Choosing wisely: practical considerations on treatment efficacy and safety of asthma in the elderly.

The prevalence of asthma in the most advanced ages is similar to that of younger ages. However, the concept that older individuals may suffer from allergic asthma has been largely denied in the past, and a common belief attributes to asthma the definition of "rare" disease. Indeed, asthma in the elderly is often underdiagnosed or diagnosed as COPD, thus leading to undertreatment of improper treatment. This is also due to the heterogeneity of clinical and functional presentations of geriatric asthma, including the partial loss of reversibility and the lower occurrence of the allergic component in this age range. The older asthmatic patients are also characterized the coexistence of comorbid conditions that, in conjunction with age-associated structural and functional changes of the lung, may contribute to complicate the management of asthma. The current review addresses the main issues related to the management of allergic asthma in the geriatric age. In particular, the paper aims at revising current pharmacological and non pharmacological treatments for allergic asthmatics of advanced ages, primarily focusing on their safety and efficacy, although most behaviors are an arbitrary extrapolation of what has been tested in young ages. In fact, age has always represented an exclusion criterion for eligibility to clinical trials. Experimental studies and real life observations specifically testing the efficacy and safety of therapeutic approaches in allergic asthma in the elderly are urgently needed.

A Multicenter Study of IgE Sensitization to Anisakis simplex and Diet Recommendations.

BACKGROUND: Allergy to Anisakis simplex (s.) is spreading due to the increased consumption of raw, smoked or marinated fish. In man, Anisakis s. can directly attack the gastrointestinal mucosa, provoking a parasitosis known as anisakiasis, or giving rise to the formation of IgE and, finally, inducing IgE-mediated reactions like urticaria, angioedema and anaphylactic shock. During recent years, a dietary approach to Anisakis s. infestation has also been addressed. METHODS: A total of 620 patients with urticaria, angioedema, or both and a history of anaphylaxis following consumption of raw, smoked or marinated fish were recruited, evaluated for specific IgE levels to Anisakis s. and subjected to Skin Prick test. Following 18 month fish-free diet, patients were reevaluated at 6, 12 and 18 months, respectively. Patients undergoing diet were selected among those who had a clinical history with multiple accesses to first aid. RESULTS: After 6-month fish-free diet, we recorded an improvement of symptoms and a remarkable reduction of specific IgE levels. The extension of the diet over 6 months in some cases resulted in a further reduction of specific IgE levels. CONCLUSION: Data obtained confirm the importance of a fish-free diet in patients with severe symptoms since a new antigenic exposure coincides with a relapse of symptoms and increased IgE levels. This last point should be kept in mind and carefully evaluated in patients at risk for anaphylaxis or angioedema.

Patients with Hereditary Hemorrhagic Telangectasia (HHT) exhibit a deficit of polymorphonuclear cell and monocyte oxidative burst and phagocytosis: a possible correlation with altered adaptive immune responsiveness in HHT.

Hereditary Hemorrhagic Telangiectasia (HHT) is a rare genetic disease characterized by mutations occurring in the endoglin and ALK-1, two receptors of transforming growth factor-beta1. From a pathogenic point of view, a possible involvement of the immune system in HHT has been suggested since a mononuclear cell infiltrate was found around the area of telangiectases. Up until now, no information has been available about the role played by leukocytes in HHT and the mechanisms elicited by secretion of their mediators. However, the fact that a deficit of adaptive immunity in HHT has been reported in a companion paper in this issue will represent a great contribution to the understanding of HHT pathogenesis. The purpose of this study was to evaluate whether patients with HHT manifest also alterations in the innate immune response. Therefore, the phenotype of T, B and natural killer lymphocytes, serum immunoglobulin levels, phagocytosis and oxidative burst activity exerted by polymorphonuclear cells (PMN) and monocytes (MO) were analyzed in 22 patients. Twenty individuals demonstrated single or multiple deficits of PMN and MO functions, while the immunophenotype of lymphocytes and serum concentrations of immunoglobulins were normal. To the best of our knowledge, this is the first demonstration of a reduction in PMN and MO functions in HHT, thus suggesting a higher susceptibility to infectious complications in these patients. The relationship between innate immune deficits and T helper 1 and monocyte-derived cytokine dysfunction in HHT, as previously reported, is discussed.

How many maternal deaths are there in Portugal?

INTRODUCTION: Maternal mortality is a public health issue, internationally considered an indicator of women's status in society, indirectly translating access to health facilities. However, it is difficult to measure and is usually underestimated by official records. METHODS: Maternal deaths missed by the official statistics in Portugal between 2001 and 2006 were estimated by multiple-recapture methods using three different data sources. An upper limit to the number of deaths was derived from the application of the mortality function of women in reproductive age to the estimated annual number of pregnancies. RESULTS: Maternal mortality decreased from 40 to less than 10 deaths per 100,000 live births between 1978 and 1986. Between 2001 and 2006, it varied from 2.5 to 19 and was underestimated by 9%-26%. Nevertheless, within the same age range, the risk of a pregnant women to die was four times less than a women in the general population. CONCLUSION: Like in other developed countries, official statistics in Portugal have systematically underestimated maternal deaths. These deaths are a rare event, but the consistent increase in the average age at pregnancy may exacerbate the main causes of death, raising concerns for the future and prompting the need for emergency facilities nearby maternities.

Validity and reproducibility of morphologic analysis of nasal secretions obtained using ultrasonic nebulization of hypertonic solution.

BACKGROUND: Collection of nasal secretions is important for the evaluation of upper airways inflammation in many nasal disorders. OBJECTIVE: To study the validity and reproducibility of nasal secretion cellularity induced by nebulization of hypertonic solution in patients with allergic rhinitis (AR), patients with nonallergic rhinitis with eosinophilia syndrome (NARES), and control subjects. METHODS: Sixty-eight individuals (29 with AR [mean +/- SD age, 33.3 +/- 16.9 years], 23 with NARES [mean +/- SD age, 46.4 +/- 16.6 years], and 16 controls [mean +/- SD age, 42.1 +/- 15.1 years]) underwent ultrasonic nebulization of hypertonic (4.5%) saline solution on 2 different occasions to study the validity and reproducibility of total and differential cell counts of nasal secretions. RESULTS: The mean +/- SD percentage of eosinophils was significantly higher in samples from patients with AR (20.8% +/- 23.1%) and NARES (18.7% +/- 22.8%) than in samples from controls (0.6% +/- 0.6%; P < .001 for both). There was a significant correlation between 2 samples of nasal secretions obtained on 2 different occasions for percentages of macrophages, neutrophils, eosinophils, and epithelial cells. CONCLUSIONS: The analysis of nasal secretions obtained using ultrasonic nebulization of hypertonic solution can distinguish patients with AR and NARES from controls. The reproducibility of this technique is good for macrophages, neutrophils, eosinophils, and epithelial cells. This method could be used to detect nasal airway inflammation in clinical settings.

Sensory Quality and Histamine Formation during Controlled Decomposition of Tuna ( Thunnus thynnus ).

Histamine production was studied during controlled tunafish decomposition at 0, 8, and 20°C. The influence of the location of the anatomic section on the amount of histamine formed and the incidence of histidine decarboxylating bacteria were also considered. By the time of sensory rejection, histamine levels in tunafish sections stored at 0 and 20°C were still below the hazard levels and the allowable levels established by both the U.S. Food and Drug Administration (FDA) and the European Union. Toxic amounts were only formed after the tunafish was considered organoleptically unsuitable for human consumption. However, at 8°C, levels of histamine between 100 and 200 mg/l00 g of fish were found before tuna reached the rejection point. Hence, physical appearance was not a good criterion for estimating the shelf life and especially the histamine-related health hazard when tuna was stored at 8°C, a common temperature in many home refrigerators.

Histidine Decarboxylase Activity of Bacteria Isolated from Raw and Ripened Salchichón , a Spanish Cured Sausage.

Twenty samples of raw sausages (before the ripening process) and 10 of ripened sausages of two different sizes of salchichón , one of the most-consumed ripened meat products in Spain, were microbiologically analyzed. Histidine decarboxylase activity of different isolates obtained from different culture media was evaluated by a decarboxylase agar medium and confirmed afterwards by an enzymatic method. Of the isolates obtained from raw sausages, 15.8% showed histamine-forming activity, most of them (78.1%) belonging to the Enterobacteriaceae family. Klebsiella oxytoca , Enterobacter aerogenes (one isolate), and Enterobacter cloacae (six isolates) showed a powerful histamine-forming activity, producing more than 3,000 µg/ml. In spite of histamine-forming activity being detected in eight of ten analyzed samples of ripened sausages, only one histamine-forming bacterium, identified as Lactobacillus curvatus , was isolated; it showed an ability to form 1,994 µg/ml of histamine in experimental conditions.

Histidine Decarboxylase Activity of Enterobacter cloacae S15/19 during the Production of Ripened Sausages and Its Influence on the Formation of Cadaverine.

The histidine decarboxylase activity of Enterobacter cloacae S15/19 was studied during the production process of salchichón , a Spanish ripened sausage. Counts of fecal coliform and histidine decarboxylase bacteria decreased during the production process, showing a good correlation in both inoculated and control samples. In the samples inoculated with Enterobacter cloacae S15/19, fecal coliforms were undetectable the last day of the survey, while the population of histidine decarboxylase bacteria was over 2 log MPN/g. Despite the fact that inoculation with Enterobacter cloacae S15/19 increased histidine decarboxylase bacteria counts, no differences were observed in the histamine concentration reached, which was undetectable in most of the control and inoculated samples. In contrast, cadaverine concentration increased significantly (P < 0.01) in the inoculated samples, suggesting that cadaverine could be used as a hygienic-quality indicator of the raw materials employed in sausage processing.