Shared Decision-Making in Allergen Immunotherapy (AIT) Options Using a Questionnaire for Respiratory Allergic Patients: A Delphi Consensus Study.

Purpose: The objective of this study was to develop and validate a questionnaire, through a Delphi consensus, to be used by allergists in their routine clinical practice to assess the preferences of patients starting allergen immunotherapy (AIT) treatment using an objective approach. Patients and Methods: A Delphi consensus-driven process was used. The scientific committee, composed of 15 allergists, led the study and participated in the preparation of the questionnaire. Two-hundred panelists from different Spanish regions were invited to complete a 16-item questionnaire on a nine-point Likert scale covering six topic blocks. Consensus was achieved if ≥66.6% of panelists reached agreement or disagreement. Results: Of the 200 experts invited to participate in the Delphi process, a total of 195 (97.5%) answered the questionnaire. The panel experts reached a consensus on "agreement" on a total of 12 of the 16 (75.0%) items, covering a total of six categories: (a) patient knowledge (2 questions), (b) barriers to patient adherence (3 questions), (c) patient behavior (4 questions), (d) future actions (3 questions), (e) treatment costs (2 questions), and (f) final patient preferences (2 questions). Conclusion: This Delphi consensus study validated a set of twelve recommended questions for patients objectively assessing their preferences and suitability for the most common AIT options available. The questionnaire intends to assist allergists in making an objective, unconditioned decision regarding the best AIT option for each patient, after informing them about the different routes.

Rescue with echoendoscopy-guided cholecystogastrostomy in a patient with rectal melanoma metastasis. A diagnostic and therapeutic challenge.

We present the case of a 70-year-old woman with a history of transanal resection of rectal melanoma who presented with obstructive jaundice. She underwent complementary tests and was diagnosed with metastasis of melanoma at ampullary level. We consider this to be an interesting case given its unusual nature, as well as its difficult diagnostic and therapeutic management.

"Omental Cake" in a Patient With Asbestosis Leading to the Diagnosis of Malignant Peritoneal Mesothelioma.

We report a case of a 68-year-old man with medical history of pleural asbestosis and diagnosed with malignant peritoneal mesothelioma. This neoplasm is rare, has a poor prognosis, and is associated with asbestosis in many cases. It manifests clinically insidiously and in relation to the intra-abdominal locoregional effect. Radiological findings are variable, although the finding of "omental cake" by CT scan is characteristic but not pathognomonic, as seen in our case. A biopsy is required for the diagnosis, which can be guided by radiology or surgery. Treatment options available are cytoreductive surgery with intraperitoneal hyperthermic chemotherapy or systemic chemotherapy. However, new therapeutic options are emerging, which are still under development and research.

Towards the elimination of hepatitis C: implementation of reflex testing in Andalusia

BACKGROUND AND AIM: undiagnosed hepatitis C virus (HCV) infection and/or inadequate access to care are barriers to the elimination of HCV. Reflex testing has proven to facilitate referral to care, treatment and viral elimination. In this study, a reflex testing program was implemented in Andalusia and its impact on access to care was evaluated. PATIENTS AND METHODS: an observational, retrospective and prospective study was performed across diagnostic laboratories responsible for HCV diagnosis in southern Spain. After surveying the barriers to performing reflex testing, the number of patients that were not referred for care in 2016 was retrospectively studied (pre-reflex cohort). Subsequently, several measures were proposed to overcome the identified barriers. Finally, reflex testing was implemented and its impact evaluated. RESULTS: the pre-reflex cohort included information from 1,053 patients. Slightly more than half of the patients (n = 580; 55%) visited a specialist for treatment evaluation during a median period of 71 days (interquartile range = 35-134) since the date of diagnosis. The post-reflex cohort (September 2017 to March 2018) included 623 patients. Only 17% (n = 106) of the patients had not been referred for care or evaluated for treatment in a median period of 52 days (interquartile range = 28-86). CONCLUSIONS: in 2016, nearly half of new HCV diagnoses in southern Spain were not referred for care. Barriers to the implementation of reflex testing were overcome in our study. Moreover, this strategy was effectively implemented in 2017. Reflex testing contributed to improving referral for care. This program will contribute to the micro-elimination of hepatitis C in Spain

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Towards the elimination of hepatitis C: implementation of reflex testing in Andalusia.

BACKGROUND AND AIM: undiagnosed hepatitis C virus (HCV) infection and/or inadequate access to care are barriers to the elimination of HCV. Reflex testing has proven to facilitate referral to care, treatment and viral elimination. In this study, a reflex testing program was implemented in Andalusia and its impact on access to care was evaluated. PATIENTS AND METHODS: an observational, retrospective and prospective study was performed across diagnostic laboratories responsible for HCV diagnosis in southern Spain. After surveying the barriers to performing reflex testing, the number of patients that were not referred for care in 2016 was retrospectively studied (pre-reflex cohort). Subsequently, several measures were proposed to overcome the identified barriers. Finally, reflex testing was implemented and its impact evaluated. RESULTS: the pre-reflex cohort included information from 1,053 patients. Slightly more than half of the patients (n = 580; 55%) visited a specialist for treatment evaluation during a median period of 71 days (interquartile range = 35-134) since the date of diagnosis. The post-reflex cohort (September 2017 to March 2018) included 623 patients. Only 17% (n = 106) of the patients had not been referred for care or evaluated for treatment in a median period of 52 days (interquartile range = 28-86). CONCLUSIONS: in 2016, nearly half of new HCV diagnoses in southern Spain were not referred for care. Barriers to the implementation of reflex testing were overcome in our study. Moreover, this strategy was effectively implemented in 2017. Reflex testing contributed to improving referral for care. This program will contribute to the micro-elimination of hepatitis C in Spain.

Occupational rhinoconjunctivitis induced by unusual allergens of carrot

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Correction to: Health care services use among long-term breast cancer survivors: a systematic review.

The article Health care services use among long-term breast cancer survivors: a systematic review, written by Anna Jansana, Margarita Posso, Inmaculada Guerrero, Alexandra Prados-Torres, Maria Isabel Del Cura, Xavier Castells and Maria Sala, was originally published electronically.

Health care services use among long-term breast cancer survivors: a systematic review.

PURPOSE: Long-term breast cancer survivors are women surviving at least 5 years after diagnosis. This systematic review aimed to summarize the main characteristics and patterns of healthcare service use (frequency of visits, health providers visited, and preventive care performed) among long-term breast cancer survivors. METHODS: We used standard Cochrane Collaboration methods and searched the MEDLINE and EMBASE databases up to January 2018. We included English language observational studies reporting health service use among long-term cancer survivors. The quality of the studies was appraised through the ROBINS-I assessment tool. Two independent reviewers performed both the study quality assessment and the data extraction. RESULTS: A total of 23 observational studies were included that reported data on health services use by long-term breast cancer survivors. Despite heterogeneity among studies, about half of them reported that breast cancer survivors visited a medical provider at least once a year, as recommended by breast cancer survival guidelines. Although survivors visited medical providers with the recommended frequency, a substantial number used specialist care instead of primary care during follow-up. The results showed underuse of the recommended annual mammogram. CONCLUSIONS: Long-term breast cancer survivors differ in their health services use with regard to the frequency of visits as well as the health providers seen. Our results indicate the need for active surveillance through primary care providers in coordination with specialized care. IMPLICATIONS FOR CANCER SURVIVORS: This review could help to standardize the management of breast cancer survivors and decision-makers to adapt their guidelines and clinical protocols.

Hepatitis C virus core antigen in the management of patients treated with new direct-acting antivirals.

We evaluated the utility of Architect core antigen assay® Abbott Diagnostics (HCVAg) for monitoring patients with HCV infection and compared to HCV-RNA quantification (Cobas Ampliprep TaqMan-Roche Diagnostics). Samples from 262 patients were studied. Mean baseline HCV RNA and HCVAg levels were similar for responders (6.2 log IU/mL and 3.4 log fmol/L) and non-responders (6.1 log IU/mL and 3.2 log fmol/L), respectively. Only 10 patients failed to achieve SVR12 and all were detected by both assays. To evaluate HCVAg quantification as a tool for the detection of failure to DAAs, we performed a retrospective study of 132 non-responder patients. Mean HCV RNA and HCVAg levels at the time of detection of therapeutic failure were 5.88±0.97 log IU/mL and 3.19±0.79 log fmol/L, respectively. HCVAg (>3 fmol/L) was detected in 130/132 patients (98.5%). HCVAg assay was useful for patient selection and for evaluating virological response to DAAs in the real world.

In vivo diagnosis with purified tropomyosin in mite and shellfish allergic patients.

BACKGROUND: Tropomyosin is the most studied shellfish allergen and has been involved in cross-reactivity among different invertebrates (crustacean, mollusks, mites, insects, and nematodes). OBJECTIVE: To determine the relevance of tropomyosin in mite- and shellfish-sensitized patients using tropomyosin skin testing. METHODS: Patients were divided into 3 groups: group M included mite allergic patients (ie, individuals with respiratory symptoms and a positive result on skin prick testing [SPT] to house dust mites), group S included shellfish allergic patients (ie, individuals who reported symptoms with shellfish), and group MS included mite- and shellfish allergic patients (ie, individuals who simultaneously fulfilled the inclusion criteria for groups M and S). Tropomyosin was purified from shrimp, characterized, and used in SPT for diagnosis in the patient population. RESULTS: Eight hundred fifty patients were included in the study: 790 (92.9%) in group M, 21 (2.5%) in group S, and 39 (4.6%) in group MS. Tropomyosin was purified from shrimp with a purity higher than 95%. Forty-two individuals tested positive to tropomyosin: the prevalence was 2.7% in group M, 28.6% in group S, and 38.5% in patients of group MS. Twenty-one (50%) of the tropomyosin-positive individuals had symptoms with shellfish, and 3 (14.3%) reported anaphylaxis. CONCLUSION: The prevalence of tropomyosin was low in mite-sensitized patients (2.7 %) and high in shellfish allergic patients (28.6%). The higher prevalence of tropomyosin was found in patients sensitized to both mite and shellfish (38.5%). The selection of tropomyosin-sensitized patients by SPT might help in the choice of appropriate treatments or management for these patients.

Evaluación de la espectrometría de masas en la identificación de levaduras de interés clínico / Evaluation of mass spectrometry for the identification of clinically interesting yeasts

INTRODUCCIÓN: La identificación de levaduras se basa en el estudio de las características morfológicas, bioquímicas y nutricionales, y en la utilización de métodos moleculares. La espectrometría de masas matrix-assisted laser desorption ionization time-of-fligh (MALDI-TOF) constituye un nuevo método de identificación de microorganismos que ha demostrado gran utilidad. Nuestro objetivo ha sido evaluar este nuevo método en la identificación de levaduras. MÉTODOS: Ensayamos un total de 600 cepas aisladas de muestras clínicas pertenecientes a 9 géneros y 43 especies. La identificación se realizó mediante secuenciación de las regiones ITS del ADN ribosómico, asimilación de compuestos de carbono (ID 32C) y espectrometría de masas en un espectrómetro Microflex (Bruker Daltonics GmbH, Alemania). RESULTADOS: Un total de 569 cepas (94,8%) fueron identificadas a nivel de especie por ID 32C, y 580 (96,7%) por MALDI-TOF. La concordancia entre ambos métodos comprendió un total de 553 cepas (92,2%), elevándose al 100% en las especies de interés clínico: Candida albicans, C. glabrata, C. parapsilosis, C. tropicalis, y casi del 100% en C. krusei. MALDI-TOF identificó especies que precisan métodos moleculares: Candida dubliniensis, C. nivariensis, C. orthopsilosis y C. metapsilosis. Observamos cierta irregularidad en la identificación de levaduras formadoras de artroconidias y de basidiomicetos. CONCLUSIÓN: La espectrometría de masas MALDI-TOF es un método rápido, rentable y económico que permite la identificación de la mayoría de las levaduras aisladas en clínica, así como la diferenciación de especies estrechamente relacionadas. Sería conveniente la inclusión de más especies en su base de datos para ampliar su rentabilidad

INTRODUCTION: The aim of the study was to analyze the incidence, management and cost associated to hematological and dermatological adverse effects (AE) in chronic hepatitis C patients on triple therapy (TT) with telaprevir (TVR) or boceprevir (BOC). METHODS: An analysis was made on the data recorded on patients who started treatment with TVR or BOC associated with peginterferon alfa and ribavirin in a 12-week follow-up period. RESULTS: Fifty-three patients were included (TVR n = 36; BOC n = 17). Thrombocytopenia (83% TVR vs. 88% BOC) followed by neutropenia (89% TVR vs. 82% BOC) were the most common AE. Dermatological AE were observed in 32% of patients. Eleven patients required treatment discontinuation (all of them received TVR), and toxicity was the main reason for discontinuation (64%). The percentage of patients who required supportive treatment for management of AE was 66%. The most used supportive treatment was erythropoietin. Eight patients required emergency health care, and 2 were hospitalized due to AE. Total cost of additional supportive resources was 32,522 Euros (625 [SD = 876] Euros/patient) (TVR 759 [SD = 1,022] Euros/patient vs. BOC 349 [SD = 327] Euros/patient; P > .05). Patients with grade iii-iv toxicity required greater supportive care with higher costs, compared to patients with grade i-ii toxicity (849 [SD = 1,143] Euros/patient vs. 387 [SD = 397] Euros/patient; P = .053). CONCLUSION: The addition of new protease inhibitors to conventional treatment leads to a higher incidence of hematological AE in our study, compared to data described in clinical trials. The elevated incidence of AE involves the use of supportive care, increasing total costs of therapy

Diferenciación de especies del complejo Mycobacterium fortuitum mediante espectrometría de masas / Differentiation of Mycobacterium fortuitum complex species using mass spectrometry

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[Evaluation of mass spectrometry for the identification of clinically interesting yeasts]. / Evaluación de la espectrometría de masas en la identificación de levaduras de interés clínico.

INTRODUCTION: Identification of yeasts is based on morphological, biochemical and nutritional characteristics, and using molecular methods. Matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry, a new method for the identification of microorganisms, has demonstrated to be very useful. The aim of this study is to evaluate this new method in the identification of yeasts. METHODS: A total of 600 strains of yeasts isolated from clinical specimens belonging to 9 genera and 43 species were tested. Identification was made by sequencing of the ITS regions of ribosomal DNA, assimilation of carbon compounds (ID 32C), and mass spectrometry on a Microflex spectrometer (Bruker Daltonics GmbH, Germany). RESULTS: A total of 569 strains (94.8%) were identified to species level by ID 32C, and 580 (96.7%) by MALDI-TOF. Concordance between both methods was observed for 553 strains (92.2%), with 100% in clinically relevant species: C. albicans, C. glabrata, C. parapsilosis, C. tropicalis, and almost 100% in C. krusei. MALDI-TOF identified species requiring molecular methods: Candida dubliniensis, C. nivariensis, C. metapsilosis and C. orthopsilosis. Some irregularities were observed in the identification of arthroconidia yeast and basidiomycetes. CONCLUSION: MALDI-TOF is a rapid, effective and economic method, which enables the identification of most clinically important yeasts and the differentiation of closely related species. It would be desirable to include more species in its database to expand its performance.

Sensibilidad a antifúngicos de especies de Scopulariopsis de origen clínico / Antifungal susceptibility of clinical isolates of Scopulariopsis species

Introducción. Scopulariopsis es un hongo saprofito del suelo. En los últimos años se ha incrementado el número y diversidad de las infecciones causadas por este hongo, incluyendo micosis superficiales e invasoras, y se ha descrito resistencia in vitro a antifúngicos, aunque existe escasa información al respecto. Nuestro objetivo fue establecer la sensibilidad in vitro de especies de origen clínico frente a un amplio número de antifúngicos. Material y métodos. Veintiocho cepas de Scopulariopsis (10 S. brevicaulis, 7 S. koningii, 3 S. acremonium, 3 S. candida, 3 S. flava, 1 S. brumptii y 1 S. fusca) fueron ensayadas mediante el método Sensititre YeastOne y el de microdilución en caldo, para determinar las concentraciones mínimas inhibitorias (CMIs) frente a anfotericina B, fluconazol, itraconazol, posaconazol, voriconazol y 5-fluorocitosina, y las concentraciones mínimas efectivas (CMEs) frente a anidulafungina, caspofungina y micafungina. Resultados. Nuestros datos confirman la alta resistencia in vitro a los antifúngicos de Scopulariopsis. Anidulafungina, caspofungina, micafungina (CMIs ≥8 mg/L), 5-fluorocitosina (CMIs ≥64 mg/L) y fluconazol (CMIs ≥128 mg/L) fueron inactivas para todas las especies. Las CMIs para anfotericina B (rango 2 a ≥8 mg/L) e itraconazol (0,5 a ≥16 mg/L) fueron altas. La mejor actividad se observó para posaconazol y voriconazol (0,5 a ≥8 mg/L). Con el método Sensititre YeastOne se obtuvieron CMIs ligeramente inferiores. Scopulariopsis candida, S. flava y S. fusca, fueron las especies más resistentes; S. acremonium y S. brevicaulis las de CMIs más bajas. Conclusiones. Las CMIs de todos los antifúngicos ensayados fueron elevadas para Scopulariopsis, lo que demuestra que las infecciones causadas por especies de Scopulariopsis podrían no responder al tratamiento. En infecciones graves, voriconazol sería una buena elección para el tratamiento, asociado a anfotericina B (AU)

Introduction. Scopulariopsis is a common soil saprophyte. In the last years the infections caused by Scopulariopsis species have increased, included superficial and invasive mycoses. This fungi has been reported resistant in vitro to some antifungal agents, although there is little information about this. The aim of the study was to establish in vitro antifungal susceptibility of clinical isolates of Scopulariopsis species against to broad-spectrum antifungal agents. Methods. A total of 28 Scopulariopsis strains (10 S. brevicaulis, 7 S. koningii, 3 S. acremonium, 3 S. candida, 3 S. flava, 1 S. brumptii and 1 S. fusca) were tested using Sensititre YeastOne and broth microdilution methods to determine the minimum inhibitory concentrations (MICs) to amphotericin B, fluconazole, itraconazole, posaconazole, voriconazole and 5-fluorocytosine, and minimun effective concentration (MECs) to anidulafungin, caspofungin and micafungin. Results. Our data confirm the high in vitro resistance of Scopulariopsis to antifungal agents. Anidulafungin, caspofungin, micafungin (MICs ≥8 mg/L), 5-fluorocytosine (MICs ≥64 mg/L), and fluconazole (MICs ≥128 mg/L) were inactive in vitro in all species. MICs of amphotericin B (range 2 to ≥8 mg/L) and itraconazole (0.5 to ≥16 mg/L) were high. The best antifungal activity was observed for posaconazole and voriconazole (0.5 to ≥8 mg/L). With Sensititre YeastOne method MICs obtained slightly lower. Scopulariopsis candida, S. flava and S. fusca were the most resistant species, while S. acremonium and S. brevicaulis showed the lowest MICs. Conclusions. MICs of all tested antifungal agents for Scopulariopsis were very high. Infections caused by Scopulariopsis species may not respond to antifungal treatment. Voriconazole is the drug of choice for treatment. We consider it appropriate to add amphotericin B in serious infections (AU)

Utilidad de la tiroglobulina en lavado de aguja del aspirado de 16 lesiones cervicales en pacientes con cáncer de tiroides / The value of thyroglobulin in washout of fine needle aspirate from 16 cervical lesions in patients with thyroid cancer

Antecedentes y objetivo La tiroglobulina del lavado de aguja (Tg-PAAF) junto con la citología de la punción-aspiración con aguja fina (cito-PAAF) son procedimientos recomendados para el diagnóstico de metástasis ganglionares cervicales y recurrencias del cáncer diferenciado de tiroides. El objetivo de este estudio fue valorar la utilidad de estas técnicas en 16 lesiones cervicales de pacientes con cáncer de tiroides del epitelio folicular (CT).Pacientes y método Se incluyeron 6 pacientes con CT y adenopatías laterocervicales evaluadas antes de la cirugía tiroidea inicial y 10 pacientes en seguimiento por CT ya operado y lesiones cervicales ecográficamente sospechosas y/o persistentes. Las 16 lesiones fueron sometidas a PAAF. Los resultados de la Tg-PAAF, cito-PAAF y de la combinación de ambas se compararon con el diagnóstico definitivo asignado a cada lesión. Resultados En 10 lesiones comprobadamente malignas tras extirpación quirúrgica (9 metástasis ganglionares y una recurrencia en lecho), la cito-PAAF, la Tg-PAAF y la combinación de ambas técnicas permitieron llegar al diagnóstico correcto en 7, 9 y 10 casos respectivamente. En 6 lesiones consideradas benignas, la cito-PAAF pudo confirmar la benignidad de la lesión en 4, resultó no diagnóstica en una y falsamente positiva en otra, mientras que la Tg-PAAF se halló por debajo del valor de corte establecido (para considerar malignidad) en todos los casos. Conclusiones En pacientes con CT y lesiones cervicales sospechosas, la Tg-PAAF mejora la rentabilidad diagnóstica de la cito-PAAF aislada justificándose así su recomendación sistemática al realizar la PAAF. Quedan sin embargo por definir una estandarización universal de la técnica y unos valores de corte válidos de Tg-PAAF (de acuerdo al inmunoanálisis empleado) por encima de los cuales considerar la lesión maligna (AU)

Background and objective Thyroglobulin in the needle washout (Tg-FNA) and cytology of fine needle aspiration (cyto-FNA) are recommended for diagnosis of metastatic lymphadenopathies and recurrence of differentiated thyroid cancer. The objective of this study was to assess the value of these procedures in 16 cervical masses from patients with thyroid cancer of the follicular epithelium (TC).Patients and methods The study included six patients with TC and cervical lymphadenopathies evaluated before initial thyroid surgery and 10 patients followed up after TC surgery with cervical lumps discovered. FNA was performed in all 16 masses. Results of cyto-FNA, Tg-FNA and of the combined tests were compared to the final diagnosis of each lesion. Results Among 10 lesions proven to be malignant at surgery, cyto-FNA, Tg-FNA and the combination of both allowed for adequate diagnosis in 7, 9, and 10 cases respectively. Among 6 lesions considered to be benign, cyto-FNA was able to confirm diagnosis in 4, was non-diagnostic in one, and was falsely negative in the remaining case, while Tg-FNA was below the established cut-off value (to consider malignancy) in all cases. ConclusionsIn patients with TC and suspect cervical masses, Tg-FNA improved the diagnostic yield of cyto-FNA alone, thus warranting its routine recommendation when FNA is performed. However, universal standardization of the technique and definition of valid cut-off thyroglobulin values (depending on the immunoassay used) above which the lesion should be considered to be malignant are still pending (AU)

The value of thyroglobulin in washout of fine needle aspirate from 16 cervical lesions in patients with thyroid cancer.

BACKGROUND AND OBJECTIVE: Thyroglobulin in the needle washout (Tg-FNA) and cytology of fine needle aspiration (cyto-FNA) are recommended for diagnosis of metastatic lymphadenopathies and recurrence of differentiated thyroid cancer. The objective of this study was to assess the value of these procedures in 16 cervical masses from patients with thyroid cancer of the follicular epithelium (TC). PATIENTS AND METHODS: The study included six patients with TC and cervical lymphadenopathies evaluated before initial thyroid surgery and 10 patients followed up after TC surgery with cervical lumps discovered. FNA was performed in all 16 masses. Results of cyto-FNA, Tg-FNA and of the combined tests were compared to the final diagnosis of each lesion. RESULTS: Among 10 lesions proven to be malignant at surgery, cyto-FNA, Tg-FNA and the combination of both allowed for adequate diagnosis in 7, 9, and 10 cases respectively. Among 6 lesions considered to be benign, cyto-FNA was able to confirm diagnosis in 4, was non-diagnostic in one, and was falsely negative in the remaining case, while Tg-FNA was below the established cut-off value (to consider malignancy) in all cases. CONCLUSIONS: In patients with TC and suspect cervical masses, Tg-FNA improved the diagnostic yield of cyto-FNA alone, thus warranting its routine recommendation when FNA is performed. However, universal standardization of the technique and definition of valid cut-off thyroglobulin values (depending on the immunoassay used) above which the lesion should be considered to be malignant are still pending.