Training of Spanish allergology residents in pediatric allergology: a survey of the current situation

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Position document: IgE-mediated cow's milk allergy

The present document offers an update on the recommendations for managing patients with cow's milk allergy - a disorder that manifests in the first year of life, with an estimated prevalence of 1.6-3% in this paediatric age group. The main causal allergens are the caseins and proteins in lactoserum (beta-lactoglobulin, alpha-lactoalbumin), and the clinical manifestations are highly variable in terms of their presentation and severity. Most allergic reactions affect the skin, followed by the gastrointestinal and respiratory systems, and severe anaphylaxis may occur. The diagnosis of cow's milk allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which constitutes the gold standard for confirming the diagnosis. The most efficient treatment for cow's milk allergy is an elimination diet and the use of adequate substitution formulas. The elimination diet must include milk from other mammals (e.g., sheep, goat, etc.) due to the risk of cross-reactivity with the proteins of cow's milk. Most infants with IgE-mediated cow's milk allergy become tolerant in the first few years of life. In those cases where cow's milk allergy persists, novel treatment options may include oral immunotherapy, although most authors do not currently recommend this technique in routine clinical practice. Enough evidence is not there to confirm the efficacy of elimination diets in the mother and infant for preventing the appearance of cow's milk allergy. Likewise, no benefits have been observed with prebiotic and probiotic dietetic supplements in infants for preventing food allergy

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Analysis of profitability in the diagnosis of allergy to beta-lactam antibiotics

Drug allergy is the third most common reason for allergy consultations. There is a tendency to call any adverse drug reaction (ADR) allergic, even without confirmatory allergy study. OBJECTIVES: (1) Evaluate time of resolution allergy to beta-lactam's study in a sample of 100 patients. (2) Analyse cost-effectiveness of current diagnostic study (skin tests, specific IgE and drug provocation test (DPT)). (3) Describe type and frequency of ADRs in adult/paediatric patients. (4) Compare cost of complete study with DPT. (5) Assess the need to restructure current study methodology according to results obtained. The study is part of a strategic plan of the allergy department (2005-2010). Patients with suspected allergy to beta-lactams were included. Procedures performed: medical history, specific IgE, skin tests and DPT. Cost/patient analysis. Cost of protocol analysis for current diagnostic/direct DPT. RESULTS: 100 patients were studied, 52 females/48 males; 43 children/57 adults. Symptoms: 89 cutaneous, 4 anaphylaxis, 3 vasovagal reactions, 6 non-specific symptoms and 4 not recalled. Allergy was confirmed in six patients (only one child). Complete-study cost: 149.3 Euros/patient. DPT-study cost: 97.19 Euros/patient (34.9% less). Resolution time 9-13 months, absenteeism 28.04%. CONCLUSIONS: In the series studied, diagnosis of allergy to beta-lactams was confirmed in 6% of patients (2.3% of paediatric patients). After analysing results and cost of the study we believe that we should propose a specific diagnostic algorithm in those paediatric patients without suspected IgE-mediated ADR, and for those patients direct DPT should be conducted. This will reduce cost/patient (−34.9%), time of resolution and absenteeism

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Intention to prescribe self-injectable epinephrine: are there differences depending on who assesses the patient post-reaction?

INTRODUCTION: Anaphylaxis is the most severe of all allergic reactions and can even prove fatal. There is limited evidence of a difference in prescribing patterns for self-injectable epinephrine (SIE) between general paediatricians and paediatricians with greater knowledge of allergology. OBJECTIVES: Assess knowledge about prescribing SIE of a sample of primary care/hospital paediatricians and paediatricians with specialised knowledge of allergology through a questionnaire asking them about clinical cases of anaphylaxis in their daily paediatric practice. MATERIALS AND METHODS: Participants were primary care and hospital paediatricians practicing in different regions of the province of Barcelona and paediatricians with specialised knowledge in the field of allergology from Spain. RESULTS: A total of 183 paediatricians responded. Of that 59.6% were paediatricians with specialised knowledge of allergology. General paediatricians in most cases correctly prescribed SIE device (more than 70% answered correctly in five of the eight clinical cases). In the case of drug anaphylaxis, which is an avoidable allergen for which SIE is not indicated, 67.5% of general paediatricians would prescribe it. In the case of exercise-induced anaphylaxis there were also differences in the prescription of epinephrine by general paediatricians, with only 40% prescribing it. CONCLUSIONS: In this study the percentage of SIE prescriptions would be higher than expected by general paediatricians, with no differences in the cases proposed between them and the paediatricians with better knowledge of allergology. Despite these results, it is important to insist on conducting education programmes and disseminating them to facilitate physicians' recognition and treatment of anaphylactic reactions

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Position document: IgE-mediated cow's milk allergy.

The present document offers an update on the recommendations for managing patients with cow's milk allergy - a disorder that manifests in the first year of life, with an estimated prevalence of 1.6-3% in this paediatric age group. The main causal allergens are the caseins and proteins in lactoserum (beta-lactoglobulin, alpha-lactoalbumin), and the clinical manifestations are highly variable in terms of their presentation and severity. Most allergic reactions affect the skin, followed by the gastrointestinal and respiratory systems, and severe anaphylaxis may occur. The diagnosis of cow's milk allergy is based on the existence of a suggestive clinical history, a positive allergy study and the subsequent application of controlled exposure testing, which constitutes the gold standard for confirming the diagnosis. The most efficient treatment for cow's milk allergy is an elimination diet and the use of adequate substitution formulas. The elimination diet must include milk from other mammals (e.g., sheep, goat, etc.) due to the risk of cross-reactivity with the proteins of cow's milk. Most infants with IgE-mediated cow's milk allergy become tolerant in the first few years of life. In those cases where cow's milk allergy persists, novel treatment options may include oral immunotherapy, although most authors do not currently recommend this technique in routine clinical practice. Enough evidence is not there to confirm the efficacy of elimination diets in the mother and infant for preventing the appearance of cow's milk allergy. Likewise, no benefits have been observed with prebiotic and probiotic dietetic supplements in infants for preventing food allergy.

Allergy medical care network: a new model of care for specialties

In 2005 the Althaia Foundation Allergy Department performed its daily activity in the Hospital Sant Joan de Deu of Manresa. Given the increasing demand for allergy care, the department's performance was analysed and a strategic plan (SP) for 2005---2010 was designed. The main objective of the study was to assess the impact of the application of the SP on the department's operations and organisational level in terms of profitability, productivity and quality of care. MATERIAL AND METHODS: Descriptive, retrospective study which evaluated the operation of the allergy department. The baseline situation was analysed and the SP was designed. Indicators were set to perform a comparative analysis after application of the SP. RESULTS: The indicators showed an increase in medical care activity (first visits, 34%; successive visits, 29%; day hospital treatments, 51%), high rates of resolution, reduced waiting lists. Economic analysis indicated an increase in direct costs justified by increased activity and territory attended. Cost optimisation was explained by improved patient accessibility, minimised absenteeism in the workplace and improved cost per visit. CONCLUSIONS: After application of the SP a networking system was established for the allergy speciality that has expanded the territory for which it provides care, increased total activity and the ability to resolve patients, optimised human resources, improved quality of care and streamlined medical cost

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Intention to prescribe self-injectable epinephrine: Are there differences depending on who assesses the patient post-reaction?

INTRODUCTION: Anaphylaxis is the most severe of all allergic reactions and can even prove fatal. There is limited evidence of a difference in prescribing patterns for self-injectable epinephrine (SIE) between general paediatricians and paediatricians with greater knowledge of allergology. OBJECTIVES: Assess knowledge about prescribing SIE of a sample of primary care/hospital paediatricians and paediatricians with specialised knowledge of allergology through a questionnaire asking them about clinical cases of anaphylaxis in their daily paediatric practice. MATERIALS AND METHODS: Participants were primary care and hospital paediatricians practicing in different regions of the province of Barcelona and paediatricians with specialised knowledge in the field of allergology from Spain. RESULTS: A total of 183 paediatricians responded. Of that 59.6% were paediatricians with specialised knowledge of allergology. General paediatricians in most cases correctly prescribed SIE device (more than 70% answered correctly in five of the eight clinical cases). In the case of drug anaphylaxis, which is an avoidable allergen for which SIE is not indicated, 67.5% of general paediatricians would prescribe it. In the case of exercise-induced anaphylaxis there were also differences in the prescription of epinephrine by general paediatricians, with only 40% prescribing it. CONCLUSIONS: In this study the percentage of SIE prescriptions would be higher than expected by general paediatricians, with no differences in the cases proposed between them and the paediatricians with better knowledge of allergology. Despite these results, it is important to insist on conducting education programmes and disseminating them to facilitate physicians' recognition and treatment of anaphylactic reactions.

Allergy medical care network: a new model of care for specialties.

UNLABELLED: In 2005 the Althaia Foundation Allergy Department performed its daily activity in the Hospital Sant Joan de Deu of Manresa. Given the increasing demand for allergy care, the department's performance was analysed and a strategic plan (SP) for 2005-2010 was designed. The main objective of the study was to assess the impact of the application of the SP on the department's operations and organisational level in terms of profitability, productivity and quality of care. MATERIAL AND METHODS: Descriptive, retrospective study which evaluated the operation of the allergy department. The baseline situation was analysed and the SP was designed. Indicators were set to perform a comparative analysis after application of the SP. RESULTS: The indicators showed an increase in medical care activity (first visits, 34%; successive visits, 29%; day hospital treatments, 51%), high rates of resolution, reduced waiting lists. Economic analysis indicated an increase in direct costs justified by increased activity and territory attended. Cost optimisation was explained by improved patient accessibility, minimised absenteeism in the workplace and improved cost per visit. CONCLUSIONS: After application of the SP a networking system was established for the allergy speciality that has expanded the territory for which it provides care, increased total activity and the ability to resolve patients, optimised human resources, improved quality of care and streamlined medical costs.

Analysis of profitability in the diagnosis of allergy to beta-lactam antibiotics.

UNLABELLED: Drug allergy is the third most common reason for allergy consultations. There is a tendency to call any adverse drug reaction (ADR) allergic, even without confirmatory allergy study. OBJECTIVES: (1) Evaluate time of resolution allergy to beta-lactam's study in a sample of 100 patients. (2) Analyse cost-effectiveness of current diagnostic study (skin tests, specific IgE and drug provocation test (DPT)). (3) Describe type and frequency of ADRs in adult/paediatric patients. (4) Compare cost of complete study with DPT. (5) Assess the need to restructure current study methodology according to results obtained. The study is part of a strategic plan of the allergy department (2005-2010). Patients with suspected allergy to beta-lactams were included. Procedures performed: medical history, specific IgE, skin tests and DPT. Cost/patient analysis. Cost of protocol analysis for current diagnostic/direct DPT. RESULTS: 100 patients were studied, 52 females/48 males; 43 children/57 adults. SYMPTOMS: 89 cutaneous, 4 anaphylaxis, 3 vasovagal reactions, 6 non-specific symptoms and 4 not recalled. Allergy was confirmed in six patients (only one child). Complete-study cost: 149.3 Euros/patient. DPT-study cost: 97.19 Euros/patient (34.9% less). Resolution time 9-13 months, absenteeism 28.04%. CONCLUSIONS: In the series studied, diagnosis of allergy to beta-lactams was confirmed in 6% of patients (2.3% of paediatric patients). After analysing results and cost of the study we believe that we should propose a specific diagnostic algorithm in those paediatric patients without suspected IgE-mediated ADR, and for those patients direct DPT should be conducted. This will reduce cost/patient (-34.9%), time of resolution and absenteeism.

Rabbit meat anaphylaxis

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Lactante de 6 meses con meningitis por Listeria Monocytogenes. Hemos de pensar en algo mas? / Lactant de 6 mesos amb meningitis per Listeriamonocytogenes. Hem de pensar en alguna altra cosa? / Six Month old infant with Listeria monocytogenes meningitis. Do we have to think of other diagnoses?

Introducció: en les últimes dècades ha augmentat la incidència de listeriosi a Europa. La meningitis per Listeriamonocytogenesés infreqüent, excepte en el període neonatal, i en embarassades, ancians i immunodeprimits. Conseqüentment, cal fer un estudi immunitari fora d'aquestessituacions. Cas clínic: es presenta el cas d'un lactant de 6 mesos ambdiagnòstic de meningitis per L. monocytogenes, motiu pelqual es fa un estudi immunològic. Davant la presència delimfopènia, immunofenotip característic (T-B+NK-) i sexemasculí, se sospita una immunodeficiència combinadagreu lligada al cromosoma X. Comentaris: malgrat que la taxa de mortalitat de meningitisper Listeriaés inferior al 10%, pot deixar seqüeles, fet queimplica un seguiment neurològic que inclogui una ressonància magnètica cerebral. Davant un pacient pediàtricamb meningitis per L. monocytogenesfora del períodeneonatal, cal plantejar-se un estudi immunitari. El diagnòstic d'una immunodeficiència combinada greu és unaemergència mèdica, i requereix una alta sospita clínica; elpronòstic vital millora si es fa un diagnòstic precoç. La supervivència en la immunodeficiència combinada greudepèn de la reconstitució ràpida de cèl•lules mare mit-jançant trasplantament de medul•la òssia o de progenitorshematopoètics de sang de cordó umbilical. La teràpia gènica, una alternativa prometedora, podria ser una possibi-litat en alguns casos

Introducción: en las últimas décadas ha aumentado la incidenciade listeriosis en Europa. La meningitis por Listeria monocytogeneses infrecuente, excepto en el periodo neonatal, y en embarazadas, ancianos e inmunodeprimidos. Consecuentemente, es necesariorealizar un estudio inmunitario fuera de estas situaciones. Caso clínico: se presenta el caso de un lactante de 6 meses condiagnóstico de meningitis por L. monocytogenes, motivo por el quese realiza un estudio inmunológico. Ante la presencia de linfopenia, inmunofenotipo característico (T-B+NK-) y sexo masculino, sesospecha una inmunodeficiencia combinada grave ligada al cro-mosoma X. Comentarios: la meningitis por Listeriatiene una tasa de mortali-dad inferior al 10%, pero puede dejar secuelas, y por ello precisaseguimiento neurológico y resonancia magnética cerebral. Ante unpaciente pediátrico con meningitis por L. monocytogenesfuera delperiodo neonatal tiene que plantearse un estudio inmunitario. Eldiagnóstico de una inmunodeficiencia combinada grave es unaemergencia médica, y requiere una alta sospecha clínica. La supervivencia en la inmunodeficiencia combinada grave depende dela reconstitución rápida de células madre mediante trasplante demédula ósea o progenitores hematopoyéticos de sangre de cordónumbilical. La terapia génica, una alternativa prometedora, podríaser una posibilidad en algunos casos

Introduction: the global incidence of listeriosis has increased in Europe in the last decades. Listeria monocytogenesmeningitis israre except during the neonatal period, and among pregnantwomen, elderly, and immunosuppressed patients. A thorough immunological evaluation should be performed when those specificconditions are not present. Case report: we report the case of a 6-month-old infant with adiagnosis of L. monocytogenesmeningitis. The presence oflymphopenia, a T-B+NK- immunophenotype, and male sex led tothe diagnosis of X-linked severe combined immunodeficiency. Discussion: although the death rate from Listeriameningitis isunder 10%, this infection can result in severe sequelae that requireclose neurological and neuroimaging follow-up. In a pediatric pa-tient being diagnosed with L. monocytogenesmeningitis outside ofthe neonatal period, immunology evaluation should be performed. The diagnosis of a severe combined immunodeficiency is a medicalemergency that requires a high level of clinical suspicion; earlydiagnosis has a major impact on outcome. Survival of patients withsevere combined immunodeficiency depends on expeditious stemcell reconstitution with hematopoietic stem cell transplantation. Gene therapy is a promising alternative in selected cases

Safety of cluster specific immunotherapy with a modified high-dose house dust mite extract.

INTRODUCTION: Although the efficacy and safety of high dose hypoallergenic mite subcutaneous immunotherapy (SCIT) using a conventional administration schedule has already been demonstrated, there is no reported experience on the safety of these extracts with cluster schedules. We wanted to determine whether the use of a cluster schedule of a hypoallergenic allergen with a high concentration of house dust mite allergens commonly used in normal practice was safe and well-tolerated in patients with dust mite allergy. MATERIAL AND METHODS: Multicentre, observational, retrospective study of dust mite allergic patients treated with a cluster schedule of SCIT (Acaroid; Day 1: 300/300 therapeutic units, TU--Day 8: 1000/1000 TU--Day 15: 3000/3000 TU) in 23 Spanish sites. RESULTS: Cluster schedule was used on 434 patients (40.1% children), with a total of 3256 doses (38.2% in children). There were 88 clinically relevant adverse reactions, 79 out of them local and 9 systemic (but mild-moderate) that amounted to 2.7% of all the administered doses. All the patients fulfilled the cluster schedule. CONCLUSIONS: Cluster schedule with high dose hypoallergenic mite-SCIT was safe and well-tolerated in routine clinical practice. Therefore, its use could reduce the costs and time needed to achieve the desired maintenance dose and increase compliance.

Eosinophilic oesophagitis: clinical manifestations and treatment options. The role of the allergologist

Eosinophilic oesophagitis (EO) is an infrequent disorder that is currently underdiagnosed. It has been described in both adults and in children, and is more prevalent among males. The etiology of EO is not clear, though atopy has been suggested as playing an important role in the development of the disease.The clinical presentation of EO is varied, and a differential diagnosis with other digestive tract disorders is required — particularly gastro-oesophageal reflux. Dysphagia and food bolus impactation within the oesophagus are the most characteristic symptoms. Diagnostic confirmation is obtained from multipleoes ophageal biopsy, with the detection in some sample or samples of over 15 eosinophils per high-magnification microscopic field. An allergological study is needed to evaluate the existence of allergens (perennial or seasonal environment alallergens and food allergens) responsible for the eosinophilic infiltration found at oesophageal level.There is no specific treatment for EO, and topical corticosteroids (swallowed) are currently the pharmacological treatment of choice. Dietary therapy in children with food allergy as the causal factor may prove effective, though the existence of polysensitisation complicates the correct implementation of such treatment. Oesophageal dilatation is reserved for cases with severe dysphagia, and is not without complications. Treatment with anti-IL-5, antileukotrienes, azathioprine, 6-mercaptopurine, anti-IgE,etc., could constitute alternatives to topical corticosteroids, although information is still lacking on their long-term safety and efficacy in the paediatric population

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Eosinophilic oesophagitis: clinical manifestations and treatment options. The role of the allergologist.

Eosinophilic oesophagitis (EO) is an infrequent disorder that is currently underdiagnosed. It has been described in both adults and in children, and is more prevalent among males. The etiology of EO is not clear, though atopy has been suggested as playing an important role in the development of the disease. The clinical presentation of EO is varied, and a differential diagnosis with other digestive tract disorders is required particularly gastro-oesophageal re-flux. Dysphagia and food bolus impactation within the oesophagus are the most characteristic symptoms. Diagnostic confirmation is obtained from multiple oesophageal biopsy, with the detection in some sample or samples of over 15 eosinophils per high-magnification microscopic field. An allergological study is needed to evaluate the existence of allergens (perennial or seasonal environmental allergens and food allergens) responsible for the eosinophilic infiltration found at oesophageal level. There is no specific treatment for EO, and topical corticosteroids (swallowed) are currently the pharmacological treatment of choice. Dietary therapy in children with food allergy as the causal factor may prove effective, though the existence of polysensitisation complicates the correct implementation of such treatment. Oesophageal dilatation is reserved for cases with severe dysphagia, and is not without complications. Treatment with anti-IL-5, antileukotrienes, azathioprine, 6-mercaptopurine, anti-IgE, etc., could constitute alternatives to topical corticosteroids, although information is still lacking on their long-term safety and efficacy in the paediatric population.