Proposal for relative units of value (RUV) for use in allergy examinations.

Health resources are limited and consequently real cost generators must be identified to optimize resources. In the present article, we describe the structure of the Homogeneous Functional Groups (HFG) for Diagnostic Techniques in the Allergy Department of the Virgen de la Arrixaca University Hospital in Murcia (Spain) and the healthcare products generated. Based on the 2005 budget, variable costing was used to calculate the costs of the healthcare products generated (skin tests, investigation of drug allergies, etc.) by one of the three HFG (the HFG for complementary investigations). On the basis of these costs, and taking as the unit the cost of one skin prick test, we assigned relative units of value (RUV) to each of the products in our services portfolio. The following conclusions can be drawn: 1) the current system of variable costing provides information, which should be useful to health professionals; 2) the real cost generators in the microcosm of daily clinical practice should be identified to allow resource reallocation; 3) the costing system used enables modifications to be made that allow decision making on optimal use of the budget; 4) to take the decisions required to optimize resources, clinical management and complementary tests should go hand-in-hand.

[Incidence of adverse reactions to additives. Our experience over 10 years]. / Incidencias de reacciones adversas con aditivos. Nuestra experiencia de 10 años.

No published information exists about the incidence of food additives reactions in the general population. Most studies have been made in patients with urticaria and bronchial asthma. The majority of them lack an adequate design and, therefore, the reported results should be interpreted with extreme caution. In this article, we expose our ten years experience in this field. We have added up 1941 oral provocation tests, with an ample battery of additives, administering the tested substances directly or in aqueous or acid solution (1110 in patients with urticaria, mainly chronic urticaria, and 831 in asthmatic subjects, with or without aspirin intolerance). From these exhaustive data, we get the following conclusions: 1) in contrast with other-investigators, and using similar or even higher provocation doses, we get a very low incidence of adverse reactions. 2) We are sceptical that food additives play any role in chronic urticaria or in other cutaneous processes (only 0.63% provocation tests resulted in an urticarial exacerbation, and none of them was repeated after re-provocation). 3) In asthmatic patients, similar results were obtained, except with sulfites in acid solution challenge test (10% asthmatic exacerbations), possibly as a sign of nonspecific bronchial hyperreactivity. 4) The prescription of food additives free restrictive diets does not seem to be justified. The should be followed only by those patients with clear evidence of additives reactions. 5) In most cases, with punctual exceptions, the study of food additives reactions, in clinical allergy, implies a waste of time.

[Adverse reactions to food preservatives]. / Reacciones adversas a conservantes alimentarios.

We relate our experiences about the number of exacerbations that certain food preservatives such as sorbic acid, benzoic acid, sodium benzoate, metabisulfite and sodium nitrate can provoke in 62 patients affected with ASA-triad in steroid dependent intrinsic asthma with nasal polyps and acute bronchospasm caused by aspirin ingestion, and in 80 patients with chronic urticaria (C.U.) as well as the first assays of the possible usefulness of the HRT (Histamine release test automatized using whole blood) for the etiologic diagnosis process. In the cases of ASA-triad, and after the ingestion of aspirin (alternating with lactose in identical capsule), we consider the result as positive when the reduction of FEV1 is superior to 20% from its baseline value. Regarding the cases of C.U., the symptoms always exacerbate twice as much with the same substance within 24 hours of its administration. We have performed the HRT on 59 patients (14 with ASA-triad, 11 with steroid dependent intrinsic asthma; 20 with C.U. were negative to oral intake of analgesics/additives and 14 with C.U. showed positive results). Successive dilutions were incubated for 30 minutes using: pyrazolones, acetylsalicylate of lysine, sodium salicylate, sodium benzoate and 4-hydroxybenzoic acid which did not produce liberation of histamine in 100 controlled individuals. All the determinations were done in duplicate, considering positive those superior to 20% of the difference between total and basal histamine. We have not observed any significant descent of the FEV1 with benzoate and salicylate in our group of 62 patients with ASA-triad, nor any manifestations presented with sodium metabisulfite, sodium nitrate and sorbic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

Síndrome ave-huevo / Bird-egg syndrome

Antecedentes. Se ha descripto una relación entre la hipersensibilidad respiratoria tipo I frente a antígenos aviares y la alergia alimentaria a la yema de huevo. Dicha asociación se denomina síndrome ave-huevo, y el responsable de dicho cuadro es la alfa-livetina o seroalbúmina de pollo, un antígeno presente tanto en la yema del huevo como en las plumas, suero y excrementos de las aves. Materiales y métodos. Estudiamos una paciente con síntomas de alergia alimentaria tras la ingesta de huevo, quien además sufría de síntomas respiratorios (rinitis/asma) causados por la exposición a aves. Se realizaron pruebas cutáneas con huevo, alfa-livetina, pollo crudo y cocido, y plumas. La IgE sérica específica fue identificada por técnica de microarrays de alérgenos (Immuno CAP ISAC). Resultados. Los prick test fueron positivos para alfa-livetina (8 mm), pollo crudo (8 mm) y plumas de gallina (7 mm). La determinación de IgE sérica específica fue de 16,61 (kU/l) para alfa­livetina. Conclusiones. El síndrome ave-huevo es producido por la sensibilización a la alfa livetina, un alérgeno que puede actuar tanto por vía alimentaria como por vía inhalatoria. Según nuestro conocimiento, es el primer caso diagnosticado a través de la técnica de microarray de alérgenos.(AU)

Background: A relationship between type I hypersensitivity with respiratory symptoms due to bird antigens and allergy to egg yolk has been described. This association is known as bird-egg syndrome, which is caused by sensitization to chicken serum albumin (alpha-livetin), present in bird feathers and serum, and egg yolk. Material and methods: We studied one patient with food allergy to egg yolk who also suffered from respiratory symptoms (rhinitis- asthma) caused by exposure to birds. Sensitization to egg yolk and bird antigens was investigated by skin prick test. Specific IgE was investigated using allergens Microarrays (Immuno CAP ISAC). Results:Our patient had a positive skin prick test to: chicken serum albumin (alpha livetin): 8 mm, bird feathers: 7 mm, raw chicken: 8 mm. Specific IgE to alpha livetin was 16.61 (kU/l). Conclusions: Bird-egg syndrome is due to a sensitization to alpha-livetin, an allergen that can act either on the respiratory or the digestive way. In our knowledgement, this is the first case described using allergen Microarrays technique.(AU)

Determination of eosinophil rate after nasal provocation test in allergic rhinitis diagnosis.

After nasal provocation test in patients with allergic rhinitis, using the allergen they were sensitized to, we have observed: 1) an increase in the percentage of nasal eosinophils after 2, 3, 24 and 48 hours; 2) sneezes, mainly in the first 30 minutes; 3) nasal obstruction in the first three hours; 4) absence of rhinorrhea, but not in all the patients; and 5) no predominance of nasal, auricular and/or palatine pruritus at any time. When patients without rhinitis, or with allergic rhinitis were stimulated using a pneumoallergen they were not sensitized to, no significative increase in the nasal eosinophils percentage was found. No symptoms were observed either. So, we can conclude that nasal secretion samples, for eosinophilia percentage determination, should be taken from 2 to 48 hours after nasal provocation, and that the most frequent symptoms, which are probably related to cellular changes, are nasal obstruction and sneezes.

The role of rhinovirus in allergic airway inflammation.

Epidemiological data demonstrate that viral infections are the most important trigger for acute asthma symptoms in children, and this association persists in many adults with asthma. Studies on volunteers experimentally infected with rhinoviruses (RV) suggest that atopy alone does not predispose to unusually severe symptoms. In contrast, experimental models combining viral infection and allergen exposure have identified potential links between virus-induced and allergen-induced inflammation. While in vitro studies suggest that cytokines may be an important part of this association, their role must be verified by sampling lower airway fluids and tissues in vivo after experimental and/or natural rhinovirus infections. Although it has long been recognized that the common cold is a potent trigger for symptoms of asthma, the mechanisms underlying the association between upper respiratory infection and increased lower airway obstruction remain obscure. The use of experimental infection of volunteers with or without respiratory allergies has enabled direct comparisons of common cold symptoms in these two groups. Furthermore, techniques such as bronchoalveolar lavage and segmental antigen challenge have been used to directly sample lower airway fluids and tissues during acute viral infection.

Pressurised metered-dose inhalers (MDIs) versus dry powder inhalers devices (DPIs) to rapid-acting inhaled b2-agonists for asthma in children.

OBJECTIVE: To compare the clinical effectiveness of pressurized metered-dose inhalers (MDIs) with that of dry powder inhalers (DPIs) in delivering short-acting b2-agonists in children with asthma. METHODS: Searches were performed in Medline (1997-March 2002), the Cochrane Library Database and the Embase reference lists of review articles and clinical trials. In addition, the international headquarters of b2-agonist manufacturers were contacted. We performed a review of randomized controlled trials. RESULTS: Ten randomized controlled trials were included. No differences in clinical effectiveness were found between MDIs and PDIs. Two studies reported that fewer adverse events occurred when the Turbuhaler was used. Two long-term studies in children found that children preferred the MDI to the Rotohaler. CONCLUSIONS: 1) In stable asthma, short-acting b2 bronchodilators in standard MDIs are as effective as dry powder inhalers. 2) Pooling of results was limited by the small number of studies and therefore no overall conclusions could be drawn. 3) From the limited data available, we found little or no evidence for an additional clinical benefit of DPI devices over standard MDIs in children with asthma.