar nuevos esquemas.
Subject(s)
Allergens/therapeutic use , Desensitization, Immunologic , Food Hypersensitivity/diagnosis , Food Hypersensitivity/therapy , Practice Patterns, Physicians' , Respiratory Hypersensitivity/diagnosis , Respiratory Hypersensitivity/therapy , Health Care Surveys , Humans , Mexico , Practice Guidelines as TopicABSTRACT
AIM OF THE STUDY: To determine whether liver-directed therapies (LDT) and no therapy affect waiting list times for liver transplant candidates from a single center. MATERIAL AND METHODS: This retrospective study included patients > 12 years of age diagnosed with hepatocellular carcinoma between January 2014 and June 2019 and followed until the date of transplant, date of delisting, loss to follow-up, or date of death. Waiting list time and associated factors were analyzed using Kaplan-Meier and Cox proportional-hazards methods. RESULTS: A total of 181 patients met the selection criteria. The mean age was 60 years with standard deviation (SD) of 7.8 years. Sixty-six percent underwent transplant, and 64% were classified within the Milan criteria. Men had a lower median waiting list time than women (191 days vs. 236 days, p = 0.0093). The overall median survival time or time to transplant for 50% of the population was 218 days (95% CI: 195-235). Men displayed a 3.1-fold (95% CI: 1.5-6.2) higher probability of transplantation than women (p = 0.002). Patients who received no therapy had a 5-fold higher probability of undergoing transplantation than patients under arterial LDT (HR [95% CI]: 5 [1.2, 20], p = 0.02). Patients under combined LDT displayed a 70% reduced probability of transplantation compared to patients who received arterial LDTs (p = 0.0009). CONCLUSIONS: LDT was associated with a prolonged stay on the transplant list, likely due to the presence of an aggressive liver tumor. However, LDTs allow the patient to remain active on the liver transplant list, increasing their chances of undergoing transplantation.
ABSTRACT
BACKGROUND: In Mexico, allergen immunotherapy (AIT) and immunotherapy with hymenoptera venom (VIT) is traditionally practiced combining aspects of the European and American school. In addition, both types of extracts (European and American) are commercially available in Mexico. Moreover, for an adequate AIT/VIT a timely diagnosis is crucial. Therefore, there is a need for a widely accepted, up-to-date national immunotherapy guideline that covers diagnostic issues, indications, dosage, mechanisms, adverse effects and future expectations of AIT (GUIMIT 2019). METHOD: With nationwide groups of allergists participating, including delegates from postgraduate training-programs in Allergy/Immunology-forming, the guideline document was developed according to the ADAPTE methodology: the immunotherapy guidelines from European Academy of Allergy and Clinical Immunology, German Society for Allergology and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma, and Immunology were selected as mother guidelines, as they received the highest AGREE-II score among international guidelines available; their evidence conforms the scientific basis for this document. RESULTS: GUIMIT emanates strong or weak (suggestions) recommendations about practical issues directly related to in vivo or in vitro diagnosis of IgE mediated allergic diseases and the preparation and application of AIT/VIT and its adverse effects. GUIMIT finishes with a perspective on AIT modalities for the future. All the statements were discussed and voted on until > 80 % consensus was reached. CONCLUSIONS: A wide and diverse group of AIT/VIT experts issued transculturized, evidence-based recommendations and reached consensus that might improve and standardize AIT practice in Mexico.
Antecedentes: En México, la inmunoterapia con alérgenos (ITA) y con veneno de himenópteros (VIT) se practica tradicionalmente combinando criterios de las escuelas europea y estadounidense; los dos tipos de extractos están comercialmente disponibles en México. Para una ITA adecuada es crucial un diagnóstico oportuno. Objetivo: Presentar GUIMIT 2019, Guía Mexicana de Inmunoterapia 2019, de base amplia, actualizada, que abarca temas de diagnóstico, indicaciones, dosificación, mecanismos, efectos adversos de la ITA y expectativas con esta modalidad de tratamiento. Método: Con la participación de múltiples grupos mexicanos de alergólogos, que incluían los centros formadores universitarios en alergia e inmunología, se desarrolló el documento de la guía según la metodología ADAPTE. Las guías de inmunoterapia de la European Academy of Allergy and Clinical Immunology, The American Academy of Allergy, Asthma and Immunology, German Society for Allergology and Clinical Immunology y del American College of Allergy, Asthma, and Immunology se seleccionaron como guías fuente, ya que recibieron la puntuación AGREE-II más alta entre las guías internacionales disponibles; su evidencia conforma la base científica de GUIMIT 2019. Resultados: En GUIMIT 2019 se emiten recomendaciones fuertes o débiles (sugerencias) acerca de temas directamente relacionados con el diagnóstico in vivo o in vitro de las enfermedades alérgicas mediadas por IgE, la preparación y aplicación de ITA o VIT y sus efectos adversos; se incluye la revisión de las modalidades de ITA para el futuro. Todos los argumentos que se exponen fueron discutidos y votados con > 80 % de aprobación. Conclusión: Un grupo amplio y diverso de expertos en ITA y VIT emitió recomendaciones transculturizadas basadas en evidencia, que alcanzaron consenso; con ellas se pretende mejorar y homologar la práctica de la inmunoterapia en México.
Subject(s)
Hypersensitivity/diagnosis , Hypersensitivity/therapy , Immunoglobulin E , Immunotherapy/standards , Humans , Hypersensitivity/immunology , Immunoglobulin E/immunologyABSTRACT
A 36-year-old woman presents to the emergency department with a 4-day history of progressive lower abdominal pain accompanied by nausea.
Subject(s)
Adenocarcinoma/diagnosis , Ileal Diseases/diagnostic imaging , Ileocecal Valve/diagnostic imaging , Intussusception/diagnostic imaging , Adult , Colonoscopy , Female , Humans , Ileal Diseases/etiology , Ileal Diseases/surgery , Ileocecal Valve/surgery , Intussusception/etiology , Intussusception/surgery , Multimodal Imaging , Tomography, X-Ray ComputedABSTRACT
A two-year-old female infant presented with a palpable scalp mass that her mother first noticed nine months before presentation. The mother denied history of pain, discomfort, trauma, fever, or neurologic manifestations. On examination, she had a single, round, firm, subcutaneous mass measuring 3x2 cm on the right posterior temporal area covered by normal skin. Histology was consistent with cranial fasciitis.
