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Resumen Los pacientes infectados por SARS-CoV-2 presentan un curso clínico variable, desde asintomáticos o con síntomas respiratorios leves hasta una evolución grave con gran reacción inflamatoria e inmune. La aparición de un componente monoclonal como manifestación de este estado inflamatorio e inmune está poco descrito. Se presenta el caso de un paciente masculino de 74 años que inicia en 2020 con síndrome anémico, livedo reticularis y acrocianosis, gatillados por frío y aliviados por calor. El laboratorio evidencia anemia hemolítica por anticuerpos fríos y su estudio complementario es compatible con enfermedad por crioaglutininas. Se trata con rituximab sin respuesta, posteriormente recibe rituximab-bendamustina resolviendo síntomas, disminuyendo el título de crioaglutininas, mejorando la anemia y normalizando el perfil bioquímico. En febrero de 2022 presenta neumonía multifocal por SARS COV 2, requiriendo hospitalización por 19 días, con reactivación mínima de su enfermedad de base. En esta etapa se detecta en electroforesis e inmunofijación en suero dos componentes monoclonales IgG kappa e IgG lambda, sumados a su IgM kappa conocido por su enfermedad por crioaglutininas. El seguimiento muestra que dichos componentes persisten detectables por 4 meses, pero un control posterior evidencia la persistencia de sólo IgM kappa en inmunofijación, con desaparición de los nuevos componentes. La electroforesis es también negativa. Usualmente las infecciones virales generan hipergammaglobulinemias policlonales, en contraste mostramos como en este caso la infección por SARS-CoV-2 se asocia a gammapatía biclonal transitoria, la que planteamos como manifestación de la intensa reacción inmune generada por el virus.

Abstract Patients infected by SARS-CoV-2 present a variable clinical course, from asymptomatic or mild respiratory symptoms to a severe evolution with a major inflammatory and immune reaction. The appearance of a monoclonal component as a manifestation of this inflammatory and immune state is poorly described. We present the case of a 74-year-old male patient, who began in 2020 with anemic syndrome, livedo reticularis and acrocyanosis triggered by cold and relieved by heat. The laboratory showed hemolytic anemia due to cold antibodies and its complementary study was compatible with cold agglutinin disease. He was treated with rituximab without response, subsequently receiving rituximab-bendamustine, resolving symptoms, decreasing cold agglutinin titer, improving anemia and normalizing biochemical profile. In February 2022, he presented multifocal pneumonia due to SARS-CoV-2, requiring hospitalization for 19 days, with minimal reactivation of his underlying disease. At this stage, two monoclonal components IgG kappa and IgG lambda are detected in electrophoresis and immunofixation in serum, added to their IgM kappa known for cold agglutinin disease. The follow-up shows that these components remain detectable for 4 months, a subsequent control shows the persistence of only IgM kappa in immunofixation, with the disappearance of the new components. The electrophoresis is also negative. Usually viral infections generate polyclonal hypergammaglobulinemias, in contrast we show how in this case the SARS-CoV-2 infection is associated with transient biclonal gammopathy, which we propose as a manifestation of the intense immune reaction generated by the virus.

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Complementary feeding (CF) is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute, and is a process that is more than simply a guide as to what and how to introduce foods. The information provided by healthcare professionals must be up-to-date and evidence-based. Most of the recommendations that appear in the different international guidelines and position papers are widely applicable, but some must be regionalized or adapted to fit the conditions and reality of each geographic zone. The Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) summoned a group of experts from each of the society's member countries, to develop a consensus on CF, incorporating, whenever possible, local information adapted to the reality of the region. The aim of the present document is to show the results of that endeavor. Utilizing the Delphi method, a total of 34 statements on relevant aspects of CF were evaluated, discussed, and voted upon.

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PURPOSE: To present the first results of intraoperative irradiation (IORT) in breast cancer with a low-energy photon system used as partial breast irradiation (PBI) or as an anticipated boost before whole breast hypo-fractionated irradiation (IORT + WBI), concerning tolerance, side effects, quality of life, and patient-reported outcomes. MATERIALS AND METHODS: Eighty patients treated with an Intrabeam® system of 50 kV X-rays received a 20 Gy dose intraoperatively were included. Moderate daily hypofractionation of 2.7 Gy in 15 fractions up to 40.5 Gy was administered if high-risk factors were present. Acute post-operative toxicity, surgery complications, chronic toxicity, patient-reported cosmesis and Breast-Q questionnaire were performed at follow-up visits. RESULTS: Thirty-one patients were treated as PBI and the remaining 49 as IORT + WBI. Only the IORT + WBI group presented acute toxicity, mainly mild acute dermatitis (11 patients) and one subacute mastitis. A total of 20 patients presented fibrosis (18 patients grade I, 2 patients grade II), 15 (30.5%) patients in the IORT + WBI group and 3 (9.6%) patients in the group of PBI. The cosmesis evaluation in 73 patients resulted poor, fair, good or excellent in 2, 7, 38 and 26 patients, respectively. In PBI group Breast-Q scored higher, especially in terms of their psychosocial well-being (78 vs 65) and satisfaction with radiation-induced toxicity (77 vs 72, respectively) compared to IORT + WBI group. CONCLUSION: IORT is a well-tolerated procedure with low toxicity, good cosmesis and favorable patient-reported outcomes mainly when administered as PBI.

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PURPOSE: Radiation-induced toxicity (RIT) is usually assessed by inspection and palpation. Due to their subjective and unquantitative nature, objective methods are required. This study aimed to determine whether a quantitative tool is able to assess RIT and establish an underlying BED-response relationship in breast cancer. METHODS: Patients following seven different breast radiation protocols were recruited to this study for RIT assessment with qualitative and quantitative examination. The biologically equivalent dose (BED) was used to directly compare different radiation regimens. RIT was subjectively evaluated by physicians using the Radiation Therapy Oncology Group (RTOG) late toxicity scores. Simultaneously an objective multiprobe device was also used to quantitatively assess late RIT in terms of erythema, hyperpigmentation, elasticity and skin hydration. RESULTS: In 194 patients, in terms of the objective measurements, treated breasts showed higher erythema and hyperpigmentation and lower elasticity and hydration than untreated breasts (p < 0.001, p < 0.001, p < 0.001, p = 0.019, respectively). As the BED increased, Δerythema and Δpigmentation gradually increased as well (p = 0.006 and p = 0.002, respectively). Regarding the clinical assessment, the increase in BED resulted in a higher RTOG toxicity grade (p < 0.001). Quantitative assessments were consistent with RTOG scores. As the RTOG toxicity grade increased, the erythema and pigmentation values increased, and the elasticity index decreased (p < 0.001, p = 0.016, p = 0.005, respectively). CONCLUSIONS: The multiprobe device can be a sensitive and simple tool for research purpose and quantitatively assessing RIT in patients undergoing radiotherapy for breast cancer. Physician-assessed toxicity scores and objective measurements revealed that the BED was positively associated with the severity of RIT.

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PURPOSE: To report long-term results of a randomized trial comparing accelerated partial breast irradiation (APBI) to whole-breast irradiation (WBI) in terms of efficacy, toxicity, and cosmesis. METHODS AND MATERIALS: WBI group was treated with 3D conformal external irradiation, 2 Gy daily/fraction, 5 fractions/week, to a total dose of 50 Gy. APBI group was treated with 3D conformal external irradiation 3.75 Gy/fraction, twice a day, 5 fractions/week, to a total dose of 37.5 Gy in the APBI group. Patients were followed up every 6 months up to 5 years and yearly thereafter. During follow-up visits, the clinician evaluated chronic toxicity and scored cosmetic results with a four-scale system. RESULTS: After a median follow-up of 10.3 years, 43 patients in each group (84%) are alive without disease. One patient died after disease progression in the APBI arm, and there was no death in the WBI arm. The rest of the patients died from another disease different than breast cancer, similarly between groups. There was greater fibrosis in the APBI group (9 patients grade 1 and one grade 2) compared to WBI (3 patients grade 1 and one grade 2); p = 0.18. Regarding cosmesis, in APBI group, 19 and 21 (43.2 and 47%) patients had excellent or good results, similar to the WBI group with 18 patients (40.9%) in each cosmesis outcome. The WBI group did not have any patient with poor cosmesis but the APBI had 3 (6.8%; p = 0.24). CONCLUSION: After a follow-up of 10 years, there were no differences in efficacy between the 2 treatment arms. Despite slight greater toxicity in the APBI group, the cosmesis was similar and satisfactory in both groups.

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INTRODUCTION: Osteoarthritis in Mexico is one of the ten most frequent causes of disability. Early diagnosis and detection of risk factors are determinant for treatment. The institutional organization establishes therapeutic guidelines according to each level of care, but effective management is not achieved. MATERIAL AND METHODS: A prospective, pilot, interventional, clinical study was conducted, which included patients diagnosed with different degrees of knee osteoarthritis in the first, second and third level of care, with an integrative model that includes a group of professionals for the intervention of nutritional, physiotherapeutic, social and psychological evaluation from the first level. RESULTS: The intervention of a multidisciplinary care group allows a correct evaluation and assignment of the level of care, optimizing human and material resources. The participation of different disciplines in nutrition, psychology, social work, physiotherapy and rehabilitation modifies the global lifestyle by involving the patients themselves in their treatment. The intervention group had improvements in the visual analog pain scale, mobility arcs, low body mass index and improvement in the psychological aspect. CONCLUSIONS: The proposed model of care demonstrates that implementation in the institution and in each clinical care unit should be considered to improve outcomes.

INTRODUCCIÓN: La osteoartritis en México es una de las 10 causas más frecuentes de discapacidad. El diagnóstico temprano y la detección de factores de riesgo son determinantes para el tratamiento. La organización institucional establece las pautas terapéuticas de acuerdo con cada nivel de atención, pero no se logra un manejo efectivo. MATERIAL Y MÉTODOS: Se realizó un estudio prospectivo, piloto, de intervención, clínico conformado por pacientes diagnosticados con diferentes grados de osteoartritis de rodilla en el primer, segundo y tercer nivel de atención, con un modelo integrador que incluyó un grupo de profesionales para la intervención de la evaluación nutricional, fisioterapéutica, social y sicológica desde el primer nivel. RESULTADOS: La intervención de un grupo de atención multidisciplinaria permite una correcta evaluación y asignación del nivel de atención optimizando los recursos humanos y materiales. La participación de diferentes disciplinas en nutrición, sicología, trabajo social, fisioterapia y rehabilitación modifica el estilo de vida global al involucrar a los propios pacientes en su tratamiento. El grupo de intervención tuvo mejoras en la escala de dolor análogo visual, arcos de movilidad, bajo índice de masa corporal y mejoría en el aspecto sicológico. CONCLUSIONES: El modelo de atención propuesto demuestra que la implementación en la institución y en cada unidad clínica de atención debe considerarse para mejorar los resultados.

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PURPOSE: Weekly irradiation in breast cancer in elderly patients is a treatment option, whose tolerance may be influenced by the fractionation used. The objective of this study is to compare the tolerance and long-term side effects of two different fractionations. MATERIALS AND METHODS: 47 elderly patients were recruited after conservative or radical treatment that also received irradiation with a dose per fraction of 6.25 Gy or 5 Gy for one session per week, 6 sessions in total. The long-term tolerance results are compared by assessing toxicity using CTCAE version 5.0 scales for dermatitis, telangectasia, fibrosis and pain of the irradiated breast. In addition, objective parameters of skin status (erythema, hyperpigmentation, elasticity and hydration) by a multi-probe MultiSkin Test-Center system were obtained and compared between groups. RESULTS: After an average follow-up of 5 years, all patients were free of disease and with complete local control. A total of 20 patients with 6.25 Gy fractionation and 27 patients with 5 Gy fractionation have been included. Patients treated with lower fractionation had a lower incidence of dermatitis, telangectasia, fibrosis, or local pain. The decrease in elasticity measured by the multi-probe system was smaller with the fractionation of 5 Gy. No differences were observed in the other objective parameters. CONCLUSION: Weekly irradiation with 5 Gy fractionation is better tolerated than with higher fractionation.

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