Calciphylaxis is an infrequent disease that almost exclusively affects patients with chronic kidney disease, although cases have been observed in patients without renal function impairment. The diagnosis is mainly made by clinical manifestations and subsequently confirmed by radiological and histological study. The optimal treatment is not known, although there is a consensus that a multifactorial approach is required. A 68-year-old woman on hemodialysis for 2 years, who presented a painful nodular lesion in the left thigh, a skin biopsy was performed resulting in a diagnosis of calciphylaxis.  Treatment was started with intravenous sodium thiosulfate. Pamidronate is added intravenously, three months later, due to an unfavorable evolution. After 6 months of treatment, improvement in nodular lesions and healing of the ulcerated lesion was observed to be generally well tolerated treatment. The combined treatment of sodium thiosulfate, pamidronate and calcitomimetics has been effectiveand safe for the treatment of calciphylaxis, inducing complete remission. Calciphylaxis or calcific uremic arteriolopathy (CUA) is a rare and severe disorder characterized by systemic medial calcification of arteries and arterioles that leads to skin and soft tissues ischemic necrosis with the development of ulcers It occurs primarily in patients who have end-stage renal disease (ESRD) and hemodialysis treatment. The incidence has been reported to be up to 4% among these patients. However, it may also occur in non-ESRD patients ,The exact pathogenesis of CUA is unclear so it is likely multifactorial. Several risk factors are known: hyperparathyroidism, hyperphosphatemia, calciums salts, high doses of vitamin D analogs. It has also been related to obesity, female sex, diabetes, hypoalbuminemia and hypercoagulable states due to protein C and S deficiency or coumarin type anticoagulant therapy There is no agreement on optimal treatment. Therapeutic must be multifactorial approach and aimed at controlling plasma calcium and phosphate concentrations: ending or control of risk factors associated, avoidance of local tissue trauma and careful local ulcers care and pain control of those wound associated Our objective is to report an infrequent case of CUA treated with sodium thiosulfate and pamidronate and showed good results.A 68-year-old woman, no known drug allergies; with ESRD stage 5D secondary to chronic glomerulonephritis on hemodialysis in later 3 years. She had medical history of hypertension; a history of morbid obesity (body mass index [BMI]= 41.5), she underwent gastric bypass 13 years ago (current weight 56 Kg), type 2 diabetes mellitus, primary hypothyroidism, secondary hyperparathyroidism and mitral insufficiency. She was an ex-smoker, stopping smoking 18 years ago, without any known toxic habits. She suffered a pulmonary thromboembolism 22 years ago, which was treated with acenocoumarol. In addition, the patient receives treatment with sevelamer, paricalcitol, cinacalcet, epoetin alfa, levothyroxine, folic acid, antidiabetic treatment and omeprazole.In May 2017, a painful nodule on her left posterior thigh was observed, which was diagnosed as a lipoma by ultrasound. Two months later, the patient reported a significant increase in pain and the nodule size and between 3 and 4 new nodules appeared on her left front and back thigh . These nDermatology Service was interconsulted, and a skin biopsy was performed obtaining anatomopathological findings compatible with calciphylaxis .On a chest and abdominal radiography showed vascular calcifications of arteries.In view of calciphylaxis diagnosis and by ruling out other disorders that may mimic CUA, the following measures were taken:Acenocoumarol therapy was discontinued and instead low molecular weight heparin therapy was started, still maintained today.VDRA  was also discontinued, maintaining the rest of treatment. Metabolic acidosis was corrected, vitamin k plasma levels were determined, and dialysis bath calcium was lowered.The administration of intravenous sodium thiosulfate 12.5 g after each hemodialysis session was started simultaneously as calciphylaxis treatment.After the skin biopsy a deep ulcer without granulation tissue (1.0 to 1.5 cm diameter) was formed, with no infection which resolved after 5 months of cures and usual follow-up satisfactorily.Three months after diagnosis, due to an unfavorable evolution and the increase in plasma calcium levels, a bisphosphonate therapy was started (intravenous pamidronate 30 mg weekly) because of its ability to inhibit vascular calcification and its anti-inflammatory effect.Due to poor digestive tolerance, cinacalcet was replaced by etelcalcetide at an ascending dose of 5 mg intravenously injection after each hemodialysis session due to its lower incidence of gastrointestinal effects.Three weeks later, because of the marked decrease in the serum calcium and phosphorous concentrations, we occasionally added a treatment with paricalcitol 1.0 mcg after hemodialysis, thus controlling the elevated levels of parathyroid hormone (iPTH).Two months after initiating treatment with etelcalcetide, the dose was increased to 10 mg after each hemodialysis session due to lack of control in iPTH levels and one month later treatment with Pamidronate was stopped due to the appearance of severe maintained hypocalcemia. (Ca = 7.5 mg / dL) .Finally, after 6 months of treatment, sodium thiosulfate was suspended due to favorable evolution of the wounds and pain reduction.The patient currently continues on hemodialysis, stable, without painful lesions and with size reduction of the nodules, making it necessary to increase the dosage of etelcalcetide to 15 mg 3 times a week due to poor control and maintenance high levels of iPTH .Written informed consent was obtained from the patient for the publication of this case report. The CUA is an infrequent disease that almost exclusively affects patients with renal impairment although any cases had been reported in patients without renal disease.The diagnosis is mainly made by clínical manifestations (painful ulcerated lesions) and is confirmed by radiological and histological studies. et al. Vedvyas Our patient presented several risk factors , so that we acted on those that could be modified pharmacologically. Specifically, the electrolyte imbalances were addressed, continuing with the use of non-calcium-containing phosphate binders, such as sevelamer; as well stopping treatment with acenocoumarol that it may contribute to disease´s progression.Treatment with selective vitamin D receptor activator  was discontinued, as it may increase to development of calciphylaxis indirectly through its action to increase serum calcium and serum phosphate and which can lead to intravascular calcium deposits in arterioles and venules The control of secondary hyperparathyroidism can be performed using calcimimetics  or by surgical parathyroidectomy in the absence of response to calcimimetics ,Bisphosphonates have been shown to be potent inhibitors of osteoclast activity and bone resorption and they are used extensively to the treatment of osteoporosis, cancer-induced hipercalcemia and Paget's disease, and cases have been described in which their use in the treatment of CUA has obtained a good response Sodium thiosulfate is a drug with proven efficacy and available as a Pharmaceutical compounding. The mechanism of action is unknown, although it is related to its ability to dissolve calcium deposits within tissues through the formation of soluble calcium thiosulfate complexes, and also due to its antioxidant action to improve endothelial dysfunction ,Combination therapy with sodium thiosulfate and bisphosphonates is an uncommon treatment strategy and no many published literature Sodium thiosulfate in combination with pamidronate and calcimimetics for treatment of CUA, has been effective and relatively safe, giving rise to the clinical remission with absence of pain and drastic size reduction of the nodules with disappearance of any of them, in a disease with poor prognosis. La calcifilaxis o arteriolopatía urémica calcificante (CUA) es un trastorno raro y grave que se caracteriza por la calcificación de la capa media de las arterias y arteriolas que da lugar al desarrollo de necrosis isquémica de la piel y de los tejidos blandos con formación de úlceras Afecta con mayor frecuencia a pacientes que presentan una enfermedad renal crónica (ERC) y en diálisis. Entre estos pacientes se alcanza una prevalencia de hasta el 4%. Sin embargo, también puede afectar a pacientes que no padecen ERC ,No está bien establecida la patogenia de la CUA por lo que es probable que sea multifactorial. Se conocen varios factores de riesgo: hiperparatiroidismo, hiperfosfatemia, análogos del calcio, altas dosis de metabolitos de la vitamina D. También se ha relacionado con la obesidad, el sexo femenino, la diabetes, la hipoalbuminemia y con estados de hipercoagulabilidad por deficiencia de las proteínas C y S o con el uso de anticoagulantes orales tipo cumarínicos No existe un acuerdo sobre el tratamiento óptimo. El abordaje terapéutico debe ser multifactorial y estar dirigido a la normalización de los niveles del calcio y el fósforo: la supresión o control de los factores de riesgo que están asociados, evitar los traumatismos y realizar un cuidado intensivo de las ulceras y un control del dolor asociado a dichas lesiones Nuestro objetivo es presentar un caso infrecuente de CUA tratado con tiosulfato y pamidronato que arrojó buenos resultados.Mujer de 68 años de edad, sin alergias medicamentosas conocidas; con ERC estadío 5D secundaria a glomerulonefritis crónica en hemodiálisis de 3 años de evolución. Presentó hipertensión arterial; con antecedentes de obesidad mórbida (IMC 41.5), fue sometida a bypass gástrico hace 13 años , presenta diabetes mellitus tipo II, hipotiroidismo primario, hiperparatiroidismo secundario e insuficiencia mitral. Exfumadora, abandonando el hábito tabáquico hace 18 años, sin presentar ningún otro hábito tóxico. Hace 22 años sufrió un tromboembolismo pulmonar, que fue tratado con acenocumarol. Además la paciente está en tratamiento con sevelamero, paricalcitol, cinacalcet, epoetina alfa, levotiroxina, ácido fólico, tratamiento antidiabético y omeprazol.En mayo de 2017 se observó la aparición de un nódulo doloroso en la cara posterior del muslo izquierdo, que fue diagnosticado como lipoma mediante ecografía. Dos meses más tarde, la paciente refirió un aumento considerable del dolor y del tamaño del nódulo y aparecieron entre 3-4 nuevos nódulos en la cara anterior y posterior del muslo izquierdo . A la paPosteriormente se realizó una interconsulta con el Servicio de Dermatología donde le practicaron una biopsia de la lesión. El diagnóstico anatomopatológico fue compatible con calcifilaxis .En la radiografía simple de tórax y abdomen se observaron calcificaciones vasculares en trayectos arteriales.Ante el diagnóstico de calcifilaxis y tras descartar otros diagnósticos de calcinosis, se tomaron las siguientes medidas:Se suspende el tratamiento con acenocumarol y en su lugar se inició un tratamiento con heparina de bajo peso molecular manteniéndose en la actualidad. La vitamina D  también se suspendió, manteniéndose el resto de la medicación. Se corrigió la acidosis metabólica, se determinaron los niveles de vitamina K, y se redujeron las concentraciones de calcio en el baño de diálisis. Se inició simultáneamente la administración de 12.5 g de tiosulfato sódico intravenoso tras cada sesión de hemodiálisis como tratamiento de la calcifilaxis. Tras la biopsia cutánea se formó una úlcera profunda de 1.0-1.5 cm pero sin tejido de granulación, no manifestándose ninguna infección y resolviéndose satisfactoriamente tras 5 meses de curas y seguimientos habituales. Tres meses después del diagnóstico, tras evidenciar empeoramiento clínico y considerando el aumento de la calcemia, se comenzó un tratamiento con bifosfonato  por su capacidad de inhibir la calcificación vascular y su efecto antiinflamatorio. Ante la persistencia de la mala tolerancia digestiva, se sustituyó el cinacalcet por la etelcalcetida a dosis ascendente de 5 mg intravenoso directo después de cada sesión de hemodiálisis debido a su menor incidencia de efectos gastrointestinales.Tres semanas más tarde, ante el descenso marcado de la calcemia y de la fosfatemia añadimos de modo ocasional un tratamiento con paricalcitol 1.0 mcg post hemodiálisis controlando así los niveles elevados de la hormona paratiroidea (PTHi).Dos meses después de iniciar el tratamiento con etelcalcetida se incrementó la dosis a 10 mg después de cada sesión de hemodiálisis ante la falta de control en los niveles de la PTHi y un mes más tarde se suspendió el tratamiento con Pamidronato por la aparición de una hipocalcemia severa mantenida (Ca= 7.5 mg/dL) .Finalmente, tras 6 meses de tratamiento, se suspendió el tiosulfato sódico por la evolución favorable de las lesiones y disminución del dolor. Actualmente la paciente continua en hemodiálisis, estable, sin lesiones dolorosas y con disminución del tamaño de los nódulos, haciéndose necesario el aumento de las dosis de la terapia con etelcalcetida a 15 mg 3 veces por semana debido al mal control y al mantenimiento de unos niveles de PTHi elevados . Se obtuvo el consentimiento informado por escrito de la paciente para la publicación de este caso.La CUA es una enfermedad infrecuente que afecta casi exclusivamente a pacientes con insuficiencia renal, aunque se han observado casos en pacientes sin esta afectación El diagnóstico es clínico  confirmándose con el estudio radiológico e histológico et al. Vedvyas Nuestra paciente presentaba numerosos factores de riesgo , por lo que se actuó sobre aquellos que podían ser modificados farmacológicamente. En concreto, se abordaron los desequilibrios electrolíticos continuando con el uso de quelantes de fósforo que no aportan calcio, como es el sevelámero; así como la supresión de tratamiento con acenocumarol ya que se ha comprobado que favorece la progresión de la enfermedad.Se suspendió el tratamiento con el análogo de vitamina D , ya que puede contribuir al desarrollo de calcifilaxis por la hipercalcemia e hiperfosforemia que puede producir y que puede dar lugar a depósitos de calcio intravascular en arteriolas y vénulas El control del hiperparatiroidismo secundario se realizó mediante el empleo de calcimiméticos  o bien mediante la extirpación de las paratiroides ante la falta de respuesta a los calcimiméticos ,Los bisfosfonatos tienen un potente efecto inhibidor sobre la actividad de los osteoclastos y la resorción ósea y se utilizan en gran medida en el tratamiento de la osteoporosis, la hipercalcemia tumoral y la enfermedad de Paget, además se han descrito casos en los que su empleo en el tratamiento de la CUA ha obtenido una buena respuesta El tiosulfato sódico es un fármaco con eficacia demostrada y disponible como fórmula magistral. Se desconoce el mecanismo de acción, aunque se relaciona con su capacidad de disolver los depósitos de calcio en los tejidos mediante la formación de complejos solubles, y por su acción antioxidante mejorando la disfunción endotelial ,El uso de una terapia combinada de tiosulfato de sodio y bifosfonato es una estrategia poco utilizada y con poca bibliografía publicada El uso combinado de tiosulfato, pamidronato y calcimiméticos para el tratamiento de CUA ha resultado efectivo y relativamente seguro, dando lugar a la remisión del cuadro con ausencia de dolor y disminución drástica del tamaño de los nódulos con desaparición de alguno de ellos, en una enfermedad de mal pronóstico.


Epidemiological studies have shown that children who grow up on traditional farms are protected from allergic diseases. However, less is known about if the environment influences the pharmacotherapy in these patients. To compare the treatment of asthmatic and rhinitis children from urban and rural areas in Medellín, Colombia. During one year, we follow up a group of children (6 to 14 years) with diagnostic of asthma or rhinitis living for more than five years in urban or rural area. A questionnaire with socio-demographic characteristics, pharmacotherapy treatments, was obtained each three months. Atopy evaluation, spirometry and clinical test for asthma and rhinitis severity were done at the beginning and one year later. p: 0.01), visit to emergency department (p <0.01) and have a less number of patients with FEV1 <80% (p: 0.05). For clinical control rural children require less pharmacotherapy than urban children (p: 0.01) and more patients with rhinitis (18% vs 8% p: 0.03) and asthma (23% vs 12% p: 0.01) in the rural group could suspended pharmacotherapy. Atopy (p: <0.07) and poli-sensitization (p: <0.08) was a little higher in urban than rural area. We observe that poverty/unhygienic indicators were risk factors for higher levels of specific IgE among patients from urban area.Eighty six point four percent patients completed the follow up . Patients in rural location required less salbutamol ( Patients with respiratory allergies located in urban area require more pharmacotherapy and have less clinical response than rural children.  A questionnaire based in the ISAAC initiative to identify socio-demographic characteristics was done at the beginning of the study. A medical doctor expert in allergy diseases recruited all patients. The previous diagnosis, medicine treatment, and control of symptoms were investigated through questionnaire surveys written by the investigators based in the ISAAC questionnaire used in Colombia We created a community cohort for a prospective follow up and collection of epidemiological data and biological samples . The population of this study was collected in Antioquia - Colombia. The genetic background of rural and urban populations is the same and results from a racial admixture between Native Americans, Spaniards, and  Africans (<10.9%) To evaluate the severity of symptoms of asthma according to the perception of patients, we use the Asthma Control Test (ACT) previously validated in Colombia To evaluate the severity of rhinitis we use the Allergic Rhinitis Symptom Questionnaire (ARSQ); the seven most common symptoms of rhinitis, rated on a scale of 0 to 4 points, are assessed according to the intensity (Absent to very severe). It is considered mild if the patient scores with 9 points or less, moderate from 10 to 19 points and severe from 20 to 28 points For asthma we register the pharmacotherapy require to clinical control in steps according to the GINA recommendations. Also, we assign for the therapy of each patient a score from 0 to 7 points according to the GINA steps .The Ethic Committee of the University of Antioquia from Medellín-Colombia approved this study. Because the participants were minors, the parents gave written informed consent. According to the request of the ethics committee, children also gave their assent, which was supervised by a child psychologist in children under 10 years of age.Using double entry by three independent persons, all data were entered, categorized and analyzed using the Statistical Package for Social Sciences software . Based on the data from a previous epidemiological survey and an analysis of children’s asthma in Colombia p <0.05 was considered significant.The Chi-square test was used to compare prevalence rates of disease severity and treatment between groups. The Mann-Whitney U was used to compare the control of symptoms between groups for abnormal distribution. Results are presented as 95% confidence intervals where appropriate. A Dermatophagoides spp (83%), were the most important sensitizers followed by Dog (28%) and insects (24%). Sensitization to milk and egg were below 5%. Atopy (p <0.07) and poli-sensitization (p <0.08) was a little higher in urban than rural area, but it was not statistically significant.From 467 patients that consult during the period of recruitment, 442 patients were selected and 382 (86.4%) finish the follow-up : 134 frop: 0.02). There were not significant differences between patients who finish the study and those who drop out.Most inhabitants living in urban and rural area were poor according to governmental indexes but most of them had assessed to basic services . Trash bp: 0.06) and ARSQ (p: 0.04)   . The cli p: 0.7) A. After After 6 months and for the rest of the follow-up, there was a reduction in salbutamol requested and medical consultation in the emergency department . This rep: 0.06, 6 months p: 0.08, 9 months p: 0.06, 12 months p: 0.8)  B. A largp: 0.03). During the follow-up both groups have a reduction in pharmacotherapy being higher in the group of rural area: Rural area mean 1.6 (SD: 2) points vs. mean 2.8 (SD: 3) points respectively (p: 0.03). At the baseline, patients in urban area had higher severity than patients in rural area and requiring a higher dose of pharmacotherapy for asthma : Rural gAlso, after 12 months patients in rural area had a higher suspension of all drugs due to a complete clinical control for asthma . p: 0.03) and asthma (23% vs 12% p: 0.01) pharmacotherapy was also higher in rural group. For rhinitis after 6 months there was also a reduction maintained until the end of the study in pharmacotherapy been higher in rural group (baseline/12 months): Rural 2/1.6 (-20%) points and Urban 2.4/2.1 (-12.5%) points . Suspensp 0.18).The usage of alternative therapy, specific immunotherapy, antibiotics and Chinese medicine, were not significantly different between groups and had little change over time .A high exposure to irritants of the respiratory tract favors the chronicity of the inflammation and generates epithelial changes that worsen the picture and make its reversibility difficult According to GINA and ARIA guideline, treatment with a regular daily dose of steroids is highly effective in reducing symptoms and reducing the risk of asthma exacerbation. However, similar to Chinese studies Rhinitis is the most common respiratory disease ,Our results have several implications. In addition to the clinical aspects that the patient suffers, the lack of control has for them and their family a great social and economic impact: children with uncontrolled respiratory symptoms, have a lower school performance and and may have personality disorders ,Our study has some limitations. The sociocultural and environmental conditions of each region limit the extrapolation of our results to other populations Compared with rural area, urban location has important consequences in the severity and control of asthma and rhinitis which are not full reversed despite the use of increased pharmacotherapy. The identification of the environmental risk factors associated with these results could help to improve the control of asthma in urban and rural areas.  ,,,,,3, CO2, NOx y pequeñas partículas de carbono (PM <10) pueden causar hiperactividad en el tracto respiratorio induciendo asma o rinitis, pero también puede alterar las estructuras de las proteínas de los alimentos y los granos de polen ,El asma y la rinitis son enfermedades respiratorias frecuentes que afectan a todas las edades, pero son predominantes en los niños Hoy en día, lograr un diagnóstico y tratamiento adecuado del asma y la rinitis en pacientes pediátricos se ha convertido en un punto clave en el control de los síntomas para prevenir complicaciones en la edad adulta ,https://www.census.gov/geo/reference/urban-rural.html). Al comienzo del estudio se realizó un cuestionario basado en la iniciativa ISAAC para identificar las características sociodemográficas. El reclutamiento de los pacientes se realizó por médicos especialistas en alergología. El diagnóstico anterior, el tratamiento médico y el control de los síntomas se investigaron a través de cuestionarios basados en el cuestionario ISAAC utilizado en Colombia Creamos una cohorte comunitaria para hacer seguimiento prospectivo y una recopilación de datos epidemiológicos y muestras biológicas . La población de este estudio fue recolectada en Antioquia - Colombia. El trasfondo genético de las poblaciones rurales y urbanas es el mismo y es el resultado de una mezcla racial entre nativos americanos, españoles y (aunque con menos frecuencia) africanos (<10.9%) Para evaluar la gravedad de los síntomas del asma según la percepción de los pacientes, utilizamos la prueba de control del asma (ACT) previamente validada en Colombia Para evaluar la gravedad de la rinitis, usamos el Cuestionario de Síntomas Alérgicos de la Rinitis (ARSQ); en la escala se evalúa los síntomas más comunes de la rinitis, clasificados en una escala de 0 a 4 puntos, se evaluaron según la intensidad (de ausente a muy grave). Se consideró leve si el paciente puntúa con 9 puntos o menos, moderado de 10 a 19 puntos y severo de 20 a 28 puntos Para el asma, registramos la farmacoterapia requerida para el control clínico de acuerdo con las recomendaciones del GINA. Además, asignamos para la terapia de cada paciente una puntuación de 0 a 7 puntos según los pasos de GINA  por semana, visitas al servicio de urgencias y la evaluación de farmacoterapia ACT y ARSQ (cada 3 a 4 meses).El estudio fue aprobado por el Comité de Ética de la Universidad de Antioquia de Medellín, Colombia. Debido a que los participantes eran menores de edad, los padres dieron su consentimiento informado por escrito para su inclusión en el estudio. De acuerdo con la solicitud del comité de ética, los pacientes también dieron su consentimiento el cuál fue supervisado por un psicólogo infantil en niños menores de 10 años.Statistical Package for Social Sciences” . Cbase en los datos de una encuesta epidemiológica previa y un análisis del asma infantil en Colombia Se realizó un doble chequeo de los datos por tres personas de forma independientes, todos los datos se ingresaron, categorizaron y analizaron utilizando el paquete “p <0.05 se consideró estadísticamente significativa.La prueba de Chi-cuadrado se utilizó para comparar las tasas de prevalencia de la gravedad de la enfermedad y el tratamiento entre los grupos. Se usó la U de Mann-Whitney para comparar el control de los síntomas entre los grupos para una distribución anormal. Los resultados se presentan como intervalos de confianza del 95% cuando corresponde. Una Dermatophagoides spp (83%), fueron la fuente de sensibilización más importante, seguido por el perro (28%) e insectos (24%). La sensibilización a la leche y al huevo fue inferior al 5%. La atopia (p <0.07) y la polisensibilización (p <0.08) fueron un poco más altas en áreas urbanas que rurales, pero no fueron estadísticamente significativas.De los 467 pacientes que consultaron durante el período de reclutamiento, se seleccionaron 442 pacientes y de estos 382 (86.4%) finalizaron el seguimiento : 134 delLa mayoría de los habitantes que vivían en áreas urbanas y rurales eran pobres según los índices gubernamentales, pero la mayoría de ellos tenían accesos a los servicios básicos . La basup: 0.06) y ARSQ (p: 0.04)   . El contp: 0.07) A. DespuéDespués de 6 meses y durante el resto del seguimiento, hubo una reducción en el requerimiento de salbutamol y en la asistencia al departamento de emergencias . Esta dip: 0.06, 6 meses p: 0.08, 9 meses p: 0.06, 12 meses p: 0.08)  B. Un grap: 0.03). Durante el seguimiento, ambos grupos presentaron una reducción en la farmacoterapia siendo más alta en el grupo del área rural: Media del grupo de área rural 1.6 puntos (DS: 2) vs. media del grupo de área urbana 2.8 puntos(DS: 3), respectivamente (p: 0.03).Al inicio, los pacientes en el área urbana tenían mayor gravedad que los pacientes en el área rural y requerían una dosis más alta de farmacoterapia para el asma : Media dAdemás, después de 12 meses, los pacientes en el área rural tenían una mayor suspensión de todos los medicamentos debido a un control clínico completo del asma .p: 0.03) y el asma (23% frente a 12% p: 0.01) también fue mayor en el grupo rural.Para el caso de los pacientes con rinitis, después de 6 meses también se observó una reducción en el uso de farmacoterapia hasta el final del estudio, siendo mayor la reducción en el grupo rural (0 meses / 12 meses): Rural 2 / 1.6 (-20%) puntos y urbano 2.4 / 2.1 (-12.5%) puntos . La suspp: 0.18).El uso de terapia alternativa, inmunoterapia específica, antibióticos y medicina china, no fue significativamente diferente entre los grupos estudiados y tuvo pocos cambios a lo largo del tiempo .Una alta exposición a los irritantes del tracto respiratorio favorece la cronicidad de la inflamación y genera cambios epiteliales que empeoran la enfermedad y dificultan su reversibilidad Según las guías GINA y ARIA, el tratamiento con una dosis diaria regular de esteroides es altamente efectivo para reducir los síntomas y reducir el riesgo de exacerbación del asma. Sin embargo, de manera similar a los estudios en chinos La rinitis es la enfermedad respiratoria más común ,Nuestros resultados tienen varias implicaciones. Además de los aspectos clínicos que sufre el paciente, la falta de control tiene para ellos y su familia un gran impacto social y económico: los niños con síntomas respiratorios no controlados, tienen un rendimiento escolar más bajo y pueden tener trastornos de la personalidad ,Nuestro estudio tiene algunas limitaciones. Las condiciones socioculturales y ambientales de cada región limitan la extrapolación de nuestros resultados a otras poblaciones En comparación con el área rural, la ubicación urbana tiene importantes consecuencias en la gravedad y el control del asma y la rinitis, que no se controlan por completo a pesar del uso de la farmacoterapia. La identificación de los factores de riesgo ambientales asociados con estos resultados podría ayudar a mejorar el control del asma en áreas urbanas y rurales.


The following information is missing from the Funding statement: MN is a doctoral student from Programa de Doctorado en Ciencias Biomédicas, Universidad Nacional Autónoma de México (UNAM), and received fellowship 239706 from Consejo Nacional de Ciencia y Tecnología, México (CONACyT) to support this study. The publisher apologizes for the error.


Venous aneurysms are rare and often diagnosed incidentally. Popliteal vein aneurysms are the most common type of venous aneurysms and have a strong association with the occurrence of deep vein thrombosis and recurrent pulmonary embolism. This article reports two cases of popliteal vein aneurysms associated with deep vein thrombosis.  Venous aneurysms were first described by Sir William Osler in 1913 and can theoretically involve any venous segment in the body.  A 15-year-old male patient presented complaining of pain and localized swelling in the right popliteal fossa with onset 1 month previously. He reported a prior history of vascular malformation in the posterior aspect of the right thigh, which had never been diagnosed definitively. Physical examination revealed a firm mass in the right popliteal fossa associated with diffuse increase of volume in the posterior region of the distal right thigh. Doppler ultrasonography was used to diagnose a voluminous right PVA. In view of the risk of thrombosis and the patient’s symptoms, the treatment chosen was open surgical venous aneurysmectomy followed by primary reconstruction of the popliteal vein   . The pa A 66-year-old female patient presented with pain and edema of the left lower limb as far as the top of the thigh. The only risk factor for thrombosis that she reported when interviewed was immobilization lasting a few hours. Doppler ultrasonography showed venous thrombosis of the left gastrocnemius and fibular veins and a left PVA   . She wa, Aneurysms of the popliteal vein are rare, although their prevalence has not been established, since there are no studies employing screening. Descriptions in the literature report prevalence rates below 0.5%.  In the first published reports of PVA, the most common clinical presentation – in up to 80% of cases – was venous thromboembolism (VTE). Nowadays, with greater availability of noninvasive imaging methods such as Doppler ultrasonography, early diagnosis of venous aneurysms in the pre-thrombotic phase or as an incidental finding in asymptomatic patients has become much more common. , Approximately two thirds of PVAs are saccular, a majority are located in the left lower limb,  Popliteal vein aneurysm should be considered a differential diagnosis possibility in patients with increased volume in the region of the popliteal fossa and in young patients with VTE in whom screening for thrombophilia is negative. ,,, The traditional treatment of choice is surgical repair for patients with aneurysms larger than 3 cm, recurrent thrombosis or pulmonary embolism after anticoagulation, and high risk for venous thrombosis. In a study published in 2013 by Maldonado-Fernandez et al., ,, Several surgical techniques are available to treat popliteal vein aneurysms and the choice depends on the anatomy of the aneurysm. Posterior access is most common, followed by resection of the aneurysm sac and lateral venorrhaphy to reconstruct the vein.  In conclusion, popliteal vein aneurysms are rare, but can potentially be fatal, because of the risk of pulmonary embolism. Doppler ultrasonography is the diagnostic method of choice. Although there is no consensus on treatment of patients with PVA, the individual level of risk of recurrence of venous thrombosis should be considered, and surgery is the most recommended option in these cases.   Os aneurismas venosos foram descritos inicialmente por Sir William Osler no ano de 1913 e podem acometer teoricamente qualquer segmento venoso do organismo  Paciente com 15 anos de idade do sexo masculino apresentava queixa de dor associada a um aumento de volume localizado em fossa poplítea direita com início há um mês. Relatou história prévia de malformação vascular em região posterior de coxa direita, porém sem diagnóstico definido. Ao exame físico, apresentava uma massa de consistência firme na região de fossa poplítea direita associada a aumento de volume difuso em região posterior distal da coxa direita. Foi realizado eco-Doppler, que diagnosticou volumoso AVP à direita. Devido ao risco de trombose e aos sintomas exacerbados do paciente, optou-se por abordagem cirúrgica com aneurismectomia venosa e reconstrução primária da veia poplítea   . Pacien Paciente com 66 anos de idade do sexo feminino apresentava quadro de dor e edema em membro inferior esquerdo desde a raiz da coxa. Relatava história de imobilização de poucas horas como único fator de risco detectável para trombose na anamnese. O eco-Doppler mostrou, além da trombose venosa de veias gastrocnêmias e fibulares à esquerda, presença de AVP   . A paci, Os aneurismas vasculares poplíteos são raros e de prevalência não estabelecida, uma vez que não existem estudos de rastreamento. Descrições na literatura relatam prevalências abaixo de 0,5%  Nos primeiros relatos de AVP publicados, a apresentação clínica mais comum – em até 80% – era o tromboembolismo venoso (TEV). Atualmente, com a maior disponibilidade de métodos de imagem pouco invasivo como o eco-Doppler, o diagnóstico precoce de aneurismas venosos na fase pré-trombótica ou como achado incidental em pacientes assintomáticos tornou-se cada vez mais frequente , Aproximadamente dois terços dos AVP são saculares, a maioria localiza-se no membro inferior esquerdo  O AVP deve ser considerado como um dos diagnósticos diferenciais em pacientes com aumento de volume na região da fossa poplítea e em pacientes jovens com TEV em que a triagem para trombofilia é negativa. O exame inicial de escolha é a ultrassonografia com Doppler venoso, por permitir a exclusão diagnóstica e a avaliação de potenciais diagnósticos diferenciais ,,, O tratamento de escolha tem sido tradicionalmente o reparo cirúrgico em pacientes com aneurismas maiores que 3 cm, recorrência de trombose ou embolia pulmonar após anticoagulação e alto risco para trombose venosa. A ocorrência de embolia pulmonar e óbito foi observada em cinco pacientes tratados com anticoagulação sistêmica isolada no estudo de Maldonado-Fernandez et al. ,, Existem várias técnicas cirúrgicas disponíveis para o tratamento do aneurisma de veia poplítea e sua escolha varia de acordo com a anatomia do aneurisma. O acesso posterior é o mais utilizado, seguido de ressecção do saco aneurismático e venorrafia lateral para reconstrução venosa  Em conclusão, os aneurismas venosos poplíteos são raros, mas potencialmente fatais, pelo risco de embolia pulmonar. O eco-Doppler é o método diagnóstico de escolha. Apesar de não haver consenso quanto ao tratamento dos pacientes com AVP, deve-se levar em conta o risco individual de recorrência de trombose venosa, sendo a cirurgia mais indicada nesses casos.