[Primary biliary cirrhosis-autoimmune hepatitis overlap syndrome in a patient with chronic hepatitis B infection]. / Evolución de cirrosis biliar primaria a síndrome de solapamiento con hepatitis autoinmune en paciente con hepatitis B crónica.

We describe the case of a female patient with a previous diagnosis of primary biliary cirrhosis (PBC) and chronic hepatitis B in inactive phase who developed increased transaminase levels with no evidence of hepatitis B virus reactivation while receiving ursodeoxycholic acid treatment. A liver biopsy showed changes compatible with overlapping autoimmune hepatitis (AIH). Budesonide treatment achieved normalization of transaminase levels. We provide a review of PBC and AIH overlap syndrome and discuss the particular features of this case that led us to this diagnosis, as well as the treatment provided.

A Screening Tool for Self-Evaluation of Risk for Age-Related Macular Degeneration: Validation in a Spanish Population.

Purpose: The objectives of this study were the creation and validation of a screening tool for age-related macular degeneration (AMD) for routine assessment by primary care physicians, ophthalmologists, other healthcare professionals, and the general population. Methods: A simple, self-administered questionnaire (Simplified Théa AMD Risk-Assessment Scale [STARS] version 4.0) which included well-established risk factors for AMD, such as family history, smoking, and dietary factors, was administered to patients during ophthalmology visits. A fundus examination was performed to determine presence of large soft drusen, pigmentary abnormalities, or late AMD. Based on data from the questionnaire and the clinical examination, predictive models were developed to estimate probability of the Age-Related Eye Disease Study (AREDS) score (categorized as low risk/high risk). The models were evaluated by area under the receiving operating characteristic curve analysis. Results: A total of 3854 subjects completed the questionnaire and underwent a fundus examination. Early/intermediate and late AMD were detected in 15.9% and 23.8% of the patients, respectively. A predictive model was developed with training, validation, and test datasets. The model in the test set had an area under the curve of 0.745 (95% confidence interval [CI] = 0.705-0.784), a positive predictive value of 0.500 (95% CI = 0.449-0.557), and a negative predictive value of 0.810 (95% CI = 0.770-0.844). Conclusions: The STARS questionnaire version 4.0 and the model identify patients at high risk of developing late AMD. Translational Relevance: The screening instrument described could be useful to evaluate the risk of late AMD in patients >55 years without having an eye examination, which could lead to more timely referrals and encourage lifestyle changes.

Frequency of Positive ANCA Test in a Population With Clinical Symptoms Suggestive of Autoimmune Disease and the Interference of ANA in its Interpretation. / Frecuencia de ANCA positivos en una población con síntomas clínicos sugestivos de enfermedad autoinmune y la interferencia de ANA en su interpretación.

BACKGROUND: Antibodies against neutrophil cytoplasm (ANCA) are associated with vasculitis. There are different methods to determine their presence. The interference of antinuclear antibodies (ANA) in the differentiation between P-ANCA and C-ANCA patterns has been described. OBJECTIVE: To determine the frequency of ANCA in a population with manifestations of autoimmune disease, and evaluate the interference of ANA in its interpretation. MATERIALS AND METHODS: Retrospective, descriptive nonexperimental cross-sectional study, including 3,330 data. The presumptive diagnosis was autoimmune disease and a test for ANCA was requested. The ANCA and ANA determinations were made by indirect immunofluorescence, L-ANCA® and CytoBead® ANCA. Anti-proteinase 3 and anti-myeloperoxidase were detected by ELISA and CytoBead® ANCA. RESULTS: ANCAs were positive in 10.21% and 12.64% of those positive for ANCA were positive for ANA. The inter-rater agreement statistic (Kappa) for anti-PR3 between CytoBead ANCA and ELISA was 100% (K=1.00; P<.05) and the agreement between anti- myeloperoxidase by ELISA and CytoBead® ANCA was high (K=0.94; P<.05). 30% of those with ANCAs had a diagnosis of a type of vasculitis; 20% of them had an autoimmune disease. CONCLUSIONS: The results suggest an overestimated request for ANCAs as a diagnostic aid in primary care which was not addressed. For an adequate evaluation of ANCAs, the indirect immunofluorescence technique should be implemented for the control and confirmation with the determination of specific antigens for anti- proteinase 3 and anti- myeloperoxidase in any of the confirmatory assays. The high concordance shown by ANCA CytoBeads makes us consider the use of this alternative for the determination of ANCAs and the confirmation. Given the interference of ANAs, the ANA test by IFI in the presence of positive P-ANCA results is recommended in order to minimize "false positives".

Cystic lesion of pectoralis minor muscle: learning from mistakes.

Hydatidosis is a frequent infestation in large endemic areas, caused by helminths. Primary localization within the muscle or bone tissues is rare. We report the case of a 52-year-old woman with a cystic lesion located in the right pectoralis minor muscle, who was initially diagnosed with cystic lymphangioma by imaging examination. She was submitted for surgical treatment; in block resection of the tumor along with the involved muscle was performed. The histopathological diagnosis was of hydatid cyst. The contribution of the ancillary lab tests is analyzed for a precise preoperative diagnostic approach. This case well illustrates that the most likely is not always what it appears to be. Facing of a cystic lesion in the lungs, liver or muscle, clinicians should always think on hydatid disease, particularly in endemic areas.

Immunogenicity, safety, and interchangeability of two inactivated hepatitis A vaccines in Chilean children.

OBJECTIVES: To compare the immunogenicity, safety, and interchangeability of two pediatric hepatitis A vaccines, Avaxim 80U-Pediatric and Havrix 720, in Chilean children. METHODS: In this randomized trial, 332 hepatitis A virus (HAV) seronegative children from 1 to 15 years of age received two doses of Avaxim, two doses of Havrix, or Havrix followed by Avaxim, 6 months apart. Anti-HAV antibody titers were measured before and 14 days after the first dose of vaccine, and before and 28 days after the second dose of vaccine. Immediate reactions were monitored; reactogenicity was evaluated from parental reports. RESULTS: Seroconversion rates after the first vaccination were 99.4% and 100% for Avaxim and Havrix, respectively. Anti-HAV geometric mean concentrations (GMCs) were 138 mIU/ml for Havrix (95% confidence interval (CI): 120; 159) and 311 mIU/ml for Avaxim (95% CI: 274; 353). GMCs increased to 4008 mIU/ml after two doses of Havrix, 8537 mIU/ml following two doses of Avaxim, and 7144 mIU/ml in children who received Havrix with Avaxim as the second dose. Following the first injection, 36% of subjects given Avaxim and 44% given Havrix reported local reactions; 38% of subjects in the Avaxim group and 40% in the Havrix group reported systemic reactions related to vaccination. Solicited reactions were less frequent after the second dose of Avaxim or Havrix, occurring in 27% to 37% of subjects. CONCLUSIONS: No significant difference in seroconversion rates was seen 14 days after a single dose of vaccine. A two-dose schedule with either vaccine or with Havrix/Avaxim provided a strong booster response. Both vaccines were well tolerated and can be recommended for routine vaccination of Chilean children. Avaxim 80 may be used to complete a vaccine schedule begun with Havrix 720.

Validation of four devices: Omron M6 Comfort, Omron HEM-7420, Withings BP-800, and Polygreen KP-7670 for home blood pressure measurement according to the European Society of Hypertension International Protocol.

BACKGROUND: Four oscillometric devices, including the Omron M6 Comfort, Omron HEM-7420, Withings BP-800, and Polygreen KP-7670, designed for self-blood pressure measurement (SBPM) were evaluated according to the European Society of Hypertension (ESH) International Protocol Revision 2010 in four separate studies. METHODS: The four devices measure brachial blood pressure (BP) using the oscillometric method. The Withings BP-800 has to be connected to an Apple® iOS device such as an iPhone®, iPad®, or iPod®. The ESH International Protocol Revision 2010 includes a total number of 33 subjects. The difference between observer and device BP values was calculated for each measure. Ninety-nine pairs of BP differences were classified into three categories (≤5 mmHg, ≤10 mmHg, ≤15 mmHg). The protocol procedures were followed precisely in each of the four studies. RESULTS: All four tested devices passed the validation process. The mean differences between the device and mercury readings were: -1.8±5.1 mmHg and -0.4±2.8 mmHg for systolic and diastolic BP, respectively, using the Omron M6 Comfort device; 2.5±4.6 mmHg and -1.2±4.3 mmHg for the Omron HEM-7420 device; -0.2±5.0 mmHg and 0.4±4.2 mmHg for the Withings BP-800 device; and 3.0±5.3 mmHg and 0.3±5.2 mmHg for the Polygreen KP-7670 device. CONCLUSION: Omron M6 Comfort, Omron HEM-7420, Withings BP-800, and Polygreen KP-7670 readings differing by less than 5 mmHg, 10 mmHg, and 15 mmHg fulfill the ESH International Protocol Revision 2010 requirements, and therefore are suitable for use by patients for SBPM, if used correctly.

Cystic lesion of pectoralis minor muscle: learning from mistakes

Hydatidosis is a frequent infestation in large endemic areas, caused by helminths. Primary localization within the muscle or bone tissues is rare. We report the case of a 52-year-old woman with a cystic lesion located in the right pectoralis minor muscle, who was initially diagnosed with cystic lymphangioma by imaging examination. She was submitted for surgical treatment; in block resection of the tumor along with the involved muscle was performed. The histopathological diagnosis was of hydatid cyst. The contribution of the ancillary lab tests is analyzed for a precise preoperative diagnostic approach. This case well illustrates that the most likely is not always what it appears to be. Facing of a cystic lesion in the lungs, liver or muscle, clinicians should always think on hydatid disease, particularly in endemic areas.

Anaplastic large T-cell lymphoma of the external ear in childhood.

Anaplastic large T-cell lymphoma is a very rare disease in childhood. The most common locations are lymph nodes and skin, while the external ear location is uncommon. We present the case of a 6-year-old child with an earlobe tumour. Surgical treatment was performed and the anatomopathological results showed anaplastic large cell lymphoma. Radiological tests were negative and there was no systemic involvement.

Immunogenicity and tolerability of a paediatric presentation of a virosomal hepatitis A vaccine in Chilean children aged 1-16 years.

We assessed the immunogenicity of the paediatric dose of Epaxal(®) (0.25 mL) and the degrees of seroprotection achieved with the standard dose (0.5 mL) of Epaxal(®) or a dose of Havrix(®) Junior, in children in an open, randomised, controlled, multi-centre, parallel-group study conducted at 2 Chilean study centres. 360 healthy children and adolescents 12 months to <17 years of age not previously vaccinated against hepatitis A were enrolled. Subjects were randomised 2:2:1 to be vaccinated with either Epaxal(®) 0.25 mL [n=146], Epaxal(®) 0.5 mL [n=142] or Havrix(®) Junior [n=72] intramuscularly on Day 1 and after 6 months (26 weeks±14 days). Primary end point was the proportion of subjects seroprotected (anti-HAV antibody concentration ≥10 mIU/mL) in the ATP population at Month 1. All vaccines elicited high seroprotection rates at Month 1: 95.7% with Epaxal(®) 0.25 mL, 99.3% with Epaxal(®) 0.5 mL and 94.0% with Havrix(®) Junior. After the booster vaccination, all subjects demonstrated 100% seroprotection with all vaccines. Antibody concentrations were similarly high in all age groups. The paediatric presentation achieved antibody concentrations similar to those achieved with the 0.5 mL dose across the entire age range, and there were no differences across the range of body weights from 9.0 kg to 82.7 kg. All study vaccines were well tolerated and there were no AEs leading to discontinuation. Thus, the paediatric 0.25 mL dose of Epaxal(®) fulfilled the primary objective of showing non-inferiority to the adult 0.5 mL dose and to Havrix(®) Junior, in terms of seroprotection rates achieved. The results show the paediatric dose of Epaxal(®) to be an attractive option when conducting childhood-vaccination programmes.

Validation of four automatic devices for self-measurement of blood pressure according to the international protocol of the European Society of Hypertension.

BACKGROUND: Four oscillometric devices for self-measurement of blood pressure (SBPM) were evaluated according to the European Society of Hypertension (ESH) international protocol and its 2010 revision in four separate studies. The Omron® M2, Omron M3, and Omron M6 measure blood pressure (BP) at the brachial level, while the Omron R2 measures BP at the wrist level. METHODS: The international protocol requires a total number of 33 subjects in which the validation is performed. The Omron M2 and Omron R2 were validated in 2009 according to the ESH international protocol, while the Omron M3 and Omron M6 were validated in 2010-2011 according to the 2010 ESH international protocol revision. The protocol procedures were followed precisely. RESULTS: All four tested devices passed the validation process. The mean differences between the device and mercury readings were 2.7 ± 5.0 and -1.4 ± 3.2 mmHg for systolic and diastolic BP, respectively, using the Omron M2 device, and 1.7 ± 3.2 and -0.9 ± 2.6 mmHg using the Omron M3, 1.6 ± 2.9 and -0.9 ± 2.5 mmHg using the Omron M6, and -1.1 ± 4.8 and -0.9 ± 4.3 mmHg using the Omron R2. CONCLUSION: Readings from the Omron M2, Omron M3, Omron M6, and Omron R2, differing by less than 5, 10, and 15 mmHg, fulfill the ESH international protocol and its 2010 revision requirements. Therefore, each of these four devices can be used by patients for SBPM.

[Immunogenicity and reactogenicity of a reduced antigen content diphtheria, tetanus and acellular pertussis vaccine dTpa) in 10 to 11 years old children and in adults]. / Inmunogenicidad y reactogenicidad de una vacuna de difteria, tétanos, pertussis acelular de contenido antigénico reducido (dTpa) en niños de 10 a 11 años de edad y en adultos.

BACKGROUND: New vaccination strategies are needed to control the increasing problem of pertussis in teenagers and adults. AIM: To determine the immunogenicity and reactogenicity of a diphtheria-tetanus-acellular pertussis (dTpa) vaccine with reduced antigen content. MATERIAL AND METHODS: A single dose of the dTpa vaccine was administered to 60 children 10 to 11 years old and 60 healthy adults. At the moment of vaccination and one month later, antibody levels were measured against 3 B pertussis antigens: anti-pertussis toxin (PT), anti-pertactin (PRN) and anti-filamentous hemagglutinin (FHA), as well as anti-tetanus and anti-diphtheria antibodies. Local and general symptoms were registered during 14 days following vaccine administration. RESULTS: Antibody response for PT, FHA and PRN was 98.3%, 100% and 100% in adults and 98.2%, 100% and 98.2% in children. Seropositivity for all pertussis antigens was 100% in adults and in children one month after vaccination. Geometric mean titers (GMT) significantly increased in adults and children. The seroprotection level achieved for tetanus and diphtheria antibodies one month after vaccination was 96.7% for adults and 100% for children, respectively. No serious adverse events were reported during the study. Among local symptoms pain was the most frequent (88-90%), but it was mostly mild or moderate. Solicited general symptoms observed for children and adults, respectively, included headache (37% and 53%), fatigue (18% and 35%) gastrointestinal symptoms (18% and 25%) and fever (8% and 3%). Only one vaccinee had fever above 39 degrees C. CONCLUSIONS: The dTpa vaccine showed an adequate safety profile and induced an intense immunological response to all antigens in adults and children aged 10-11.

El brote de influenza AH1N1 en tres colegios de la región metropolitana: impacto de las medidas de control adoptadas / Outbreak of H1N1 influenza in three schools in the metropolitan area: impact of control measures

Se compara el impacto de tres estrategias distintas de medidas no farmacológicas (MNF) en tres colegios de la Región Metropolitana en Chile para controlar el brote de influenza AH1N1: colegio A) con suspensión de clases,colegio B) con suspensión selectiva y colegio C) sin suspensión de clases y sin administración de antivirales. Utilizando cuestionarios e información de los colegios, los datos recolectados indican que la tasa de incidenciaacumulada fue 40,3 por ciento (colegio A), 39,6 por ciento (colegio B) y 42,5 por ciento (colegio C). Al restringir la comparación a los dosúltimos colegios, es decir, aquellos en los que la suspensión de clases fue selectiva o bien no hubo suspensión, larazón de tasas (ajustada) del colegio C vs. B fue 1,09 (p = 0,473). A pesar de no alcanzar significancia estadística,este resultado apoya la hipótesis de que la suspensión selectiva de clases tuvo un impacto en reducir la magnituddel brote infeccioso. Los beneficios de una suspensión selectiva de clases (menor tasa de incidencia acumulada ydensidad de incidencia) tienen asociada, sin embargo, una limitación debido a una mayor inasistencia a clases.

The impact of three different strategies of nonpharmacologic measures (MNF) at three schools in the Metropolitan Region in Chile to control outbreaks of influenza AH1N are compared: school A) suspension of classes, school B) selective suspension, C) no suspension of classes and without administration of antiviral drugs. Data collected through questionnaires and information from schools, indicate that the incidence rate was 40.3 percent (school A), 39.6 percent (school B) and 42.5 percent (school C). Restricting the comparison to the last two schools, ie those in which the suspension of classes was selective or no suspension, the rate ratio (adjusted) of C school vs B was 1.09 (p = 0.473). Although not statistically significant, this result supports the hypothesis that the selective suspension of classes had an impact in reducing the magnitude of the outbreak. The benefits of selectively discontinuing classes (lower cumulative incidence and incidence density) are counterbalanced, however, by the limitation of higher non-attendance to school.