Daily Clinical Practice in the Management of Chronic Urticaria in Spain: Results of the UCREX Study.

BACKGROUND: Chronic Urticaria (CU) is a debilitating disease whose treatment is mainly symptomatic. UCREX study aimed to identify CU patients' profile, disease management and quality-of-life (QoL) in daily clinical practice in Spain. METHODS: Observational, 12-months prospective, multicenter study, included de novo or established CU patients attending to dermatology/allergy consultations in 39 Spanish hospitals. MAIN VARIABLES: Urticaria Activity Score (UAS), UAS over 7 days (UAS7). Secondary variables: CU-QoL Questionnaire (CU-Q2oL), EuroQol-5 dimensions (EQ-5D), Medical Outcomes Study Sleep (MOS-Sleep) scale, Hospital Anxiety and Depression Scale (HADS). RESULTS: 361 patients included. Of them, 176 (48.8%) considered for the main objective analysis. Mean age (SD) of 46.6 (14.2) years and 71.8% women. The year prior to inclusion, most patients (57.1%) were treated with non-sedating H1-antihistamines (NS-H1AH). At baseline, mean (SD) 3.6 (6.8) visits were registered to primary care. Mean (SD) UAS7 at baseline was 14.3 (11.0) and CU-Q2oL 24.1 (17.0) which tended to improve by 8.6 (9.7) and 13.9 (15.0), respectively, at 12-months. MOS-Sleep and EQ-5D remained steady during the study, except pain/discomfort and anxiety/depression which went from 58.7% and 49.6% to 29.6% and 26.9%, respectively. At baseline, HADS showed a mean (SD) anxiety of 8.7 (4.5) and depression 5.1 (4.4), decreasing to 7.0 (4.3) and 4.7 (4.3), respectively, at 12-months. CONCLUSIONS: Although most CU patients are treated with NS-H1AH, disease activity is still important, negatively affecting patients' QoL, work activity and healthcare resources use. An appropriate disease management could be the basis for symptoms control, QoL improvement and resources optimization.

Daily Clinical Practice in the Management of Chronic Urticaria in Spain: Results of the UCREX Study. / [Artículo traducido] Práctica clínica diaria en el manejo de la urticaria crónica en España: resultados del estudio UCREX.

BACKGROUND: Chronic Urticaria (CU) is a debilitating disease whose treatment is mainly symptomatic. UCREX study aimed to identify CU patients' profile, disease management and quality-of-life (QoL) in daily clinical practice in Spain. METHODS: Observational, 12-months prospective, multicenter study, included de novo or established CU patients attending to dermatology/allergy consultations in 39 Spanish hospitals. MAIN VARIABLES: Urticaria Activity Score (UAS), UAS over 7 days (UAS7). Secondary variables: CU-QoL Questionnaire (CU-Q2oL), EuroQol-5 dimensions (EQ-5D), Medical Outcomes Study Sleep (MOS-Sleep) scale, Hospital Anxiety and Depression Scale (HADS). RESULTS: 361 patients included. Of them, 176 (48.8%) considered for the main objective analysis. Mean age (SD) of 46.6 (14.2) years and 71.8% women. The year prior to inclusion, most patients (57.1%) were treated with non-sedating H1-antihistamines (NS-H1AH). At baseline, mean (SD) 3.6 (6.8) visits were registered to primary care. Mean (SD) UAS7 at baseline was 14.3 (11.0) and CU-Q2oL 24.1 (17.0) which tended to improve by 8.6 (9.7) and 13.9 (15.0), respectively, at 12-months. MOS-Sleep and EQ-5D remained steady during the study, except pain/discomfort and anxiety/depression which went from 58.7% and 49.6% to 29.6% and 26.9%, respectively. At baseline, HADS showed a mean (SD) anxiety of 8.7 (4.5) and depression 5.1 (4.4), decreasing to 7.0 (4.3) and 4.7 (4.3), respectively, at 12-months. CONCLUSIONS: Although most CU patients are treated with NS-H1AH, disease activity is still important, negatively affecting patients' QoL, work activity and healthcare resources use. An appropriate disease management could be the basis for symptoms control, QoL improvement and resources optimization.

SEAIC Specialty Forum: Analysis of the Current Situation of Allergology in Spain and Outlook for the Future.

BACKGROUND AND OBJECTIVES: Allergology has been a recognized medical specialty in Spain, with fully defined aims and competencies for more than 4 decades. However, in recent years, its visibility seems to have decreased somewhat. Objectives: To identify which specific factors have contributed to the waning of the importance of the specialty and find tangible solutions to consolidate its place as a front-line medical specialty. MATERIAL AND METHODS: An online population survey comprising 60 items of interest was prepared. The degree of agreement and the level of satisfaction with each item were assessed, and implementable initiatives in the short, medium, and long terms were defined in order to provide solutions to the issues identified. RESULTS: The survey was completed by a total of 167 specialists with an average of 18 years' experience. Most were from public reference hospitals, and 29.3% were heads of department. The line of action for which a good degree of agreement was achieved was to promote the inclusion of an allergist in multidisciplinary teams. The priority lines of action were to improve undergraduate and graduate training in allergology and specialized nursing, to identify curricula in Spain, and to develop robust teaching projects. CONCLUSIONS: The results revealed a high degree of homogeneity between professionals. The basic pillars highlighted were as follows: quality training, knowledge, and research in immunotherapy; an innovative portfolio of services endorsed by clinical practice guidelines; and presence in multidisciplinary teams and relevant hospital committees.

Therapeutic Strategy According to Differences in Response to Omalizumab in Patients With Chronic Spontaneous Urticaria.

Chronic spontaneous urticaria (CSU) is a heterogeneous condition that can severely impact quality of life. Consequently, rapid disease control is essential. First-line treatment of the symptoms of CSU is the licensed dose of second-generation H1 antihistamines. For second-line treatment, this dose may be increased by up to 4 times. In patients who fail to respond to higher doses of H1 antihistamines, omalizumab for up to 24 weeks is recommended to achieve disease control. After this 24-week period, the patient's response to omalizumab should be assessed in order to identify refractory patients. Optimal management of refractory patients has not been established. Therefore, the aim of the present consensus document, which was drafted by allergists and dermatologists with specific expertise in treating urticaria, was to define specific patient profiles based on differences in their response to omalizumab. We also developed a treatment algorithm based on the specific response profile. After a comprehensive literature review, a group meeting was held to discuss issues related to the therapeutic management of patients with CSU that had not been addressed in previous studies. The experts considered both the available evidence and their own clinical experience with omalizumab. We believe that implementation of the proposed algorithm will optimize management of CSU patients who are refractory to antihistamines, reduce disease-related costs, and improve quality of life.

Parietaria judaica and dermo-respiratory allergy in Barcelona: a study of 250 cases.

The wide geographical distribution of parietaria in southern and western Europe is responsible for the high incidence of pollinic hypersensitivity. Our centre detected the existence of hypersensitivity to parietaria judaica in 250 patients (12.15%) out of a group of 2.057 patients. Exclusive consideration of the pollinic patients in this group 980/2,057 showed that the parietaria is the spore responsible for 25.5% of these patients. The most common symptomatology was rhinoconjunctivitis (41.2%) and the least frequent, the dermic picture (1.2%). The diagnostic methodology of these 250 patients included: anamnesis, rhinoscopy, rhinomanometry, skin tests, respiratory function, immunoglobulin levels (IgG, IgA, IgM, IgE), specific IgE and histamine release test. All patients were subjected to immunotherapy using parietaria judaica extracts. The overall evolution following immunotherapy was favourable in more than 80% of the patients, which confirms the suitability of the pareitaria judaica extract in the diagnosis and treatment of this pollinosis.

[Sensitivity and specificity of the determination of IgE using chemiluminescence (CLA allergy test)]. / Estudio de la especificidad y sensibilidad de la determinación de la IgE mediante quimioluminiscencia (CLA allergy test).

We studied 80 patients. All patients underwent a thorough clinical evaluation, including a comprehensive study and physical examination of the ear, nose, throat and chest. Each patient underwent prick testing and a nasal provocation test. In addition, blood was drawn for the allergen-specific IgE test (RAST) and total serum IgE levels. We selected 11 allergens for this study: grass (Dactylis glomerata-orchard grass, Phelum pratense-Timothy grass, Lolium-raygrass), weeds (Chenipodium, Parietaria), tree (European olive), dog, cat, mites (D. pteronyssinus, D. farinae) and mould (Alternaria). To evaluate the efficiency, specificity and sensitivity of this method, test results obtained in our centre were compared to the clinical standard. Sensitivity is related to the lowest concentration of specific IgE detected by test method. Specificity is related to the antibody test's ability to detect the specific substance being measured without interference from related molecules. Chemiluminescent assay system (CLA) demonstrated a good balance between sensitivity and specificity and was consistent for the following allergens: D. pteronyssinus, D. farinae, Parietaria pollen and Gramineae pollena.

Angioedema, rhinitis and asthma provoked by fishing bait (Eisenia foetida).

The Eisenia foetida is an earthworm that is used as fishing bait in river fishing. We report a case of facial angioedema, rhinitis and asthma in an amateur fisherman who used this worm (Eisenia foetida) as fishing bait when fishing in rivers. However, the manifestations of dermo-respiratory hypersensitivity did not arise when he used other fishing bait (Tenibrio molitor and Marphysa sanguinea) in open-sea fishing. "In vivo" and "in vitro" tests using a battery of the usual neumoallergens and food (fish) were negative. Consequently, extracts of Eisenia foetida, Tenibrio molitor and Marphysa sanguinea were prepared. Skin tests, nasal challenge, histamine release curve and levels of specific IgE were positive when using an extract of Eisenia foetida. These parameters, however, were negative for beetle larvae (Tenibrio molitor) and marine worm (Marphysa sanguinea). The allergo-immunological study was also negative for the group of healthy and atopic controls when using these three extracts of fishing bait. The rarity of the allergen responsible for this dermo-respiratory picture stresses the need to include, on occasions, not only insects but also worms in the battery of the usual neumoallergens.

Hypersensitivity to wheat flour in bakers.

Eleven bakers and 4 pastry cooks with hypersensitivity to wheat flour underwent skin tests to flours (wheat, barley, rye, oats), pollens (wheat, barley, rye, oats, grasses), mites (dermatophagoides pteronyssinus, dermatophagoides farinae), molds (alternaria, aspergillus) and weeds (parietaria judaica). The levels of serum immunoglobulins (IgG, IgA, IgM and IgE) were studied and the values of specific IgE (RAST) in the presence of wheat flour and the histamine release test for wheat flour, grass pollens, mites, molds and weeds were assessed. All the patients underwent a nasal challenge test to wheat flour. The results demonstrated the existence of cross reactions between the extracts of barley and rye flour with wheat flour (15/15) as well as between the pollens of cereals and cereal flours. The levels of specific IgE (PRU greater than .35) and the percentages of histamine release (greater than 10%) were positive in 14/15 cases. The nasal challenge test was positive for all the 15 patients under study. Of the patients studied, 11 received immunotherapy for periods ranging from 12 to 18 months. Of these patients, 9/11 continued working in the same occupation whereas the 2 who left their jobs in the industry corresponded to the cases of severe asthma which were polysensitized (flour, mites, molds).

Evaluation of immune parameters (including specific IgG4) during immunotherapy.

A group of 26 patients with allergic asthma and rhinitis, exclusively sensitized to house dust and mites, underwent immunotherapy with an extract of Dermatophagoides pteronyssinus (Allpyral) for a period of 36 months. Every 6 months we carried out a clinical examination and assessed IgE levels, specific IgE to house dust and mites, histamine release curve to house dust and mites, CD3+ CD4+ CD8+ lymphocyte subpopulations, anti-Dermatophagoides pteronyssinus specific IgG and anti-Dermatophagoides pteronyssinus specific IgG4. The results did not show any significant differences in the IgE levels pre therapy and those monitored every 6 months. However, the anti-Dermatophagoides pteronys-sinus specific IgE generally registered a decrease during hyposensitization when compared with the levels obtained before the therapy. The histamine release curve to house dust and mites registered superior histamine release percentages pre immunotherapy to those obtained after 36 months of treatment. The T subpopulations did not show any statistically significant differences at any of the times they were monitored. The assessment of anti-Dermatophagoides pteronyssinus specific IgG did not yield any significant differences in the levels pre, during or at the end of the hyposensitizing period. The study of the levels of anti-Dermatophagoides pteronyssinus specific IgG4 showed a mean overall increase between 6 and 24 months of immunotherapy. When separately comparing these increases in specific IgG, with the clinical course no relationship was found between the increase in these antibodies and levels of the "in vivo" assessment scale.(ABSTRACT TRUNCATED AT 250 WORDS)

"In vivo" and "in vitro" evaluation of four antihistamines (astemizole, azatadine, mequitazine, terfenadine).

A group of 32 patients with perennial allergic rhinitis sensitized exclusively to house dust and mites were evaluated for "in vivo" modifications (skin tests for histamine, house dust and mites) and "in vitro" alterations (seric IgE, specific IgE, histamine release curve to different concentrations of Dermatophagoides pteronyssinus and histamine release curve to this pneumoallergen after incubation with H1 receptor antagonists) to four antihistamines (astemizole, azatadine, mequitazine and terfenadine). The patients were divided into 4 groups of 8 and the "in vivo" and "in vitro" tests were performed on days -1, +15 and +30 of administration of these drugs. The reduction in the size of the wheal (prick test) for histamine when comparing days -1 and +15 and -1 and +30 was 69% and 79% (astemizole), 64% and 71% (azatadine), 69% and 64% (mequitazine) and 61% and 64% (terfenadine), respectively. The difference in the mean size of the wheal in mm2 for house dust, Dermatophagoides pteronyssinus and farinae was statistically significant (p less than 0.001) except when comparing the results obtained for mequitazine on days -1 and +15. This was also the case on days -1 and +30 for terfenadine. The values of the serum IgE and specific IgE did not attain statistical significance (p greater than 0.05) in the various tests carried out. After incubation with H1 receptor antagonists an inhibition curve of the histamine release in the presence of Dermatophagoides pteronyssinus was obtained. The inhibition of this curve on day -1 was higher for terfenadine and mequitazine than for azatadine and astemizole.(ABSTRACT TRUNCATED AT 250 WORDS)

Occupational allergy caused by cow dander: detection and identification of the allergenic fractions.

We describe two cases involving cow farmers, both males, one aged 28 and the other 45, who attended our center because his presented symptoms of rhinoconjunctivitis and asthma with 18 months and 4 year of evolution respectively, related to this laboral environment. The study included the following tests: skin tests (prick tests) to inhalant allergens (mites, pollens, moulds, dog and cat epithelium), foods, cow epithelium-dander, cow serum, beef and milk proteins. We determined the total seric IgE, specific IgE (RAST-CAP System) to cow meat and cow dander. Nasal provocation test with freeze-dried biological standardized extract of cow epithelium-dander were carried out. We observed the symptoms and realized control with a previous active computerized rhinomanometry. Cow dander proteins used for the provocation test were separated by means of SDS-PAGE or isoelectric focusing (IEF). The allergenic component were identified by immunoblotting with the patients' serum. The skin tests were positive to cow dander, and negative to the other allergens tested, including cow serum, cow milk and beef. The seric IgE were 383 and 477 kU/L, and the RAST was positive to cow dander, 20.10 and 36.4 kU/L (class 4). The provocation test were positive with a concentration of 500 SBU. We observed that the IgE of the two patients reacted with the same allergens: 3 major bands were identified with MW of 11, 15, 62.3 kDa. All these bands correspond to protein with acid pl.