Professional burnout and work satisfaction in Spanish allergists: analysis of working conditions in the specialty.

BACKGROUND: Burnout is a worrying problem in the medical profession and has proven to be highly prevalent in all the care settings and specialty areas in which it has been studied.We applied 2 widely used questionnaires to analyze the working conditions of Spanish allergists in terms of quality of professional life and degree of burnout perceived. METHODS: Participants completed 2 questionnaires: the 22-item Maslach scale, a structured questionnaire covering different aspects of the feelings and attitudes of professionals toward their work and patients; and the Spanish Quality of Professional Life Questionnaire (CPV-35), a 35-item questionnaire evaluating job satisfaction and perceived quality of life at work. RESULTS: We received 404 questionnaires from throughout Spain. The main sources of motivation were better pay (94.4%), more available resources/technology (85.1%), access to research activities (81%), and promotion in one's professional career (80.1%). Analysis of the scores from the Maslach scale revealed that two-thirds of the allergists interviewed experienced medium and high levels of negative burnout (67.9% and 66.2%, respectively, for emotional exhaustion and depersonalization). This situation was in part compensated for by the fact that a slightly lower proportion of the group (59.2%) obtained very high scores on personal accomplishment in their work. Analysis of the scores from the CPV-35 questionnaire revealed 3 complementary aspects of job satisfaction: perceptions of the workload borne (5.8), management support available to cope with daily patient workload (5.6), and levels of intrinsic motivation for work (7.7), which was the highest value. The score for the item summarizing self-perceived overall quality of working life was acceptable (6.4). CONCLUSION: Promoting intrinsic motivation of Spanish allergists using the motivating factors identified in this study could protect against professional burnout.

Omalizumab. A review of the new treatment of allergic asthma and seasonal allergic rhinitis.

The causal role of immunoglobulin E (IgE) in triggering the cascade of biochemical events leading to allergic disease is well established. Treatments that selectively inhibit IgE activity are a logical approach in managing the allergic response. Omalizumab is a recombinant humanised monoclonal antibody which specifically binds to the Cε3 domain of immunoglobulin (Ig) E, the site of high-affinity IgE receptor binding. The clinical benefit and steroid-sparing effect of treatment with the anti-immunoglobulin-E (IgE) antibody, Omalizumab, was assessed in patients with moderate-to-severe allergic asthma and seasonal allergic rhinitis. Intravenous and subcutaneous administration of anti-IgE mAb reduces circulating levels of IgE in atopic patients to low levels commonly seen in non-atopic individuals. Anti-IgE therapy offers protection against allergen-induced bronchoconstriction, reduces the need for short acting inhaled beta 2-agonist and corticosteroids among asthmatic patients and reduces severity of symptoms of allergic rhinitis. Adverse events were infrequent in clinical trials of omalizumab, and not significantly different from placebo. The most frequent drug-related event was mild to moderate urticaria. They do not induce anaphylaxis and the occurrence of antibodies against anti-IgE mAb is sporadic. The results of cited studies suggest that humanized anti-IgE monoclonal antibodies may have important immunotherapeutic benefit for treatment of allergic disorders.

How to fill an application for accreditation of Continuing Medical Education activity in Allergology.

Continuing medical education (CME) is a critical tool as well as a generally accepted concern for physicians, while being both a commitment and an obligation for the Administration. In Spain, during the past decades, CME has been a constant concern of many groups; however, it was not until the end of the eighties when efforts at accreditation began to emerge. A significant step was the establishment of the Commission on Continuing Education of Health Professions of the National Health System, an agency of the Consejo Interterritorial (Inter-regional Council), whose accreditation system started in 1998, using the figure of Sector Conference, included in Articles 5 and 8 of the Ley de Régimen Jurídico de las Administraciones Públicas y del Procedimiento Administrativo Común (Law on Legal Regime of Public Administration and Common Administrative Procedures), as Senior Technical Body on the matter. Since then, various Regional Committees and the Spanish Accreditation System of Continuing Medical Education (SEAFORMEC) have been created. Although we earlier published a guide, in this manuscript we have updated the steps that must be taken to apply for accreditation of CME activity in Allergology, explaining the different items in the official application form, clarifying to whom the request should be addressed, and outlining the foundations on which the activities will be evaluated for accreditation purposes, in order to ensure that the training meets the highest standards for quality, so that the objectives that lead to achieving maximum performance and competence of health professionals may be reached.

Efficient bibliographic searches on allergy using ISI databases.

The aim of this article is to provide an introduction to using databases from the Thomson ISI Web of Knowledge, with special reference to Citation Indexes as an analysis tool for publications, and also to explain the meaning of the well-known Impact Factor. We present the partially modified new Consultation Interface to enhance information search routines of these databases. It introduces distinctive methods in search bibliography, including the correct application of analysis tools, paying particular attention to Journal Citation Reports and Impact Factor. We finish this article with comment on the consequences of using the Impact Factor as a quality indicator for the assessment of journals and publications, and how to ensure measures for indexing in the Thomson ISI Databases.

Anisakis simplex allergy and nephrotic syndrome.

BACKGROUND: Anisakis simplex is a helmintic parasite of fish and shellfish that can induce in humans, after consumption, an immunoallergic response with multiorganic affectation, especially cutaneous (urticaria and angioedema), gastrointestinal and anaphylactic symptoms. Nephrotic syndrome can be produced by helmintic infection, especially schistosomiasis. OBJECTIVE: To report the unusual case of nephrotic syndrome associated to an allergic response to A. simplex. METHODS: A 60-year-old woman suffered from nephrotic syndrome three weeks after a generalized urticaria, angioedema and nauseas episode, following a raw anchovy's ingestion. Etiological study of nephrotic syndrome and urticaria/angioedema, cutaneous test, serum total and specific IgE determination, IgE-immunoblotting, and HLA typing were performed for diagnostic evaluation. RESULTS: Prick-test with A. simplex extract was positive. It was observed a significance increase of total IgE to the three weeks of anchovy's ingestion and then it diminished progressively. Specific IgE to A. simplex was > 100 UI/ml. Immunoblotting to A. simplex, revealed the existence of IgE-binding proteins with molecular mass ranging from 20 kDa to 99 kDa. Class I HLA expressed by the patient was type HLA-B12. Other secondary causes of nephrotic syndrome were carefully ruled out. CONCLUSIONS: These data suggest, for the first time, the association between allergy to A. simplex and nephrotic syndrome.

Efficient bibliographic searches on allergology using PubMed.

INTRODUCTION: PubMed is the most important of the non-specialized databases on biomedical literature. International and quickly updated is elaborated by the American Government and contains only information about papers published in scientific journal/s. Although it can be used as an unique Data Base, as a matter of fact is the addition of several subgroups (among them MEDLINE) that can be searched simultaneously. OBJECTIVES: To present the main characteristics of PubMed, as well as the most important procedures of search, for obtaining efficient results in searches on allergology. CHARACTERISTICS AND SEARCH PROCEDURES: PubMed is elaborated by the American Administration, that condition the character of the registered papers, 90 % of them are written in English in American (50 %) or British (20 %) Journals. Because of this, the information for certain specialties or countries must be obtained from other sources. This paper shows how PubMed allows to search in natural language due to the Automatic Term Mapping that links terms from the natural language with the descriptors producing searches with a higher sensitivity although with a low specificity. Nevertheless the MeSH (Medical Subject Headings) thesaurus allows to translate those terms from the natural language to the equivalent descriptor, as well as to make queries in the PubMed's documental language with a high specificity but with lower sensitivity than the natural language. The use of union (OR), intersection (AND) and exclusion (NOT) operators, as well as tags, such as delimiters of the search fields, allows to increase the specificity of the results. Similar results may be obtained with the use of Limits. Searches done using Clinical Queries are very interesting due to their direct clinical application and because allow to find systematic reviews, metaanalysis or clinically oriented papers (treatment, diagnostic, etiology, prognosis or clinical prediction guides) on the area of interest. Other procedures such as the Index, History of searches, and the widening of the selection using Related Articles and the storing of separate results in the Clipboard to be kept by the user, are presented in this paper.

Non-compliance with appointments amongst patients attending an Allergology Clinic, after implementation of an improvement plan.

BACKGROUND: Non-compliance is a common cause of failed medical action, contributing to absence of regular check-ups. Our group has already published studies that analyse the level of non-compliance with appointments amongst patients attending our Allergology clinic, and we have made proposals for improvement. OBJECTIVE: This article evaluates the results obtained three years after setting up and launching telephone reminders for patients' first appointments. METHODS: All patients who were given appointments for first and subsequent visits during 2005 were included. A total of 18215 appointments were studied (3115 first appointments and 15100 subsequent ones). Of these, there were 2479 missed appointments (438 first appointments and 2041 subsequent ones), corresponding to 2215 patients (412 first visits and 1803 subsequent ones), with a mean of 1.12 appointments/patient/year. RESULTS: The non-compliance rate was 13.61%. The most common non-compliers were men (14.11% missed appointments against 13.24% missed appointments in women) and in the age range 20-29 years and 30-39 years (16.46% and 15.28% non-compliance, respectively). The mean age of non-compliers was 34.55 +/- 14.73 years. We observed a significant number of patients who missed more than one appointment (5.12% of all non-compliers and 0.7% of all patients). Differences were found in the degree of non-compliance depending on the type of appointment (14.06% non-compliance with first visits and 13.52% with subsequent visits). We observed a significant increase in missed appointments during the Summer holidays; July and August showed the highest percentage of missed appointments for both the first visit (20.62% in July and 23.59% in August) and subsequent visits alike (16.14% in July and 14.23% in August). CONCLUSIONS: A slight reduction in non-compliance was observed after implementing the proposals made in our previous study. In view of the high costs incurred from missed appointments, the government should finance studies to reduce this problem. The causes of non-compliance may be difficult to control, including present access to the public health service. We must be alert to and/or take preventive measures in young patients and cases of previous non-compliance. The degree of non-compliance is a quality indicator, because it reduces the yield of appointments, and it evidences a lack of cohesion of patients with Primary Health Care Units for first appointments, and with Specialist Care Units for subsequent appointments. Once certain levels of attendance have been attained, it is difficult to achieve an effect on this point in order to improve attendance rates.

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.

Direct patient treatment costs in the Allergology Service of a University Hospital.

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 Allergy Unit of the University Hospital Virgen de la Arrixaca in Murcia (Spain), the health area in which allergic patients are attended, and the final healthcare products generated. Based on the 2004-2005 budget, variable costing was used to calculate the costs of the healthcare products generated (first visits, subsequent visits, and diverse laboratory tests) by two of the three homogeneous functional groups (HFG), i.e., HFG of the ambulatory service and HFG of complementary tests. 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) clinical management and complementary tests should go hand in hand with a view to optimizing resources.

Cold urticaria associated with acute serologic toxoplasmosis.

Cold urticaria is defined as a urticarial and/or angioedematous reaction of the skin to contact with cold objects, water or air. Types of urticaria associated with infectious diseases, such as mononucleosis, rubeola, varicella, syphilis, hepatitis, and HIV infection have been reported. We present the case of a patient who developed cold urticaria associated with acute serologic toxoplasmosis. The patient was a 34-year-old man who for the previous 2 months had presented cutaneous pruritus accompanied by several papular lesions in parts of the skin exposed to cold as well as those in contact with cold water. The result of an "ice-cube test" was positive. Serologic tests for Toxoplasma gondii showed an IgG level of 68 UI/ml and were positive for IgM, while a test for cryoglobulins was positive. One month later cryoglobulins were negative and a serologic test for T. gondii showed an IgG concentration of 75 UI/ml and positive IgM. Three months later cryoglobulins were still negative, IgG for T. gondii was 84 UI/ml, and IgM was positive. After 6 months cryoglobulins were still negative, IgG level was 68 UI/ml and IgM was still slightly positive. In the final evaluation, 14 months later, IgG level was 32 UI/ml and IgM was negative. The patient continues to present clinical manifestations of cold urticaria, although he has experienced some improvement and his tolerance to cold has increased after treatment with cetirizine.

Characterization of human peripheral blood lymphocyte cells on the basis of surface properties.

Human lymphocytes are divided into two populations, thymus-dependent or T-cells, required for cell-mediated immunity, and B-cells which are thymus independent and responsible for antibody-mediated immunity. Conventional light microscopy cannot differentiate between T and B lymphocytes, but the introduction and studies of lymphocyte membrane markers have shown a lymphocyte heterogeneity. In the present paper, various methods for characterization of human peripheral blood lymphocyte cells; based on surface properties, have been studied. Because of the membrane markers of receptors on human lymphocytes, the immune function of the subpopulations may be described. Functional studies may be performed on cell suspensions in which subpopulations are eliminated or concentrated by means of their respective membrane markers. The surface of various lymphocyte subpopulations are characterized by the presence of receptors for immune molecules, immunoglobulin, complement, hormones active in immune processes, prostaglandins and histamine. The presence of these receptors may allow for the participation of the lymphocyte in the various stages of immune processes.

Chronic idiopathic urticaria treatment.

Chronic idiopathic urticaria (CIU) is a common skin condition that affects 0.1-3 % of people in the USA and Europe and accounts for nearly 75 % of all chronic urticaria cases. Up to 40 % of patients who have chronic urticaria for more than 6 months still have urticarial wheals 10 years later. The therapeutic management should first be oriented towards palliation of symptoms. A 2 % solution of ephedrine as a local spray is very useful for oropharyngeal edema. H1 antihistamines with a low potential for sedation are the most important first-line treatment. Combinations of various antihistamines may be useful in suppressing symptomatology. These include: a) First generation H1 antihistamines; b) Combinations of first and second generations using non-sedating agents in the morning and first generation drugs at night; c) Combinations of second generation antihistamines; d) Combination of doxepin with a first or second generation antihistamine; e) Combination of an H2 anti-receptor antihistamine (eg, cimetidine or ranitidine) with a first or second generation antihistamine. Preliminary reports suggest that desloratadine and anti-leukotrienes may be effective in treating some patients with chronic idiopathic urticaria.

[Techniques for determining case mix and their application to Allergology. 2]. / Técnicas de medición del "Case-Mix" y su aplicación a la Alergología (2a parte).

In this second part, we review the Generic Algorithms, the RUGs and the Ambulatory Visits Groups, remarking their possible application in our specialty. In an Allergology Service, most resources are spent on outpatients attendance. This fact allows us to propose that a production unit of that Service (GFH) could develop its activities, in its health area, ambulatorily. Its objectives and responsibilities, together with its human and material resources, could be clearly defined. An allergy outpatients clinic basic technological requirements are scarce, its costs being mainly determined by those of the staff. This makes possible the application of algorithms, to obtain the AVGs in Allergology, and to calculate the "cost by process", with the use of an indirect cost imputation system. The systematic use of evaluation technics in our specialty case-mix is a necessity in the present, because it permits: 1) a correct planning, fixing and ordering the objectives; 2) a better user of resources; 3) an adequate request of budgets, according to production; 4) obtaining a clinical and epidemiological data base; 5) billing the services; 6) information to the customer (patient) about the expenses his attention has generated.

[Techniques for determining case mix and their application to Allergology. 1]. / Técnicas de medición del "Case-Mix" y su aplicación a la Alergología (1a parte).

The use of adequate technics, in the Allergology case-mix evaluation, is a necessity in the present, and an aim to the future. Doing so, we shall be able to guarantee the quality of medical assistance. This article's objective is to introduce the reader, with a clear language, in the diverse procedures employed, in the actuality, to evaluate the diverse Health Services productive processes. We point out their advantages and disadvantages, and make a final proposal about the use of some of them in Allergology. Firstly, we analyze and describe the International Disease Classification (IDC-9-CM), the Diagnosis Related Groups (DRGs), the AS-SCORE, the Patients Severity Illness, the Staging Disease, the APACHE, and the Patients Management Categories. In the second part, we review the Generic Algorithms, the RUGs and the Ambulatory Visits Groups (AVGs). Finally, we propose some methods to improve activities in our specialty, to increase our knowledge, and to educate our colleagues under training in the basic concepts they need, to carry out their activities. In this way, we'll be able to guarantee a good assistance for the allergic patients, and to present objective data to the society, about the efficacy and efficiency with which public funds are used.

[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)