Tree Nuts Anaphylaxis in Preschool Age Children.

Summary: Introduction. The incidence of food-induced anaphylaxis (FIA) is increasing in young children. Although the commonest culprits are cow's milk and egg, FIA to tree nuts (TNs) have been increasing. Objective. Characterization of children referred to our allergy department due to TNs-induced anaphylaxis (TNs-FIA) during preschool age. Materials and methods. We have retrospectively included 25 children with clinical history of preschool TNs-FIA, proven by allergological work-up. TNs sensitization was assessed by skin prick tests and/or specific IgE. Results. The mean age of the first anaphylactic episode was 3.1±1.2 years. The majority (92%) had an allergic disease (52% asthma). The implicated TNs were cashew (11 children), walnut (8), pine nut (5), hazelnut (2) and almond (1). The reaction occurred after the first known ingestion in 68%. In 92%, symptoms appeared within 30 minutes after exposure. The most frequent clinical symptoms were mucocutaneous (96%), respiratory (80%) and gastrointestinal (52%). Twenty-one children were admitted to the emergency department, although only 48% were treated with epinephrine. An underneath IgE-mediated mechanism was proven in all cases. Immunologic cross-reactivity with other TNs was identified in 84%, and with peanut in 36%. Overall, in our center, TNs-FIA represents 18% of all causes of FIA. Conclusions. In preschool age children with TNs-FIA, cashew and walnut were the commonest implicated nuts. Most reactions occurred briefly after exposure to minimal amounts of TNs, demonstrating the high potency of these allergens. About one-third also had peanut sensitization. Potentially life-threatening TNs allergy can occur early in childhood and adequate management should be undertaken.

Isolation, characterization, and evaluation of three Citrus sinensis-derived constitutive gene promoters.

KEY MESSAGE: Regulatory sequences from the citrus constitutive genes cyclophilin (CsCYP), glyceraldehyde-3-phosphate dehydrogenase C2 (CsGAPC2), and elongation factor 1-alpha (CsEF1) were isolated, fused to the uidA gene, and qualitatively and quantitatively evaluated in transgenic sweet orange plants. The 5' upstream region of a gene (the promoter) is the most important component for the initiation and regulation of gene transcription of both native genes and transgenes in plants. The isolation and characterization of gene regulatory sequences are essential to the development of intragenic or cisgenic genetic manipulation strategies, which imply the use of genetic material from the same species or from closely related species. We describe herein the isolation and evaluation of the promoter sequence from three constitutively expressed citrus genes: cyclophilin (CsCYP), glyceraldehyde-3-phosphate dehydrogenase C2 (CsGAPC2), and elongation factor 1-alpha (CsEF1). The functionality of the promoters was confirmed by a histochemical GUS assay in leaves, stems, and roots of stably transformed citrus plants expressing the promoter-uidA construct. Lower uidA mRNA levels were detected when the transgene was under the control of citrus promoters as compared to the expression under the control of the CaMV35S promoter. The association of the uidA gene with the citrus-derived promoters resulted in mRNA levels of up to 60-41.8% of the value obtained with the construct containing CaMV35S driving the uidA gene. Moreover, a lower inter-individual variability in transgene expression was observed amongst the different transgenic lines, where gene constructs containing citrus-derived promoters were used. In silico analysis of the citrus-derived promoter sequences revealed that their activity may be controlled by several putative cis-regulatory elements. These citrus promoters will expand the availability of regulatory sequences for driving gene expression in citrus gene-modification programs.

Hypersensitivity to beta-lactam antibiotics: a three-year study.

BACKGROUND: Beta-lactams antibiotics (BL) are the most frequent elicitors of allergic drug reactions. The aim of our study was to characterize the patients referred with suspected hypersensitivity (HS) to BL. METHODS: Over a three-year period (2011-2013), a total of 234 adult and paediatric patients (pts) with suspected HS to BL were investigated according to the European Network for Drug Allergy guidelines. RESULTS: HS to BL was confirmed in 43 pts (18%), without differences between adult and paediatric pts; anaphylaxis was reported by 20 pts. Diagnosis was ascertained by: serum-specific IgE antibodies in 5 pts (12%), skin prick tests in 5 (12%), intradermal tests in 25 (58%), 3 with delayed reading, and the remaining 8 (18%) by drug provocation tests. Penicillins / derivatives were the culprit drugs in 39 pts, mainly amoxicillin, and cephalosporins in 4. CONCLUSION: In most of these patients with suspected HS to BL, allergological work-up was negative and HS was excluded. One fourth of confirmed cases had a plausible non-IgE mediated mechanism.

Translation to Portuguese and cultural adaptation of Food Allergy Quality of Life Questionnaire - Parent Form (FAQLQ-PF).

Food allergy is a health problem with significant negative impact in Quality of Life (QoL). We aimed to translate into Portuguese and culturally adapt to our population the Food Allergy Quality of Life Questionnaire - Parent Form (FAQLQ-PF). Cross-cultural translation was performed according to guidelines. Linguistic validation consisted in 3 steps: forward translation, backward translation and comprehensibility testing. A consensual version was obtained and tested in parents of food allergic children by cognitive debriefing. Twelve questionnaires were fulfilled, all completed in ≤ 15 min. No comments, doubts or suggestions were posed, except for 2 parents regarding a question about the number of food their children had to avoid. Two gave special positive feedback about the utility of FAQLQ-PF. Changes have been included after this pre-test in accordance to doubts and suggestions of participants, and the Portuguese version is now able to be used in clinics and research.

Can esophageal dilation be avoided in the treatment of severe esophageal stricture caused by eosinophilic esophagitis?

Eosinophilic esophagitis (EoE) is an inflammatory immune-mediated disease with predominant eosinophilic inflammation characterized by the presence of esophageal dysfunction symptoms. Treatment delay can be associated with disease complications, like esophageal strictures, that can justify the use of invasive procedures which are not deprived of side effects. We present a case report of a 14 year old child with severe esophageal stricture secondary to EoE, that was treated with topical and systemic corticosteroid before any invasive procedure was considered. After 26 weeks of medical treatment, significant improvement of esophageal dysfunction occurred with histological remission and stricture resolution. In patients with severe esophageal strictures secondary to EoE, the need for esophageal dilation procedures should be considered only after anti-inflammatory treatment.

One-year survey of paediatric anaphylaxis in an allergy department.

AIM: To determine the frequency of anaphylaxis in an allergy outpatient department, allowing a better understanding regarding aetiology, clinical manifestations and management, in children and adolescents. METHODS: From among 3646 patients up to 18 years old observed during one-year period, we included those with history of anaphylaxis reported by allergists. RESULTS: Sixty-four children had history of anaphylaxis (prevalence of 1.8%), with mean age 8.1±5.5 years, 61% being male. Median age of the first anaphylactic episode was 3 years (1 month-17 years). The majority of patients had food-induced anaphylaxis (84%): milk 22, egg 7, peanut 6, tree nuts 6, fresh fruits 6, crustaceans 4, fish 4 and wheat 2. Food-associated exercise-induced anaphylaxis was reported in 2 adolescents. Drug-induced anaphylaxis occurred in 8%: 4 non-steroidal anti-inflammatory drugs and 1 amoxicillin. Three children had cold-induced anaphylaxis, one adolescent had anaphylaxis to latex and one child had anaphylaxis to insect sting. The majority (73%) had no previous diagnosis of the etiologic factor. Symptoms reported were mainly mucocutaneous (94%) and respiratory (84%), followed by gastrointestinal (42%) and cardiovascular (25%). Fifty-one patients were admitted to the emergency department, although only 33% were treated with epinephrine. Recurrence of anaphylaxis occurred in 26 patients (3 or more episodes in 14). CONCLUSIONS: In our paediatric population, the main triggering agent of anaphylaxis was IgE-mediated food allergy. Epinephrine is underused, as reported by others. Often, children have several episodes before being assessed by an allergist. We stress the importance of systematic notification and improvement of educational programmes in order to achieve a better preventive and therapeutic management of this life-threatening entity.

4 Domain Sports PROM in Spanish: Cross-cultural adaptation in the Chilean population and reliability analysis. / 4 Domain Sports PROM en español: adaptación transcultural en la población chilena y análisis de confiabilidad.

BACKGROUND: Patient-Reported Outcome Measures (PROMs) are tools of increasing interest in the sports population. The purpose of this study was to perform the cross-cultural adaptation and reliability analysis of the 4 Domain Sports Patient-Reported Outcome Measure (4DSP) into Spanish. METHODS: A six-stage cross-cultural adaptation protocol was executed to obtain the Spanish version of the 4DSP (S-4DSP). Subsequently, the questionnaire was administered to a population of 108 postoperative athletes with ACL (Anterior Cruciate Ligament) injuries. The questionnaire was administered again after 30 days. Acceptability, floor and ceiling effects, internal consistency (Cronbach's alpha), and reproducibility (Intraclass Correlation) were evaluated. RESULTS: The S-4DSP was fully completed by 108 participants (mean age 34±10.75, 26% women), achieving 100% acceptability. No floor effect was detected. The statistical analysis yielded a global Cronbach's alpha for the questionnaire of 0.65, and domain-specific alphas of 0.88, 0.72, 0.27, and 0.68 for the first, second, third, and fourth domains, respectively. The Intraclass Correlation test reached a maximum of 0.94 and a minimum of 0.48 for the first and fifth questions, respectively. CONCLUSIONS: The S-4DSP is a reliable and useful tool for evaluating Spanish-speaking athletes after ACL reconstruction.

IgE-mediated metamizol allergy and the usefulness of the cellular allergen stimulation test.

Metamizol is a pyrazolone-derivative nonsteroidal anti-inflammatory drug that is commonly associated with hypersensitivity reactions. Some of these reactions are IgE-mediated and potentially severe, which limits the diagnosis based on oral drug challenge. We describe 6 selective metamizol hypersensitivity cases, regarding clinical evaluation and diagnosis management, with focus on the usefulness of skin tests and the cellular allergen stimulation test (CAST). All patients were female, aged 27 to 50 years old. All had immediate reactions after metamizol administration: 3 had anaphylaxis and 3 had urticaria and angioedema. Skin prick tests with metamizol were positive in 2 patients. Intradermal tests were positive in the remaining, all with 1/100 dilution, and elicited systemic reactions in 2 of them. CAST to metamizol was negative in all cases. The patients tolerated other nonsteroidal anti-inflammatory drugs. Skin tests proved to be a good diagnostic method to identify IgE-mediated metamizol allergy, although skin tests elicited systemic symptoms in some cases. Despite this being a small sample, our results showed a very low sensitivity for CAST which differs from data previously reported in the literature.

Intraoperative fractures and ligament tears during total knee arthroplasty. A 1795 posterostabilized TKA continuous series.

INTRODUCTION: Intraoperative fractures are a reported complication during the course of primary total knee replacement. Major ligament disruptions can also occur. Clinical data are lacking to tell how much these incidents affect implantation quality and outcome. HYPOTHESIS: A thorough knowledge of these occasional incidents helps proper decision making when confronted to such situations at surgery. MATERIALS AND METHODS: This report is based on a series of primary, posterostabilized total knee arthroplasties (posterostabilized, mobile bearing TKA with a third median condyle from Tornier Laboratory). We studied all possible mechanical complications that developed during the course of arthroplasty and analyzed their cause. We compared the functional results of patients presenting these complications to those of the total series and to data from the literature. The entire operative reports for the 1795 TKA performed during this study were available and evaluated. A clinical and radiological review was performed for 1624 patients at an average follow-up time of 36.8+/-34 (2-193) months. RESULTS: At this last follow-up, the average International Knee Society (IKS) score was 91.2 (19-100) and the function score was 77.76 (0-100). One hundred and thirty-two patients were deceased (unrelated to TKA) at this last follow-up evaluation. A total of 69 mechanical complications were accounted for at the time of surgery (3.8%): 40 definite fractures or fissures around the knee (2.2%), 29 tendon or ligament disruptions or attenuations (1.6%). The risk of tibial cracks was statistically more significant, with the smaller sizes tibial trays (size 1) (p=0.019) or when an anterior tibial tuberosity elevation had been performed (p=0.02). Survival curve analysis (at an average seven and a half-years postoperative follow-up) showed that all prosthetic components were still present in 93.3% of cases in the series of patients with these peroperative complications, and in 93.8% of cases in the series of patients without these intraoperative complications; this survival rate amounted to 91.9% of cases at an average 16-years postoperative follow-up. CONCLUSION: This large, homogeneous series of primary, posterostabilized TKA took on 3.8% of intraoperative bone or ligament complications. All these complications could be prevented by a rigorous surgical technique. The improvement of ancillary materials, the saws, and good knowledge of such complications by the surgeon are essential. LEVEL OF EVIDENCE: Level IV. Therapeutic Study.