Blood or skin: what is best in predicting cow's milk allergy diagnosis?

Summary: Cut-off values for both skin prick tests (SPT) and specific IgE (sIgE) levels for predicting cow´s milk allergy (CMA) diagnosis are not universally defined. This study is a retrospective analysis of consecutive children (0-18 years-old) with suspected CMA tested with SPT and sIgE for cow's milk (CM) and its fractions between 2016-2017. CMA diagnosis was defined by a positive oral food challenge or a highly suggestive clinical history of CMA and SPT and/or sIgE positive to CM and/or its fractions. One hundred and five patients were included, 58% males with a median age of 2.5 (P25-P75:1-6) years and the diagnosis was confirmed in 83 patients (79%). The variables associated with CMA diagnosis were SPT with CM (p minor 0,05) and casein (p minor 0,05) and all sIgE to CM and its fractions (alfa Lactalbumin, beta Lactoglobulin and casein; p minor 0,05 for all). Optimal cut39 off points (Youden's index) for CMA diagnosis were, for the mean wheal diameter, to CM milk of 4.5mm and to casein of 3mm. For sIgE levels the optimal cut-off points were: for CM of 4.36 kUA/L, alfa-lactalbumin of 1.6 kUA/L, beta-lactoglobulin of 1.7 kUA/L and for casein of 2.6 kUA/L. The role of SPT and sIgE levels to cow´s mlik and its fractions is unequivocal in CMA follow-up. Moreover, sIgE levels seem to be more discriminatory than SPT.

Whole-genome sequencing resolves a polyclonal outbreak by extended-spectrum beta-lactam and carbapenem-resistant Klebsiella pneumoniae in a Portuguese tertiary-care hospital.

Klebsiella pneumoniae has emerged as an important nosocomial pathogen, with whole-genome sequencing (WGS) significantly improving our ability to characterize associated outbreaks. Our study sought to perform a genome-wide analysis of multiclonal K. pneumoniae isolates (n=39; 23 patients) producing extended spectrum beta-lactamases and/or carbapenemases sourced between 2011 and 2016 in a Portuguese tertiary-care hospital. All isolates showed resistance to third-generation cephalosporins and six isolates (five patients) were also carbapenem resistant. Genome-wide-based phylogenetic analysis revealed a topology representing ongoing dissemination of three main sequence-type (ST) clades (ST15, ST147 and ST307) and transmission across different wards, compatible with missing links that can take the form of undetected colonized patients. Two carbapenemase-coding genes were detected: blaKPC-3, located on a Tn4401d transposon, and blaGES-5 on a novel class 3 integron. Additionally, four genes coding for ESBLs (blaBEL-1, blaCTX-M-8, blaCTX-M-15 and blaCTX-M-32) were also detected. ESBL horizontal dissemination across five clades is highlighted by the similar genetic environments of blaCTX-M-15 gene upstream of ISEcp1 on a Tn3-like transposon. Overall, this study provides a high-resolution genome-wide perspective on the epidemiology of ESBL and carbapenemase-producing K. pneumoniae in a healthcare setting while contributing for the adoption of appropriate intervention and prevention strategies.

Mucoid degeneration of the anterior cruciate ligament: magnetic resonance imaging findings of an underdiagnosed entity.

Although imaging and clinical criteria are already established for the diagnosis of mucoid degeneration of the anterior cruciate ligament (ACL), many radiologists remain unaware of their existence. Once regarded as a rare occurrence, it has been recently suggested that its incidence is in fact very much higher than previously thought, and that it is probably underdiagnosed or misdiagnosed as partial ruptures of the ACL or as cystic ganglia. In this review, the authors revisit the literature concerning this subject and present their personal experience with it, stressing the paramount importance of magnetic resonance imaging and correlation with clinical data for a correct diagnosis.

Urinary oxalate and urate to creatinine ratios in a healthy pediatric population.

The purpose of the study was to determine reference percentiles for the urinary (U) oxalate (Ox) and urate (Ura) to creatinine (Cr) concentration ratios in the second morning urine of healthy infants, children, and adolescents. The urinary oxalate and urate to creatinine ratios were determined in the spontaneously voided second morning urine sample. To test reproducibility, two urine samples were analyzed on 2 consecutive weeks in 63% of the subjects. Three hundred eighty-four healthy children (181 girls, 203 boys), aged 1 month to 17 years, from nurseries, kindergartens, and schools of Lausanne, Switzerland, were studied. The 5th and 95th percentiles were determined from the total number of urine samples (627) after confirmation that there was no order effect between repeated measurements and there were no significant sex differences. A nonlinear regression analysis in terms of age was used to smooth the calculated percentiles. In this manner, curves were obtained from which the reference values can be read at any given age. The 95th percentiles decreased with age: for UOx/Cr from 0.175 mg/mg (0.22 mol/mol) at 1 to 6 months to 0.048 mg/mg (0.06 mol/mol) from 7 years and beyond; and UUra/Cr from 2.378 mg/mg (1.6 mol/mol) at 1 to 6 months to 0.594 mg/mg (0.4 mol/mol) in adolescence. We provide 5th and 95th percentile curves for the UOx/Cr and UUra/Cr ratios determined from the second morning urine samples in a large cohort of healthy infants, children, and adolescents. Values were determined by standard analytical chemical techniques and were analyzed by powerful statistical methods. The calculated 95th percentile for the UOx/Cr values fell rather rapidly and reached normal adult values by the age of 7 years, whereas for UUra/Cr, the 95th percentile decreased slowly and stabilized in adolescence.

Spot urine samples for evaluating solute excretion in the first week of life.

AIM: To evaluate whether the urinary creatinine concentration is a reliable reference value to standardise urinary solute excretion in a spot urine sample during the first week of life. METHODS: Spontaneously voided urine specimens were obtained in 48 healthy, full term neonates, aged 1 to 6 days (median 2.4) and in 168 healthy older children with a median age of 1.5 years (range 1 month to 3 years). In 62% of the children two urine samples were available with an interval of 2 to 4 (neonates) and 7 days (older children). RESULTS: In neonates both the urinary creatinine concentration and the urinary creatinine:osmolality ratios were significantly higher than in the older children, and were spread over a wider range. During the first postnatal week of life the mean urinary creatinine and urinary creatinine: osmolality ratio values in the first urine samples were also significantly higher than in the second samples. In children aged between 1 month and 3 years of age, these data were remarkably stable without any significant changes between repeat urine samples. CONCLUSIONS: The urinary creatinine concentration during the first days of life is high and variable, even when corrected for urinary osmolality. This is the opposite of what is found in older children and adults. Urinary creatinine and the urinary creatinine:osmolality ratio, therefore, cannot be used to standardise the urinary excretion of solutes in the first week of life.

[Adjuvant therapy with a glycoprotein IIb-IIa inhibitor (abciximab) in coronary angioplasties with a high thrombotic risk]. / Terapêutica adjuvante com inibidor da glicoproteína IIb-IIIa (abciximab) em angioplastias coronárias com elevado risco trombótico.

INTRODUCTION: We retrospectively studied our experience with adjunctive therapy with glycoprotein IIb-IIIa inhibitor (abciximab) on patients with a high risk of thrombotic complications during coronary angioplasty (PTCA). PATIENTS AND METHODS: From September 1996 to November 1997, we performed PTCA in 210 patients, and abciximab was given to 38 (18%) of them. The interventions were urgent (primary PTCA in acute myocardial infarction) in 55% of the cases. The mean age of patients was 68.6 +/- 12 years and 71% were male. The reasons for coronary intervention were: acute myocardial infarction in 21 patients (55.3%), unstable angina in 9 (23.7%) and stable angina in 8 (21%). Coronary stents were implanted in 13 patients (34%) and an intra aortic balloon pump was used in 4 (11%). The reasons for using abciximab were: thrombus containing lesion: 22 (57.9%); other type B2/C lesion characteristics: 6 (15.9%); acute closure post balloon PTCA: 9 (23.7%), sub-acute stent thrombosis: 1 (2.6%). Oral acetilsalicilic acid and intravenous heparin were given to all patients at the beginning of the intervention. The mean APTT was 124 +/- 32 seconds at the end of the procedure. RESULTS: The arterial sheaths (8 French) were removed six hours after procedure, according to the normalisation of APTT values. Angiographic success in this group of patients was 100%. One patient died during hospitalisation due to left ventricular failure. There was no need for repeated angioplasty or coronary bypass grafting during hospital stay. The main complications related to the use of abciximab were: bleeding (requiring transfusion) in four patients 10.5%); severe thrombocytopenia (< 50,000 platelets/mm3): 1 (2.6%): cardiac tamponade (requiring pericardiocentesis): 1 (2.6%) and pseudo-aneurysm of femoral artery (requiring vascular surgery): 1 (2.6%). CONCLUSIONS: The use of abciximab as adjunctive therapy in this small group of patients undergoing coronary interventions with high risk of thrombotic complications is associated with high procedural success, but at the expense of high rates of bleeding complications. Therefore, special care must be applied during and after the procedure to enhance the safety of the patients treated with this drug.

[Pacemaker implantation in a patient with persistent left superior vena cava and atresia of the right superior vena cava]. / Implantação de pacemaker em doente com persistência da veia cava superior esquerda e atrésia da veia cava superior direita.

Persistent left superior vena cava with absence or atresia of right superior vena cava is a congenital abnormality of systemic venous return to the heart which may complicate the insertion of a pacemaker electrode. We present a case report of a patient with conduction system disturbances in whom this abnormality was diagnosed during pacemaker implantation, with the possibility of using a transvenous electrode without active fixation system.

Recurrent intracardiac mass in a pregnant woman with antiphospholipid syndrome.

Clinical manifestations of the antiphospholipid syndrome result from thromboembolic phenomena that occur in all vascular territories. Cardiac manifestations frequently associated with this syndrome include valvular and myocardial lesions. We present a case report of primary antiphospholipid syndrome in a pregnant young woman with a right atrial mass detected by echocardiography. Its morphological characteristics presented problems in establishing differential diagnosis within atrial thrombus and atrial myxoma. This case was complicated by pulmonary embolism and recurrence of the mass within four months. Cardiac surgery was performed and two masses excised. Histopathological studies showed them to be thrombotic in nature.

[A recurrent intracardiac mass in a pregnant woman with the antiphospholipid antibody syndrome]. / Massa intracardíaca recidivante em grávida com síndrome dos anticorpos antifosfolípidos.

Clinical manifestations of the antiphospholipid syndrome result from thromboembolic phenomena that occur in all vascular territories. Cardiac manifestations frequently associated with this syndrome include valvular and myocardial lesions. We present a case report of primary antiphospholipid syndrome in a pregnant young woman with a right atrial mass detected by echocardiography. Its morphological characteristics presented problems in establishing differential diagnosis within atrial thrombus and atrial myxoma. This case was complicated by pulmonary embolism and recurrence of the mass within four months. Cardiac surgery was performed and two masses excised. Histopathological studies showed them to be thrombotic in nature.

[HIV, the Latin woman and her concerns]. / El VIH, la mujer Latina y sus preocupaciones.

AIDS: At the Fifth National Skills Building Conference, many women had the opportunity to discuss their needs and concerns. Education is paramount in the prevention of the spread of AIDS. Child care is needed so that HIV-positive mothers can visit doctors and attend support groups. Latin women need more community involvement. Many live in fear of revealing their HIV-positive status because of the negative stigma attached to HIV. More services are needed for HIV-positive children who may have social as well as medical problems. A magazine by women, for women, dealing with female issues would be useful.^ieng

Complications of endomyocardial biopsy in heart transplant patients: a retrospective study of 2117 consecutive procedures.

BACKGROUND: Endomyocardial biopsy (EMB) remains the gold standard for the diagnosis of graft rejection after heart transplantation (HT). Our purpose was to evaluate the rate of complications of this invasive procedure. METHODS: This was a retrospective study of 175 patients, who were transplanted between November 2003 and October 2010 and survived more than 1 month after surgery. We evaluated the number of inconclusive EMB and described the incidence, nature, and subsequent management of several complications associated with this procedure. RESULTS: Over a period of approximately 7 years, we performed 2217 EMB yielding 4972 specimens, namely, an average of 2.3 fragments per procedure. The majority of EMBs (95.3%) were performed by the femoral approach. Only 12 EMB (0.57%) were inconclusive. The overall complication rate was 0.71%. During puncture, one patient experienced a vasovagal reaction and another one, a femoral artery false aneurysm. During the biopsy, there was one case of cardiac perforation with tamponade, two cases of supraventricular tachycardia, and three atrioventricular conduction abnormalities. In 19 patients, histological analysis revealed chordal tissue, but only two patients developed mild tricuspid regurgitation. We observed five cases of coronary artery fistulae. The clinical outcomes were favorable in all cases. CONCLUSION: EMB proved to be a suitable, safe method to monitor rejection after HT.

Amygdalae and striatum calcification in lipoid proteinosis.

Lipoid proteinosis is a rare genodermatosis characterized by multisystem involvement due to intracellular deposition of an amorphous hyaline material. Lipoid proteinosis is caused by mutations in the ECM1 gene. In many patients, skin and mucosa abnormalities are the first manifestation. When the CNS is affected, a wide variety of neurologic abnormalities may be present. The hallmark findings are calcifications, mostly occurring in the amygdalae, hippocampus, parahippocampal gyrus, or even the striatum. Present in half of the patients, moniliform blepharosis is considered a pathognomonic finding. In the other half of patients imaging could assist in the diagnosis. The authors present a series of 3 cases of lipoid proteinosis with brief clinical data and imaging findings.

In vitro methods for specific IgE detection in cow's milk allergy.

BACKGROUND: A new method for determining serum specific IgE (IMMULITE 2000 3gAllergy) has recently become available. OBJECTIVE: To evaluate the clinical performance of IMMULITE 2000 in the diagnosis of cow's milk allergy compared with that of UniCAP. Additionally, we verified the behavior of both methods at two diagnostic decision points proposed by other authors. METHODS: The study population consisted of 31 children with cow's milk allergy (group A) and a control group of 19 atopic children without food allergy (group B). A blood sample from each child was tested using both methods and the results were compared. RESULTS: In group A, the values for cow's milk IgE ranged from 0.35 kU/L (the lowest common detection limit) to above 100 kU/L. In group B, the values were less than 1.1 kU/L for IMMULITE 2000 and less than 1.6 kU/L for UniCAP. An agreement of 90% in IgE classes was obtained. Both methods demonstrated exactly the same diagnostic performance (sensitivity: 100%; specificity: 78.9%; negative predictive value: 100%; positive predictive value: 84.6%; efficiency: 90.2%). The evaluation of the two methods at the two different decision points proposed in the literature showed a better positive predictive value with UniCAP, but we obtained equivalent performance with IMMULITE 2000 by choosing higher cutoff values. CONCLUSIONS: We conclude that IMMULITE 2000 is as effective as UniCAP in the diagnosis of cow's milk allergy. Both methods can be used to obtain site-specific decision points that are population, age and disease dependent.

[The immature kidney]. / Le rein immature.

In humans, urine formation starts with the metanephros at the 10th week of gestation. Nephrogenesis progresses during gestation and is achieved around the 35th week. Clamping of the cord is the signal for a striking increase in renal function which reaches mature levels at the end of the first year of life. The integrity of several hormonal systems (the renin-angiotensin system, the prostaglandins) is mandatory for kidney growth and the development of renal function. The mechanisms underlying renal homeostasis are fragile and can easily be disturbed during respiratory and cardiovascular distress, or be affected by the administration of vasoactive agents. Thus, perinatal asphyxia or hypoxemia, as seen in respiratory distress syndrome or neonatal pulmonary hypertension induces intense renal vasoconstriction, with consequent oligoanuria. Congestive heart failure also results in renal hypoperfusion and sodium retention. Vasoactive agents and diuretics (indomethacin, tolazoline, furosemide) used to threat these conditions can result in renal vasoconstriction, renal hypoperfusion and failure. The pathogenesis and pathophysiology of neonatal renal disturbances being now better defined, a rational approach to the treatment of renal functional abnormalities during the neonatal period is possible.

Urinary phosphate/creatinine, calcium/creatinine, and magnesium/creatinine ratios in a healthy pediatric population.

OBJECTIVE: To determine reference values for urinary phosphate/creatinine (Cr) concentration ratios and to complete reference values for urinary calcium/creatinine and magnesium/creatinine ratios in the second morning urine sample of healthy infants, children, and adolescents. DESIGN: Urinary P/Cr, Ca/Cr, and Mg/Cr ratios were determined from the second morning urine sample. Two urine samples were obtained 1 week apart from most subjects to assess reproducibility. SETTING: Kindergartens and schools of Lausanne, Switzerland. PARTICIPANTS: A total of 410 healthy children aged 1 month to 17 years (197 girls and 213 boys) participated in the study. RESULTS: The 5th and 95th percentiles were estimated from 664 urine samples. There were no differences related to sex. A nonlinear regression in terms of age was used to smooth the estimated percentiles yielding reference curves from which critical values may be obtained for any given age. The 95th percentile for urinary Ca/Cr and Mg/Cr agreed with previously reported values in children older than 7 years. The upper limit of the three solute/creatinine ratios decreased significantly with age: for urinary P/Cr from 19.0 mol/mol at 1 month to 2.7 at 14 years; for urinary Ca/Cr from 2.2 to 0.7 mol/mol, and for urinary Mg/Cr from 2.2 to 0.6 mol/mol. Lower limits varied little. Interindividual and intraindividual variations decreased with age. CONCLUSIONS: Urinary P/Cr, Ca/Cr, and Mg/Cr ratios vary strongly with age. We provide reference values, expressed both in SI and in mass units, for urinary P/Cr, Ca/Cr, and Mg/Cr in children aged one month to 17 years.