Predictors of a positive oral food challenge to cow's milk in children sensitized to cow's milk.

INTRODUCTION AND OBJECTIVES: The diagnosis of IgE-mediated cow's milk allergy (CMA) is often based on clinical history and on specific IgE levels and/or skin-prick tests (SPT), both of which are sensitive but not specific. The gold standard, oral food challenge (OFC), is expensive and time-consuming and involves a risk of severe allergic reactions. This study aimed to determine the value of specific IgEs, ratios of specific IgEs for cow's milk and its components to total IgE, and wheal size on SPT for predicting a positive OFC for CMA. MATERIAL AND METHODS: We retrospectively studied 72 patients [median age, four years; age range 0.75-15 years] sensitized to cow's milk who underwent OFCs to milk. predictive variables between patients with positive and negative OFCs were compared. Receiver operator characteristic (ROC) curves were uses to assess variables' discriminatory capacity and Youden's index to determine the best cut-offs for predicting CMA. RESULTS: The OFC was positive in 39 (54%) patients. Wheal size on SPT and all specific IgEs and specific-to-total IgE ratios were significantly different between patients with positive OFCs and those with negative OFCs (p<0.001). The variable with the greatest area under the ROC curve was casein-specific IgE (0.98), followed by ß-lactoglobulin-specific IgE (0.923), casein-specific-to-total-IgE ratio (0.919), and α-lactalbumin-specific IgE (0.908). Casein-specific IgE ≥0.95kU/L yielded 88.9% sensitivity and 90.9% specificity. CONCLUSIONS: In our center, casein-specific IgE >0.95kU/L can obviate an OFC to cow's milk for the diagnosis of CMA in patients sensitized to cow's milk with a compatible history.

[Respiratory treatments in neuromuscular disease]. / Tratamientos respiratorios en la enfermedad neuromuscular.

In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained.

[Recommendations for management of patients with lung disease planning a flight or high altitude travel]. / Recomendaciones previas al vuelo y a viajes con exposición a altitud en pacientes con patología respiratoria.

Every year a large number of children travel by plane and/or to places with high altitudes. Most of these journeys occur without incident. Immigration and recent socioeconomic changes have also increased the number of patients with cardiopulmonary disease who travel. Environmental changes in these places, especially lower oxygen, can lead to a risk of significant adverse events. The paediatrician must be aware of the diseases that are susceptible to complications, as well as the necessary preliminary studies and recommendations for treatment in these circumstances. The Techniques Group of the Spanish Society of Paediatric Chest Diseases undertook to design a document reviewing the literature on the subject, providing some useful recommendations in the management of these patients.

[Diagnosis and treatment guidelines for difficult-to-control asthma in children]. / Guía de diagnóstico y tratamiento del asma de control difícil en el niño.

Children suffering from difficult-to-control asthma (DCA) require frequent appointments with their physician, complex treatment regimes and often admissions to hospital. Less than 5% of the asthmatic population suffer this condition. DCA must be correctly characterised to rule out false causes of DCA and requires making a differential diagnosis from pathologies that mimic asthma, comorbidity, environmental and psychological factors, and analysing the factors to determine poor treatment compliance. In true DCA cases, inflammation studies (exhaled nitric oxide, induced sputum, broncho-alveolar lavage and bronchial biopsy), pulmonary function and other clinical aspects can classify DCA into different phenotypes which could make therapeutic decision-making easier.

[Respiratory function assessment in cooperative patients. Part II]. / Estudio de la función pulmonar en el paciente colaborador. Parte II.

Analysis of bronchial hyperresponsiveness using bronchial provocation tests are a key feature in the diagnosis of asthma, as well as a valid tool for monitoring disease severity, clinical course, and treatment response. We review non-specific bronchial challenge tests, including pharmacological stimuli (methacholine, adenosine) and physical stimuli (exercise, hypertonic saline, cold air hyperventilation). Although there is some correlation among responses to the distinct tests, individual responses are also observed. The indication for a single test will depend on whether the procedure will be used for diagnostic or epidemiologic purposes, and on experience of its use. Frequently, complementary information will be obtained. Indirect airway challenges tests such as physical stimuli and adenosine are more specific for asthma diagnosis.

[Respiratory function assessment in cooperative patients. Part I. Spiromery and bronchodilator reversibility testing]. / Estudio de la función pulmonar en el paciente colaborador. Parte I.

Assessment of respiratory function is the principal tool in the study of patients with lung diseases, allowing physiopathological alterations to be detected, and the severity of the process, its clinical course, and treatment response to be identified. Nowadays, assessment of respiratory function is among the investigations used by Spanish pediatricians. The Techniques Group of the Spanish Society of Pediatric Pneumology undertook the design of a protocol for the study of pulmonary function in children that would incorporate the most recent published consensus documents on basic pulmonary function assessment (spirometry and bronchodilator reversibility testing) and on airway hyperreactivity evaluation using nonspecific provocation tests. The aim of this protocol is to provide a guide to good clinical practice until new changes, based on scientific evidence, are produced.

[Management of parapneumonic pleural effusions]. / Tratamiento de los derrames pleurales paraneumónicos.

Pleural effusion in children is most often due to bacterial pneumonia. Between 0.6 and 2% of pneumonias are complicated by empyema and approximately 40% of children hospitalized with pneumonia have a pleural effusion. In recent years Streptococcus pneumoniae is the most prevalent organism. Treatment is based on the early and judicious use of antibiotics, imaging techniques, thoracocentesis, pleural drainage, fibrinolytics, thoracoscopy and thoracotomy. Indications for early pleural drainage are gross pus, positive Gram stain in pleural fluid, pleural glucose less than 50mg/dL, pleural fluid pH of less than 7 and sonographic evidence of loculations. Local fibrinolytics may decrease the need for surgical treatment, with a success rate between 38 and 100%, according to the effusion stage. Thoracoscopic debridement is useful in the fibrinopurulent stage with loculations, with favorable results in 30-100% of patients, also depending on the effusion stage.

[Cystic fibrosis: a new disease in adults]. / Fibrosis quística: una nueva patología del adulto.

OBJECTIVE: Cystic fibrosis (CF) has undergone substantial epidemiological changes. The life expectancy of CF patients and the proportion of affected adults are rising because of advances in diagnosis and treatment. In order to find out more about our current situation, we sent an anonymous questionnaire to all affected members of the Catalonian Association of CF. PATIENTS AND METHODS: The questionnaire was sent to 180 patients and their parents asking for information about demographical aspects, diagnosis, pulmonary function, microbiological data, complications, treatment, number of medical visits to CF centers, personal, social and professional development, and the degree of satisfaction with the medical care received. RESULTS: The questionnaire was correctly completed by 75 patients. Of these, 20% were older than 18 years of age. The mean age at diagnosis was 3.25 years. The initial symptoms were: meconium ileus (8%), growth retardation (24%), respiratory problems (34%) and gastrointestinal problems (36%). Sixty percent of the patients showed positive sputum cultures. The most frequently isolated microorganism was P. aeruginosa. Apart form the usual therapy with antibiotics, enzyme replacement and vitamin supplements, other therapeutic measures employed included: alimentary supplements (54%), mucolitics (27%), bronchodilators (45%) and inhaled anti-inflammatories (20%). Complications were present in 56% of the patients and these included hemoptysis, polyps, rectal prolapse, hepatic disease, diabetes, psychological changes, biliary litiasis, pneumothorax, infertility or pancreatitis. The proportion of positive sputum cultures, the type of germ identified and the complications observed changed according to the patient's age. CONCLUSIONS: National registers can be very useful tools to make public health plans. They are also good instruments to evaluate the progress made in the treatment of diseases such as CF.