Impaired bone mineral density and microarchitecture in female adolescents with IgE-mediated cow's milk allergy.

This study compared the bone parameters of adolescents with persistent cow's milk allergy (CMA) with those of healthy adolescents. Adolescents with CMA had compromised bone parameters (lower bone mineral density, impaired trabecular microarchitecture, and lower bone strength). Partial exclusion diet was associated with better bone parameters than total exclusion diet. BACKGROUND: Persistent immunoglobulin E (IgE)-mediated cow's milk allergy (CMA) may impair bone parameters and increase the risk of fractures. High-resolution peripheral quantitative computed tomography (HR-pQCT) is a novel methodology that not only assesses trabecular and cortical bone compartments and volumetric density measurements, but also evaluates bone microarchitecture and estimates biomechanical properties through finite element analysis (FEA). Both HR-pQCT and bone strength parameters derived from FEA have shown a strong correlation with fracture risk. PURPOSE: To assess the bone density, microarchitecture, and bone strength of adolescents with persistent IgE-mediated CMA (IgE-CMA). METHODS: This was an observational, cross-sectional study with female adolescents with persistent IgE-CMA and healthy control participants matched by female sex and sexual maturation. Bone parameters were assessed by areal bone mineral density (aBMD) through dual-energy X-ray absorptiometry (DXA), bone microarchitecture by HR-pQCT at the radius and tibia, and laboratory markers related to bone metabolism. RESULTS: The median age of adolescents with persistent IgE-CMA (n = 26) was 13.0 years (interquartile range (IQR) 11.4-14.7) and of healthy control participants (n = 28) was 13.6 years (IQR 11.9-14.9). Adolescents with IgE-CMA ingested 27.4% less calcium (p = 0.012) and 28.8% less phosphorus (p = 0.009) than controls. Adolescents with IgE-CMA had lower bone mineral content (BMC) (38.83 g vs. 44.50 g) and aBMD (0.796 g/cm2 vs. 0.872 g/cm2) at lumbar spine, and lower BMC (1.11 kg vs. 1.27 kg) and aBMD (0.823 g/cm2 vs. 0.877 g/cm2) at total body less head (TBLH) (p < 0.05). However, Z-scores BMC and Z-scores aBMD at lumbar spine and TBLH, when adjusted for Z-score height/age, were not significantly different between the groups. Moreover, CMA adolescents had lower bone strength at the distal tibia (S 169 kN/mm vs. 194 kN/mm; F Load 8030 N vs. 9223 N) (p < 0.05). Pairing of groups by the presence of menarche showed compromised parameters at the tibia-lower total volumetric BMD (Tt.vBMD) (293.9 mg HA/cm3 vs. 325.9 mg HA/cm3) and trabecular vBMD (Tb.vBMD) (170.8 mg HA/cm3 vs. 192.2 mg HA/cm3), along with lower cortical thickness (Ct.th) (1.02 mm vs. 1.16 mm) and bone strength (S 174 kN vs. 210 kN; F Load 8301 N vs. 9950 N)-and at the radius (S 61 kN/mm vs. 71 kN/mm; F Load 2920 N vs. 3398 N) (p < 0.05) among adolescents with IgE-CMA. Adolescents with IgE-CMA on a total exclusion diet (n = 12) showed greater impairment of bone features than those on a partial exclusion diet (n = 14), with lower lumbar spine Z-score BMC (- 0.65 vs. 0.18; p = 0.013), lumbar spine trabecular bone score (TBS) (1.268 vs. 1.383; p = 0.005), Z-score TBS (0.03 vs. 1.14; p = 0.020), TBLH Z-score BMC (- 1.17 vs. - 0.35; p = 0.012), TBLH Z-score aBMD (- 1.13 vs. - 0.33; p = 0.027), Tt.vBMD at the tibia (259.0 mg HA/cm3 vs. 298.7 mg HA/cm3; p = 0.021), Ct.th at the tibia (0.77 mm vs. 1.04 mm; p = 0.015) and Ct.th at the radius (0.16 mm vs. 0.56 mm; p = 0.033). CONCLUSION: Adolescents with persistent IgE-CMA had lower aBMD and compromised microarchitecture (impaired trabecular microarchitecture and lower bone strength). Adolescents on a partial exclusion diet had better bone parameters than those on a total exclusion diet.

Perfil etiológico, sociodemográfico e desfechos dos pacientes com asma internados por síndrome respiratória aguda grave (SRAG) no Brasil de 2020 a 2022: uma análise de 83.452 internações / Etiology, sociodemographic profile, and outcomes of patients with asthma hospitalized for severe acute respiratory illness (SARI) in Brazil from 2020 to 2022: an analysis of 83,452 hospitalizations Braian

Introdução: A asma é uma das doenças crônicas mais frequentes na população brasileira. O objetivo deste estudo foi determinar as etiologias, o perfil sociodemográfico e os fatores de risco para óbito entre pacientes com asma internados por síndrome respiratória aguda grave (SRAG) no Brasil entre 2020 e 2022. Métodos: A partir do banco de dados SIVEP-Gripe, incluímos todos os pacientes com idade maior que 5 anos registrados no banco de 01/01/2020 até 21/07/2022, hospitalizados por SRAG, com antecedente de asma e com desfechos conhecidos. Como exposições, foram estudadas a idade, sexo, região de moradia, etnia e agentes etiológicos virais isolados. Os desfechos foram internação em unidade de terapia intensiva, necessidade de ventilação mecânica e óbito. Para calcular a razão de chances entre exposição e desfechos, utilizamos modelos lineares generalizados mistos multinível. Resultados: Foram incluídas na análise 83.452 internações, sendo 14.062 crianças e adolescentes, e 69.390 adultos. A mortalidade aumentou com a idade, indo de 0,6% entre 5-10 anos para 33% nos maiores que 60 anos. Na população pediátrica, morar na região Norte e Nordeste e ter entre 10-20 anos foram associados a maior mortalidade (OR 2,14 IC95% 1,41- 3,24 e OR 3,73 IC95% 2,65-5,26 respectivamente). Quanto aos agentes etiológicos, apenas o SARS-CoV-2 conferiu maior risco de óbito (OR 5,18 IC95% 3,62-7,42). Entre adultos, sexo feminino e etnias não brancas foram protetoras (OR 0,87 IC95% 0,83-0,9 e OR 0,90; IC95% 0,85-0,94 respectivamente) para óbito. Faixas etárias mais avançadas, morar nas regiões Norte e Nordeste e o diagnóstico de COVID-19 foram associados a maior mortalidade. Conclusões: Há importantes vulnerabilidades sociodemográficas nos desfechos das internações de pacientes com asma por SRAG, com maior mortalidade nas regiões Norte-Nordeste, entre adolescentes na faixa etária pediátrica e entre idosos nos adultos. Além disso, destaca-se o protagonismo da COVID-19 entre as infecções associadas a maior mortalidade.

Introduction: Asthma is one of the most common chronic diseases affecting the Brazilian population. We aimed to determine the etiology, sociodemographic profile, and risk factors for death in patients with asthma hospitalized for severe acute respiratory illness (SARI) in Brazil from 2020 to 2022. Methods: We included all patients over 5 years of age registered in the Influenza Epidemiological Surveillance Information System (SIVEP Gripe) database of the Brazilian Ministry of Health from January 1, 2020 to July 21, 2022 hospitalized for SARI. Patients had to have a history of asthma and known outcomes. As exposures, age, sex, region of residence, ethnicity, and viral etiological agent were evaluated. The outcomes measured were admission to an intensive care unit, need for mechanical ventilation, and death. We used multilevel generalized linear mixed models to calculate the odds ratio between exposure and outcomes. Results: A total of 83,452 hospitalizations were included, of which 14,062 were children and adolescents and 69,390 were adults. Mortality increased with age, ranging from 0.6% in those aged 5-10 years to 33% in those over 60 years. In the pediatric population, living in the north and northeast regions (OR 2.14, 95%CI 1.41-3.24) and having between 10-20 years (OR 3.73, 95%CI 2.65-5.26) were associated with higher mortality. As for etiologic agents, only SARS-CoV-2 was associated with a higher risk of death (OR 5.18, 95%CI 3.62-7.42). Among adults, female sex (OR 0.87, 95%CI 0.83-0.9) and non-White ethnicities (OR 0.90, 95%CI 0.85-0.94) were protective factors against death. Older age groups, living in the north and northeast regions, and a diagnosis of COVID-19 were associated with higher mortality. Conclusions: There are important sociodemographic vulnerabilities in the outcomes of patients with asthma hospitalized for SARI, with higher mortality rates in the north and northeast regions, among adolescents in the pediatric age group, and among older adults. Furthermore, COVID-19 was one of the main infections associated with higher mortality.

Intergeracionalidade e promoção da saúde: reflexões e desafios na atenção à pessoa idosa / Intergenerationality and Health Promotion: Reflections and Challenges in the Care of Older Adults

Resumo Objetivo Discutir sobre a promoção da saúde da pessoa idosa por meio da intergeracionalidade, com ênfase na educação intergeracional nos Programas Intergeracionais, como uma proposta de educação para o protagonismo da pessoa idosa e o envelhecimento bem-sucedido. Método Ensaio teórico, de cunho reflexivo com abordagem qualitativa. Embasando-se na leitura de documentos que reforçam o aumento da longevidade e a preocupação com a promoção da saúde para a pessoa idosa no Brasil, a fim de refletir sobre a intergeracionalidade na promoção da saúde e a utilização da educação intergeracional para promover o envelhecimento bem-sucedido, por meio dos Programas Intergeracionais. Resultados Organizaram-se em três tópicos: Promoção da saúde da pessoa idosa: desafios para o seu protagonismo; Compreensão sobre envelhecimento para a aprendizagem intergeracional; Programa intergeracional: protagonismo para a promoção da saúde da pessoa idosa. Conclusão Experiências exitosas na saúde, especificamente nos espaços ocupados pela Atenção Primária à Saúde ainda se mostram restritas ou pouco visualizadas para a construção de uma educação transformadora para a promoção da saúde da pessoa idosa. O desafio é fomentar pesquisas científicas, para que os profissionais, a partir da educação permanente, possam potencializar os momentos de educação em saúde a partir da educação intergeracional, sendo assim, a construção e implementação de Programas Intergeracionais podem representar essa possibilidade.

Abstract Objective To discuss the promotion of health for older adults through intergenerationality, with an emphasis on intergenerational education within Intergenerational Programs, as a proposal for education fostering the protagonism of older adults and successful aging. Method Theoretical essay, reflective in nature with a qualitative approach. Grounded in the examination of documents emphasizing the increase in longevity and the concern for health promotion among older adults in Brazil, the aim is to contemplate intergenerationality in health promotion and the utilization of intergenerational education to foster successful aging through Intergenerational Programs. Results Organized into three topics: Health promotion for older adults: challenges for their protagonism; Understanding aging for intergenerational learning; Intergenerational program: protagonism for the health promotion of older adults. Conclusion Successful experiences in health, specifically within the realms of Primary Health Care, still appear to be limited or insufficiently recognized for the development of transformative education in health promotion for older adults. The challenge lies in fostering scientific research so that professionals, through continuous education, can enhance health education moments through intergenerational education. Thus, the establishment and implementation of Intergenerational Programs may represent this promising possibility.

Managing moderate-to-severe paediatric asthma: a scoping review of the efficacy and safety of fluticasone propionate/salmeterol.

BACKGROUND: Fluticasone propionate/salmeterol xinafoate (FP/SAL) is an inhaled corticosteroid (ICS) and long-acting ß2-agonist (LABA) combination, indicated for the regular treatment of children (aged >4 years) with asthma that is inadequately controlled with ICS monotherapy plus as-needed short-acting ß2-agonists, or already adequately controlled with ICS/LABA. OBJECTIVE: Compared with the adult population, fewer clinical studies have investigated the efficacy of FP/SAL in paediatric patients with moderate and moderate-to-severe asthma. In this review, we synthesise the available evidence for the efficacy and safety of FP/SAL in the paediatric population, compared with other available therapies indicated for asthma in children. ELIGIBILITY CRITERIA: A literature review identified randomised controlled trials and observational studies of FP/SAL in the paediatric population with moderate-to-severe asthma. SOURCES OF EVIDENCE: The Medline database was searched using PubMed (https://pubmed.ncbi.nlm.nih.gov/), with no publication date restrictions. Search strategies were developed and refined by authors. CHARTING METHODS: Selected articles were screened for clinical outcome data (exacerbation reduction, nocturnal awakenings, lung function, symptom control, rescue medication use and safety) and a table of key parameters developed. RESULTS: Improvements in asthma outcomes with FP/SAL include reduced risk of asthma-related emergency department visits and hospitalisations, protection against exercise-induced asthma and improvements in measures of lung function. Compared with FP monotherapy, greater improvements in measures of lung function and asthma control are reported. In addition, reduced incidence of exacerbations, hospitalisations and rescue medication use is observed with FP/SAL compared with ICS and leukotriene receptor antagonist therapy. Furthermore, FP/SAL therapy can reduce exposure to both inhaled and oral corticosteroids. CONCLUSIONS: FP/SAL is a reliable treatment option in patients not achieving control with ICS monotherapy or a different ICS/LABA combination. Evidence shows that FP/SAL is well tolerated and has a similar safety profile to FP monotherapy. Thus, FP/SAL provides an effective option for the management of moderate-to-severe asthma in the paediatric population.

Antimicrobial Resistance, Genetic Lineages, and Biofilm Formation in Pseudomonas aeruginosa Isolated from Human Infections: An Emerging One Health Concern.

Pseudomonas aeruginosa (PA) is a leading nosocomial pathogen and has great versatility due to a complex interplay between antimicrobial resistance and virulence factors. PA has also turned into one the most relevant model organisms for the study of biofilm-associated infections. The objective of the study focused on analyzing the antimicrobial susceptibility, resistance genes, virulence factors, and biofilm formation ability of thirty-two isolates of PA. PA isolates were characterized by the following analyses: susceptibility to 12 antimicrobial agents, the presence of resistance genes and virulence factors in PCR assays, and the quantification of biofilm production as evaluated by two distinct assays. Selected PA isolates were analyzed through multilocus sequence typing (MLST). Thirty PA isolates have a multi-resistant phenotype, and most of the isolates showed high levels of resistance to the tested antibiotics. Carbapenems showed the highest prevalence of resistance. Various virulence factors were detected and, for the quantification of biofilm production, the effectiveness of different methods was assessed. The microtiter plate method showed the highest accuracy and reproducibility for detecting biofilm-producing bacteria. MLST revealed four distinct sequence types (STs) in clinical PA, with three of them considered high-risk clones of PA, namely ST175, ST235, and ST244. These clones are associated with multidrug resistance and are prevalent in hospitals worldwide. Overall, the study highlights the high prevalence of antibiotic resistance, the presence of carbapenemase genes, the diversity of virulence factors, and the importance of biofilm formation in PA clinical isolates. Understanding these factors is crucial for effective infection control measures and the development of targeted treatment strategies.

Teste de provocação oral com alimentos: o panorama brasileiro / Oral food challenge: a Brazilian panorama

Introdução: O teste de provocação oral (TPO) com alimentos é o padrão ouro para avaliação diagnóstica e de aquisição de tolerância em pacientes com alergia alimentar (AA). Exige, no entanto, equipe especializada e local apropriado para execução, uma vez que reações alérgicas, incluindo anafilaxia, podem acontecer. Foi recém-incorporado como procedimento reconhecido pelo Sistema Único de Saúde e pela Agência Nacional de Saúde, mas apenas no contexto da alergia ao leite de vaca para pacientes com até 24 meses de vida. Pouco se sabe sobre sua disponibilidade/execução no território brasileiro. Objetivos: Explorar o perfil de realização de TPO com alimentos em âmbito nacional, bem como as limitações para a sua não realização. Métodos: Inquérito virtual foi disponibilizado por e-mail aos 2.500 sócios cadastrados na Associação Brasileira de Alergia e Imunologia questionando sobre a prática de TPO, formação do profissional, limitações para sua não realização e possíveis soluções para sua execução. Resultados: Foram obtidas 290 respostas (11,6% dos associados), sendo a maioria deles proveniente da Região Sudeste (56,1%). Realizam TPO 54,5% (158/290) dos associados, 62% destes mais de 5 TPOs/mês, principalmente para leite e ovo. A execução de TPO na atualidade, majoritariamente na rede privada, esteve associada à prática do procedimento durante a especialização. Falta de recurso e ambiente apropriados são as maiores limitações para a não realização do TPO. Conclusões: Apesar do viés de seleção inerente à metodologia empregada do estudo, este inquérito pioneiro em território nacional tem importância por esclarecer e discutir a realização do TPO no âmbito do Brasil. Certamente este procedimento ainda é insuficientemente realizado no Brasil.

Background: Oral food challenge (OFC), the gold standard for diagnosing food allergy and determining tolerance levels, requires specialized staff and appropriate conditions since anaphylaxis may occur. In 2022, OFC was officially recognized in Brazilian public and private health systems, although only for milk allergy in children up to 24 months of age. Little is known about OFC practices in Brazil. Objectives: To explore OFC practices, barriers, and solutions among Brazilian allergists and immunologists. Methods: A survey was e-mailed to 2500 associates of the Brazilian Association of Allergy and Immunology regarding OFC practices, training experiences, barriers to this procedure, and workable solutions. Results: A total of 290 associates responded (11.6%), more than a half of whom (56.15) practiced in the southeast region: 158 (54.5%) reported performing OFC, of whom 62% performed > 5 procedures each month, mostly for cow milk and hen egg. OFCs were mostly performed in private practice and were associated with specialized training. Lack of an appropriate setting was seen as the main barrier to performing the procedure. Conclusions: Although this study's methodology involves intrinsic biases, this is the first exploration of OFC practice in Brazil. OFCs are still underperformed nationwide.

IgE-mediated cow's milk allergy in Brazilian children: Outcomes of oral food challenge.

Background: Oral food challenge (OFC) is useful for diagnosing food allergies and assessing tolerance, but severe reactions may occur during the procedure. Objective: To characterize the frequency and severity of reactions during cow's milk (CM) OFCs. Methods: A cross-sectional study was conducted to analyze the outcome of cow's milk oral food challenges (CMOFCs) performed to confirm IgE-mediated CM allergy or to assess food tolerance. CM was given first as baked milk (BM), followed by whole CM if there was no prior reaction to BM. An OFC was considered positive if IgE-mediated symptoms developed up to 2 h after ingestion. Symptoms were described and variables including age at OFC, prior anaphylaxis, other atopic diseases, and skin test results were compared according to the OFC outcomes. Results: A total of 266 CMOFCs were performed, including 159 patients with a median age of 6.3 years old. One hundred thirty-six tests were positive and 62 resulted in anaphylaxis. Thirty-nine anaphylactic reactions were observed up to 30 min after the first dose. Severe anaphylaxis (cardiovascular and/or neurological involvement) was reported in 5 tests. A second dose of epinephrine was required in 3 tests, and 1 presented a biphasic response. Younger patients had a higher risk of anaphylaxis during baked milk oral food challenge (BMOFC) (p = 0.009). The frequency of anaphylaxis was higher in patients submitted to BM (p = 0.009). Conclusions: Anaphylaxis is a known complication of CMOFCs even when there is no prior anaphylaxis or when conducted with baked products. This study reinforces the importance of conducting OFC in appropriate settings with a well-trained team.

Incidentes críticos na convivência familiar e social de idosos com hiv/aids / Critical incidents in family and social life of elderly people with hiv/aids / Incidentes críticos en la interacción familiar y social de personas mayores con vih/sida

O aumento das Infecções Sexualmente Transmissíveis e dos casos de contágio pelo HIV/AIDS na população idosa reflete aspectos da prática sexual e vulnerabilidades que podem estar sendo enfrentadas por essas pessoas em seu convívio social e familiar. Objetivo: descrever, por meio de incidentes críticos, as situações, comportamentos e consequências relacionadas à descoberta do HIV/AIDS por pessoas idosas soropositivas. Método: estudo descritivo, com abordagem qualitativa, realizado no Centro de Infectologia de um município da região sul do estado do Ceará, utilizando a Técnica de Incidente Crítico (TIC), nos meses de fevereiro a setembro de 2020. Participaram 25 idosos cadastrados no serviço, com idades entre 55 e 77 anos. Os dados foram coletados por meio de entrevista semiestruturada e o conteúdo analisado com auxílio do software IRaMuTeQ por meio de categorias temáticas. Resultados: os dados empíricos contendo as situações, comportamentos e consequências (incidentes críticos) elucidaram quatro categorias empíricas: descoberta do diagnóstico de HIV/AIDS; sentimentos, estigmas e preconceitos vivenciados; soropositividade e reflexos no convívio familiar e social; e mudanças no comportamento sexual após diagnóstico de HIV/AIDS. Conclusão: as relações familiares e sociais vivenciadas e os desafios enfrentados pelas pessoas idosas com HIV/AIDS constituíram incidentes críticos complexos, afetando-as desde o momento do diagnóstico, com impactos negativos sobre seus modos de vida familiar e social, que dificultam a convivência inclusiva e não estigmatizante dentro e fora de casa.

The increase of Sexually Transmitted Infections and cases of HIV/AIDS in the elderly population reflects aspects of sexual practice and vulnerabilities that may be faced by these people in their social and family life. Objective: to describe, through critical incidents, the situations, behaviors and consequences related to the discovery of HIV/AIDS by seropositive elderly people. Method: a descriptive study with a qualitative approach, conducted at the Infectious Diseases Center of a city in the southern region of the state of Ceará, using the Critical Incident Technique (CIT), from February to September 2020. Twenty-five elderly people enrolled in the service, aged 55 to 77 years, participated. The data were collected through semi-structured interviews and the content analyzed with the help of IRaMuTeQ software through thematic categories. Results: The empirical data containing situations, behaviors and consequences (critical incidents) elucidated four empirical categories: discovery of the HIV/AIDS diagnosis; feelings, stigmas and prejudices experienced; seropositivity and reflections on family and social life; and changes in sexual behavior after the diagnosis of HIV/AIDS. Conclusion: the family and social relationships experienced and the challenges faced by elderly people with HIV/AIDS constituted complex critical incidents, affecting them from the moment of diagnosis, with negative impacts on their family and social lifestyles, which hinder inclusive and non-stigmatizing coexistence inside and outside the home.

El aumento de las Infecciones de Transmisión Sexual y de los casos de VIH/Sida en la población anciana refleja aspectos de la práctica sexual y vulnerabilidades que pueden enfrentar estas personas en su vida social y familiar. Objetivo: describir, a través de incidentes críticos, las situaciones, comportamientos y consecuencias relacionadas con el descubrimiento del VIH/SIDA por personas mayores seropositivas. Método: estudo descritivo, com abordagem qualitativa, realizado no Centro de Infectologia de um município da região sul do estado do Ceará, utilizando a Técnica de Incidente Crítico (TIC), nos meses de fevereiro a setembro de 2020. Participaron 25 ancianos registrados en el servicio, con edades comprendidas entre 55 y 77 años. Os dados foram recolhidos através de entrevistas semiestructuradas e o conteúdo foi analisado com a ajuda do software IRaMuTeQ através de categorias temáticas. Resultados: los datos empíricos que contienen las situaciones, comportamientos y consecuencias (incidentes críticos) elucidaron cuatro categorías empíricas: descripción del diagnóstico de VIH/SIDA; sentimientos, estigmas y preconceptos vividos; seropositividad y reflejos en la convivencia familiar y social; y cambios en el comportamiento sexual tras el diagnóstico de VIH/SIDA. Conclusão: as relações familiares e sociais vividas e os desafios enfrentados pelos idosos com HIV/AIDS constituem incidentes críticos complexos, afetando-as desde o momento do diagnóstico, com impactos negativos sobre seus modos de vida familiar e social, que dificultam a convivência inclusiva e não estigmatizante dentro e fora de casa.

[Phenotypes and endotypes of food allergy]. / Fenotipos y endotipos en alergia alimentaria.

Food allergy is a common event, especially in the pediatric population, affecting between 3-6% of children. There are various challenges in the care of patients with food allergy, but certainly the diversity of symptoms and the outcome of the disease are important aspects in the treatment of patients, in the development of care guidelines and in the knowledge of the Natural history of disease. The classification into phenotypes allows a better understanding of the evolution of food allergy. The endotype is a subtype of a phenotype defined by its pathophysiological characteristic. Genetic, epigenetic, and environmental characteristics interfere with the construction of the phenotype and its possible endotypes. Understanding the phenotypes and endotypes of food allergies brings with it two fundamental aspects: 1) the need to understand that the analysis of phenotypes and endotypes in food allergies will allow establishing prognoses and helping in intervention with specific therapies, and 2) the importance of understanding The characterization of local endotypes and phenotypes, and the dietary diversity of the different countries that make up Latin America brings with it a varied menu of foods that may pose a risk of allergy that needs to be studied.

La alergia alimentaria es un evento frecuente, especialmente en la población pediátrica, que afecta entre el 3-6% de los niños. Existen diversos desafíos en el cuidado de los pacientes con alergia alimentaria, pero ciertamente la diversidad de los síntomas y el desenlace de la enfermedad son aspectos importantes en el tratamiento de los pacientes, en la elaboración de las pautas de cuidado y en el conocimiento de la historia natural de la enfermedad. La clasificación en fenotipos permite una mejor comprensión de la evolución de la alergia alimentaria. El endotipo es un subtipo de un fenotipo definido por su característica fisiopatológica. Las características genéticas, epigenéticas y ambientales interfieren en la construcción del fenotipo y sus posibles endotipos. Entender los fenotipos y endotipos de las alergias alimentarias trae consigo dos aspectos fundamentales: 1) la necesidad de entender que el análisis de fenotipos y endotipos en alergia alimentaria permitirá establecer pronósticos y ayudar en la intervención con terapias específicas, y 2) la importancia de comprender la caracterización de los endotipos y fenotipos locales, y la diversidad alimentaria de los diferentes países que conforman América Latina trae consigo un variado menú de alimentos que puede suponer un riesgo de alergia que es necesario estudiar.

Dermatite atópica grave: guia prático de tratamento da Associação Brasileira de Alergia e Imunologia e Sociedade Brasileira de Pediatria / Severe atopic dermatitis: a practical treatment guide from the Brazilian Association of Allergy and Immunology and the Brazilian Society of Pediatrics

A dermatite atópica (DA) é uma doença cutânea inflamatória, crônica, comum, complexa e de etiologia multifatorial, que se manifesta clinicamente com prurido muitas vezes incapacitante, lesões recorrentes do tipo eczema, xerose e que pode evoluir para liquenificação. Embora o conhecimento sobre a sua fisiopatologia venham crescendo nos últimos anos, ainda as formas graves são frequentes e representam um desafio para o clínico. Para o presente guia realizou-se revisão não sistemática da literatura relacionada à DA grave refratária aos tratamentos habituais com o objetivo de elaborar um documento prático e que auxilie na compreensão dos mecanismos envolvidos na DA, assim como dos possíveis fatores de risco associados à sua apresentação. A integridade da barreira cutânea é um dos pontos fundamentais para a manutenção da homeostase da pele. Além dos cuidados gerais: evitação dos agentes desencadeantes e/ou irritantes, o uso de hidratantes, suporte emocional, entre outros, o uso de agentes anti-inflamatórios/imunossupressores de uso tópico e/ou sistêmico também foi revisado. A aquisição de novos agentes, os imunobiológicos e as pequenas moléculas, melhorou a terapêutica para os pacientes com formas graves de DA, sobretudo as refratárias aos tratamentos convencionais.

Atopic dermatitis is a chronic, common, and complex inflammatory skin disease with a multifactorial etiology. It manifests clinically with often disabling pruritus, recurrent eczema-like lesions, and xerosis, and can progress to lichenification. Although understanding of the disease's pathophysiology has been growing in recent years, severe forms are still frequent and represent a challenge for clinicians. A non-systematic review of the literature on severe atopic dermatitis refractory to conventional treatment was conducted to develop the present guide, whose purpose is to help clarify the mechanisms involved in the disease and possible risk factors. The integrity of the skin barrier is fundamental for maintaining skin homeostasis. In addition to general care, patients should avoid triggering and/or irritating agents and moisturizers and seek emotional support, etc.; the use of topical and/or systemic anti-inflammatory/immunosuppressive agents was also reviewed. New agents, immunobiologicals, and small molecules have led to a broader range of therapies for patients with severe forms of the disease, especially cases refractory to conventional treatment.

Anafilaxia durante o primeiro ano de vida em pacientes com alergia à proteína do leite de vaca / Anaphylaxis during the first year of life of infants with cow's milk protein allergy

Objetivo: Descrever as manifestações de anafilaxia precoce em lactentes com alergia à proteína do leite de vaca (APLV) e descrever as condutas terapêuticas utilizadas. Método: Estudo observacional transversal retrospectivo que analisou pacientes com APLV atendidos no Instituto da Criança e do Adolescente do Hospital das Clínicas da FMUSP, entre 1990-2015, que apresentaram sintomas de alergia no primeiro ano de vida, com diagnóstico de anafilaxia, comparados a pacientes alérgicos sem anafilaxia desencadeada por ingestão de leite de vaca. Os pacientes foram caracterizados de maneira epidemiológica, tipo de sintoma apresentado e tratamento realizado. Os dados foram analisados no programa estatístico GraphPad Software Inc. Para avaliar a associação entre categorias, foi utilizado o Teste Exato de Fisher, e para comparações entre grupos, o Teste de Mann Whitney. Os resultados de p < 0,05 foram considerados significativos. Resultados: De um total de 120 crianças avaliadas (68 M:52 F), 85 (70,83%) lactentes preencheram os critérios da World Allergy Organization (WAO) para anafilaxia. As manifestações de alergia IgE mediada foram prioritariamente cutâneas [102 (85%)]. Nos pacientes com diagnóstico de anafilaxia, as principais manifestações foram urticária [39 (45,8%)], vômito [36 (42,3%)] e dispneia [19 (22,3%)]. A recorrência do episódio de anafilaxia ocorreu em 41 (34,16%) pacientes. A adrenalina (45%) e o anti-histamínico (63,3%) foram os medicamentos mais utilizados. Observa-se também que 6 (7%) pacientes com diagnóstico de anafilaxia não receberam nenhum tratamento. Conclusão: Anafilaxia no primeiro ano de idade apresenta quadro clínico semelhante aos pacientes mais velhos, mas ainda há elevada taxa de recorrência de episódios e subtratamento. Mais estratégias de educação precisam ser desenvolvidas.

Objective: To describe the early manifestations of anaphylaxis in infants with cow's milk protein allergy (CMPA) and the therapeutic approach. Method: In this cross-sectional observational study, we retrospectively reviewed the medical records of patients with CMPA treated at the Institute for Children and Adolescents of Hospital das Clínicas, University of São Paulo Medical School, from 1990 to 2015. Patients who developed allergic symptoms during the first year of life and had a diagnosis of anaphylaxis were compared with allergic patients without anaphylaxis triggered by cow's milk. Patients were characterized according to epidemiological features, type of symptoms, and treatment received. Data were analyzed using GraphPad software. Associations between categories were assessed by Fisher's exact test, and groups were compared by the Mann-Whitney test. Results with p<0.05 were considered statistically significant. Results: Of 120 infants evaluated (68 male: 52 female), 85 (70.83%) met the World Allergy Organization criteria for anaphylaxis. Most infants had cutaneous manifestations of immunoglobulin E (IgE)-mediated allergy (n=102, 85%). In those with a diagnosis of anaphylaxis, the main manifestations were urticaria (n=39, 45.8%), vomiting (n=36, 42.3%), and dyspnea (n=19, 22.3%). Anaphylaxis recurred in 41 patients (34.16%). Epinephrine (45%) and antihistamines (63.3%) were the most used drugs. Six patients (7%) with a diagnosis of anaphylaxis received no treatment. Conclusion: Anaphylaxis during the first year of life showed clinical features similar to those of older pediatric patients, but the rates of episode recurrence and undertreatment are still high. More education strategies need to be developed.

Current Progress and Future Perspectives on the Use of Bacillus clausii

Bacillus clausii is a probiotic that benefits human health. Its key characteristics include the ability to form spores; the resulting tolerance to heat, acid, and salt ensures safe passage through the human gastrointestinal tract with no loss of cells. Although B. clausii has been widely used for many decades, the beneficial properties of other probiotics, such as Lactobacillus spp. and Bifidobacterium spp., are better disseminated in the literature. In this review, we summarize the physiological, antimicrobial, and immunomodulatory properties of probiotic B. clausii strains. We also describe findings from studies that have investigated B. clausii probiotics from the perspective of quality and safety. We highlight innovative properties based on biochemical investigations of non-probiotic strains of B. clausii, revealing that B. clausii may have further health benefits in other therapeutic areas.

Idiopathic musculoskeletal pain, musculoskeletal pain syndromes, and use of electronic devices in adolescents with asthma

Abstract Objective: To evaluate idiopathic musculoskeletal pain, musculoskeletal pain syndromes, and use of electronic devices in adolescents with asthma and healthy controls. Methods: Cross-sectional study was conducted on 150 asthmatic adolescents and 300 controls. Adolescents completed a self-administered questionnaire regarding painful symptoms, use of electronic devices, and physical activity. Seven musculoskeletal pain syndromes were evaluated, and Asthma Control Test (ACT) was assessed. Results: Musculoskeletal pain (42% vs. 61%, p = 0.0002) and musculoskeletal pain syndromes (2.7% vs. 15.7%, p = 0.0006) were significantly lower in asthmatic adolescents than in controls. The frequency of pain in the hands and wrists was reduced in asthmatic than in controls (12.6% vs. 31.1%, p = 0.004), in addition to cell phone use (80% vs. 93%, p < 0.0001), simultaneous use of at least two electronic media (47% vs. 91%, p < 0.0001), myofascial syndrome (0% vs. 7.1%, p = 0.043), and tendinitis (0% vs. 9.2%, p = 0.008). Logistic regression analysis, including asthma with musculoskeletal pain as the dependent variable, and female sex, ACT > 20, simultaneous use of at least two electronic devices, cell phone use, and weekends and weekdays of cell phone use, as independent variables, showed that female sex (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.929-6.316; p = 0.0009) and ACT ≥ 20 (OR, 0.194; 95% CI, 0.039-0.967; p = 0.045) were associated with asthma and musculoskeletal pain (Nagelkerke R2 = 0.206). Conclusion: Musculoskeletal pain and musculoskeletal pain syndromes were lower in adolescents with asthma. Female sex was associated with musculoskeletal pain in asthmatic, whereas patients with asthma symptoms and well-controlled disease reported a lower prevalence of musculoskeletal pain.

Introdução dos alimentos no primeiro ano de vida e prevenção da alergia alimentar: quais as evidências? / Introduction of food in the first year of life and food allergy prevention: what is the evidence?

Objetivo: A incidência das doenças alérgicas cresceu nas últimas décadas. Na tentativa de conter o aumento da alergia alimentar (AA) ao longo dos anos, estratégias de prevenção vêm sendo implementadas. Para promover um melhor entendimento dos dilemas que permeiam a introdução alimentar no primeiro ano de vida, esse artigo trata de uma revisão bibliográfica narrativa sobre a introdução dos alimentos complementares no primeiro ano de vida e possíveis associações com a prevenção primária da alergia alimentar. Fonte dos dados: Publicações relevantes foram pesquisadas nas bases de dados Cochrane Library, MEDLINE, PubMed, Guidelines International Network, National Guidelines Clearinghouse e revisadas recomendações do guia e do consenso nacional de alergia alimentar. Resultados: Estudos observacionais diversos e ensaios clínicos randomizados estão disponíveis, bem como recomendações publicadas por organizações científicas; no entanto, de qualidade variável. Foram consideradas as recomendações de diretrizes de prática clínica classificadas como de alta qualidade e publicações recentes ainda não categorizadas de forma sistemática em sua qualidade, mas internacionalmente reconhecidas como relevantes para a atenção primária. Conclusão: Até o momento, não há evidências consistentes de que a introdução precoce, antes dos 6 meses, dos alimentos alergênicos, contribua para a prevenção de alergia a alimentos na população geral.

Objective: The incidence of allergic diseases has increased in recent decades. In an attempt to contain the increase in food allergy (AA) over the years, prevention strategies have been implemented. To promote a better understanding of the dilemmas that permeate the introduction of food in the first year of life, this article deals with a narrative literature review on the introduction of complementary foods in the first year of life and possible associations with the primary prevention of food allergy. Data source: Relevant publications were searched in the Cochrane Library, MEDLINE, PubMed, Guidelines International Network, National Guidelines Clearinghouse, and revised recommendations from the national food allergy guide and consensus. Results: Several observational studies and randomized controlled trials are available, as well as recommendations. published by scientific organizations; however, of variable quality. Recommendations from clinical practice guidelines classified as high quality and recent publications not yet systematically categorized in their quality, but internationally recognized as relevant to primary care, were considered. Conclusion: To date, there is no consistent evidence that the early introduction, before 6 months, of allergenic foods contributes to the prevention of food allergy in the general population.

Idiopathic musculoskeletal pain, musculoskeletal pain syndromes, and use of electronic devices in adolescents with asthma.

OBJECTIVE: To evaluate idiopathic musculoskeletal pain, musculoskeletal pain syndromes, and use of electronic devices in adolescents with asthma and healthy controls. METHODS: Cross-sectional study was conducted on 150 asthmatic adolescents and 300 controls. Adolescents completed a self-administered questionnaire regarding painful symptoms, use of electronic devices, and physical activity. Seven musculoskeletal pain syndromes were evaluated, and Asthma Control Test (ACT) was assessed. RESULTS: Musculoskeletal pain (42% vs. 61%, p = 0.0002) and musculoskeletal pain syndromes (2.7% vs. 15.7%, p = 0.0006) were significantly lower in asthmatic adolescents than in controls. The frequency of pain in the hands and wrists was reduced in asthmatic than in controls (12.6% vs. 31.1%, p = 0.004), in addition to cell phone use (80% vs. 93%, p < 0.0001), simultaneous use of at least two electronic media (47% vs. 91%, p < 0.0001), myofascial syndrome (0% vs. 7.1%, p = 0.043), and tendinitis (0% vs. 9.2%, p = 0.008). Logistic regression analysis, including asthma with musculoskeletal pain as the dependent variable, and female sex, ACT > 20, simultaneous use of at least two electronic devices, cell phone use, and weekends and weekdays of cell phone use, as independent variables, showed that female sex (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.929-6.316; p = 0.0009) and ACT ≥ 20 (OR, 0.194; 95% CI, 0.039-0.967; p = 0.045) were associated with asthma and musculoskeletal pain (Nagelkerke R2 = 0.206). CONCLUSIONS: Musculoskeletal pain and musculoskeletal pain syndromes were lower in adolescents with asthma. Female sex was associated with musculoskeletal pain in asthmatic, whereas patients with asthma symptoms and well-controlled disease reported a lower prevalence of musculoskeletal pain.

Microbiological profile in chronic granulomatous disease patients in a single Brazilian primary immunodeficiencies center

Background: Chronic granulomatous disease (CGD) is a rare primary immunodeficiency. Infections of the lungs, skin, lymph nodes, and liver are the hallmark of CGD with frequent initial manifestations of the disease. The aim of the present study was to describe the sites of infections and their causative agents in 38 CGD pediatric patients. Methods: This was a retrospective single-center cohort study comprising CGD patients, and followed for over last 40 years at the Allergy and Immunology Unit of a tertiary hospital in São Paulo, Brazil. Sites of infections and their causative agents were described. Results: A total of 38 patients were included (36 males and 2 females). Median age at the onset of symptoms was 45 days (7 days–7 years) and that at the time of diagnosis was 23 months (1 month–12 years); 31.6% of the parents reported death of relatives during childhood and 21% (8 cases) had another male family member with CDG. The most common infections were pneumonia (81.6%), skin infections (50.0%), adenitis (42.1%), and liver abscess (23.7%). In all, 188 cultures were positive (85.6% for bacteria and 14.4% for fungi). The most prevalent bacterial agents were Staphylococcus sp. (12.4%), Staphylococcus aureus (11.2%), and Klebsiella pneumoniae (9.3%). Aspergillus sp. and Candida sp. were 56% and 22.2% of the isolated fungi, respectively. Mycobacterium tuberculosis was isolated in 5.6% and Mycobacterium bovis in 0.9% (only in 1 patient) of cultures. Conclusion: Staphylococcus sp., Staphylococcus aureus, and Aspergillus sp. were the most frequent agents in this cohort. M. tuberculosis should be considered in endemic areas. Detection of infectious agents drives to find adequate treatment and benefits the evolution of patients with CGD (AU)

Efectos del juguete terapéutico instructivo en la terapia intravenosa en niños hospitalizados / Effects of the Instructive Therapeutic Toy on Intravenous Therapy for Hospitalized Children

Introducción: El juguete terapéutico instructivo puede revelar las necesidades implícitas al paciente y ayudarle a comprender las metodologías, diagnósticos y terapias a las que será sometido, lo que promueve su tranquilidad, seguridad y acuerdo con el tratamiento, además de proporcionar una mejor interacción con los profesionales de la salud. Objetivo: Analizar los efectos del uso del juguete terapéutico instructivo en la preparación del niño hospitalizado para realizar la terapia intravenosa. Métodos: Estudio cuasi-experimental de enfoque cuantitativo, realizado en un hospital pediátrico público de la ciudad de Juazeiro do Norte- Ceará, Brasil. La población de estudio fue compuesta por 31 niños en edad preescolar y escolar. La recolección de datos se realizó de julio a septiembre de 2019, a través de la observación, y el análisis se realizó a través del programa Statistical Package for the Social Sciences, por medio de la Prueba t y McNemar. Resultados: Hubo una reducción estadísticamente significativa de todas las variables que indican una menor aceptación del niño a la terapia intravenosa, con la excepción de la variable colabora pasivamente. Si bien hubo un aumento estadísticamente significativo en algunas variables que indican una mayor aceptación del niño a la terapia intravenosa. Conclusión: El juguete terapéutico instructivo se establece como una herramienta tecnológica fundamental para la promoción de la responsabilidad, la autonomía y la corresponsabilidad del cuidado de la salud, valoración del sujeto/usuario como un ser humano singular, y la deconstrucción de prácticas de salud deshumanizadas, especialmente en enfermería pediátrica(AU)

Introduction: The instructive therapeutic toy can reveal the needs implicit to the patient and help them understand the methodologies, diagnoses and therapies to which they will be subjected, which promotes his peace of mind, safety and agreement with treatment, in addition to providing better interaction with healthcare professionals. Objective: To analyze the effects of using the instructive therapeutic toy in the preparation of the hospitalized child prior to performing intravenous therapy. Methods: Quasiexperimental study with a quantitative approach, carried out in a public pediatric hospital in Juazeiro do Norte City, Ceará, Brazil. The study population consisted of 31 preschool and school-age children. Data collection was carried out from July to September 2019, through observation, and the analysis was carried out by means of the Statistical Package for the Social Sciences program, using t-test and McNemar's test. Results: There was a statistically significant reduction in all the variables that indicate the child´s lower acceptance of intravenous therapy, with the exception of the variable they collaborate passively. However, there was a statistically significant increase in some variables that indicate the child's greater acceptance of intravenous therapy. Conclusion: The instructive therapeutic toy is established as a fundamental technological tool for promoting responsibility, autonomy and co-responsibility of health care, valuating the subject/user as a singular human being, and the deconstruction of dehumanized health practices, especially in pediatric nursing(AU)

Multidrug-resistant Klebsiella pneumoniae harboring extended spectrum ß-lactamase encoding genes isolated from human septicemias.

Klebsiella pneumoniae is a major pathogen implicated in nosocomial infections. Extended-spectrum ß-lactamase (ESBL)-producing K. pneumoniae isolates are a public health concern. We aim to characterize the type of ß-lactamases and the associated resistance mechanisms in ESBL-producing K. pneumoniae isolates obtained from blood cultures in a Portuguese hospital, as well as to determine the circulating clones. Twenty-two cefotaxime/ceftazidime-resistant (CTX/CAZR) K. pneumoniae isolates were included in the study. Identification was performed by MALDI-TOF MS and the antimicrobial susceptibility testing by disk-diffusion. The screening test for ESBL-production was performed and ESBL-producer isolates were further characterized. The presence of different beta-lactamase genes (blaCTX-M, blaSHV, blaTEM, blaKPC, blaNDM, blaVIM, blaOXA-48, blaCMY-2, blaDHA-1, blaFOX, blaMOX, and blaACC) was analyzed by PCR/sequencing in ESBL-producer isolates, as well as the presence of other resistance genes (aac(6')-Ib-cr, tetA/B, dfrA, qnrA/B/S, sul1/2/3) or integron-related genes (int1/2/3). Multilocus-sequence-typing (MLST) was performed for selected isolates. ESBL activity was detected in 12 of the 22 CTX/CAZR K. pneumoniae isolates and 11 of them carried the blaCTX-M-15 gene (together with blaTEM), and the remaining isolate carried the blaSHV-106 gene. All the blaCTX-M-15 harboring isolates also contained a blaSHV gene (blaSHV-1, blaSHV-11 or blaSHV-27 variants). Both blaSHV-27 and blaSHV-106 genes correspond to ESBL-variants. Two of the CTX-M-15 producing isolates carried a carbapenemase gene (blaKPC2/3 and blaOXA-48) and showed imipenem resistance. The majority of the ESBL-producing isolates carried the int1 gene, as well as sulphonamide-resistance genes (sul2 and/or sul3); the tetA gene was detected in all eight tetracycline-resistant isolates. Three different genetic lineages were found in selected isolates: ST348 (one CTX-M-15/TEM/SHV-27/KPC-2/3-producer isolate), ST11 (two CTX-M-15/TEM/SHV-1- and CTX-M-15-TEM-SHV-11-OXA-48-producer isolates) and ST15 (one SHV-106/TEM-producer isolate). ESBL enzymes of CTX-M-15 or SHV-type are detected among blood K. pneumoniae isolates, in some cases in association with carbapenemases of KPC or OXA-48 type.