[Clinical processes in a high resolution clinic of specialist outpatient clinics]. / Procesos médicos susceptibles de alta resolución en consultas ambulatorias.

OBJECTIVES: The high resolution clinic (HRC) is an outpatient care process by which treatment and diagnosis are established, recorded, and completed in a single day. The aim of this study was to assess the extent to which patients with medical conditions may benefit from a single consultation system. MATERIAL AND METHODS: A descriptive study of 795 first visit events, randomly selected as high-resolution consultations in cardiology, gastroenterology, internal medicine, and chest diseases. A discussion is presented on the percentage of patients who benefited from HRC and the complementary tests performed. RESULTS: A total of 559 (70%, 95% CI: 67-73%) of all first visits became HRCs, and 483 (61%, 95% CI: 57%-64%) required a diagnostic test that was reviewed on the same day. There were differences between medical consultations (86% in cardiology versus 44% in gastroenterology consultations, P<.001). Performing a test on the same day significantly increased the percentage of HRCs (49 versus 22%, P<.001). Ischaemic heart disease, dyspepsia, headache, and asthma were the conditions most commonly leading to HRC. The most common tests were cranial tomography, blood analysis, and ultrasound. CONCLUSIONS: Medical consultations may largely benefit from an HRC system, only requiring some organisational changes and no additional costs.

Induction of oral tolerance to peanut: a successful home-based protocol.

In Spain, peanut allergy is increasingly prevalent. Successful protocols for the induction of oral tolerance (LOT) with several foods have been reported. We aimed to induce clinical tolerance to peanut in a child with severe peanut allergy (age 4 years, facial urticaria and lip angioedema upon licking a peanut; peanut skin prick test, 13 x 10 mm; specific immunoglobulin (Ig) E > 100 kUA/L). At age 6, the threshold oral challenge dose was 62.5 mg. Several peanut solutions were prepared and sequentially administered at the patient's home. Over 138 days, the dose was increased from 0.625 to 5500 mg. There were 43 mild-to-moderate reactions (28% of the doses administered). Pre-LOT and post-LOT peanut IgE and IgG4 values were 265 vs 487 kUA/L, and 6.11 vs 14.8 mg/L. This is the first report of successful LOT to peanut in Spain. This home-based regimen is safe under permanent and close medical supervision by an allergist.

Evaluation of drug-related hypersensitivity reactions in children.

Patients with drug reactions are often referred to allergists for "allergy". Skin testing and clinical history seem to have a good negative predictive value, however, although drug challenge could be dangerous, it is the only way to confirm the diagnosis. We aimed to demonstrate that most children with a history of non-life-threatening drug reactions do not have a true drug allergy and examined the use of drug challenge in childhood. Patients with reactions were referred to our clinic by pediatricians. In 1 year, 354 reactions were studied in 239 children. Patients were classified according to their positive or negative history of drug allergy. Skin prick testing was done in all cases. Exclusion criteria for challenge included drug anaphylaxis, Stevens-Johnson syndrome, systemic reactions with severe concomitant illness, beta-inhibitor drug therapy or positive skin test to the implicated drug with a positive history. It was found that the beta-lactam antibiotics were involved in 50% of suspected reactions, aspirin in 10% and sulfonamides in 9%. Histories were considered positive only in 25%. Drug challenges confirmed only 4% of all reactions. It was concluded that drug challenge may be the gold standard for most childhood reactions that are considered to be allergic, non-life-threatening and drug-related. Only 4% of these suspected reactions were exclusively caused by drug allergy.

IgE crossreactivity between mugwort pollen (Artemisia vulgaris) and hazelnut (Abellana nux) in sera from patients with sensitivity to both extracts.

BACKGROUND: An association between sensitization to Compositae pollens and hypersensitivity to hazelnut has been previously described. There is no previous in vitro study about crossreactivity between mugwort pollen and hazelnut. OBJECTIVES: To study mugwort pollen and hazelnut allergens and to assess if there is IgE crossreactivity between mugwort pollen and hazelnut. METHODS: A serum pool formed by 28 individual sera with specific IgE to mugwort pollen and hazelnut was used to investigate IgE crossreactivity. RAST-inhibition, SDS-PAGE/IEF immunoblotting inhibition assays were performed by preincubation of the sera with mugwort pollen and hazelnut. RESULTS: RAST to hazelnut was inhibited up to 63% by mugwort pollen, but the mugwort pollen RAST was only inhibited up to 36% by hazelnut. In SDS-PAGE immunoblotting mugwort pollen showed nine allergens ranging from <16 to 65 kDa and hazelnut had four main allergens: 42 kDa, 17 kDa and <16 kDa (two bands). In the SDS-PAGE immunoblotting inhibition hazelnut partially inhibited all the mugwort pollen bands, except that with 19kDa, whereas mugwort pollen produced a nearly total inhibition of all the hazelnut allergens. In isoelectrofocusing immunoblotting mugwort pollen had two groups of allergens: pI 7.5-8.5 and pI 3.5-5.2 and hazelnut one group of allergens: pI 5.2-5.8. In the isoelectrofocusing immunoblotting inhibition hazelnut produced a partial inhibition of all the bands of mugwort pollen and mugwort pollen partially inhibited all the allergenic bands of hazelnut. CONCLUSIONS: The RAST and SDS-PAGE/IEF immunoblotting inhibition results provide evidence of IgE cross reactivity between mugwort pollen and hazelnut allergens. The inhibition of hazelnut by mugwort pollen is higher than the inhibition of mugwort pollen by hazelnut in both RAST inhibition and SDS-PAGE immunoblotting inhibition. These results suggest that mugwort pollen allergens would behave as primary immunogens in the association between sensitivity to mugwort pollen and hazelnut.

Atopy and bronchial hyperresponsiveness in pure extrinsic childhood asthma.

Nonspecific bronchial hyperresponsiveness and atopy are considered risk factors in the development of asthma. Bronchial responsiveness to allergens could be the most important factor in extrinsic asthma. The trial was designed to investigate the role of specific and nonspecific bronchial responsiveness and atopy in a pure model of extrinsic asthma in children. One hundred and thirty-seven patients with pollen allergy were evaluated. Twenty children with allergy to grass pollen (Lolium perenne) alone, with symptoms only in the grass pollen season, were selected. Their score of symptoms, airway responsiveness to methacholine in and out of season, airway responsiveness to Lolium perenne out of season, and total and specific IgE were assessed. Twelve were male and eight female. Mild asthma was observed in 14, and moderate asthma in six. Age of onset of symptoms ranged from three to 13 years of age. Significant seasonal increase in airway responsiveness to methacholine was found (p = 0.002). Specific bronchial challenge test was positive in all patients. Lolium pernne PD20 ranged from 2.3 to 155.5 inhalation units. An inverse association between age of onset of symptoms and severity of asthma was shown (p = 0.001). Increase in nonspecific bronchial responsiveness was related to the appearance of symptoms during the spring, but it showed no relationship to the severity of symptoms. Severity of asthma during the spring correlated with the intensity of allergen airway responsiveness (p = 0.02). Levels of total and specific IgE were not related to the degree of specific or nonspecific airway responsiveness. Severity of extrinsic childhood asthma is determined by bronchial response to allergens. Bronchial hyperresponsiveness to methacholine during the spring can be the consequence of environmental exposure to allergens. The intensity of airway responsiveness to methacholine has no predictive value in the severity of pure extrinsic childhood asthma.

Nonspecific bronchial hyperresponsiveness and development of asthma in children with hay fever.

It has been suggested that patients with allergic rhinitis who present nonspecific bronchial hyperresponsiveness (BHR) are those most likely to develop asthma. Therefore, a study was conducted in children with rhinoconjunctivitis to ascertain whether BHR to methacholine might predict the development of asthma in these patients. Fifteen patients with hay fever and no previous symptoms of asthma were selected. All underwent clinical symptom tests and methacholine tests, during the pollen season in the 4 consecutive years following the start of the study. At the end of this period, 5 patients had developed asthma. It may thus be affirmed that, in this group, neither the presence nor the degree of previous BHR was useful for predicting which patients would later develop asthma.

Cross-reactivity of IgE-binding components between boiled Atlantic shrimp and German cockroach.

IgE-antibody reactivity to boiled Atlantic shrimp (Pandalus borealis) and German cockroach (Blattella germanica) of sera from 89 patients, sensitive to one or the other, was investigated with an enzymatic immunoassay for specific IgE detection (CAP-FEIA System, Pharmacia, Sweden). IgE serum levels to both antishrimp and anticockroach allergens were found to be positive in 76 of the 89 (85.4%) tested sera. A positive anticockroach IgE was very rare in the absence of detectable antishrimp IgE (five of 89 sera). Linear regression analysis on antishrimp and anti-German cockroach IgE levels-log plot revealed a correlation coefficient (r) of 0.73. Inhibition experiments showed that boiled Atlantic shrimp extract inhibited CAP with German cockroach, and vice versa. Immunoblotting showed the strongest IgE binding for both allergenic extracts between 30 and 43 kDa. By blot inhibition, the binding capacity of German cockroach was totally abolished by Atlantic shrimp extract, while German cockroach extract only partially IgE binding to Atlantic shrimp. Cross-reactivity exists between shrimp, an important food allergen, and German cockroach, which has an increasing role in allergic asthma. It could be important to determine the clinical significance of cross-allergy to both allergens, in which exposures occur in different ways.

Exercise-induced anaphylactic reaction to hazelnut.

Reproducible, exercise-induced anaphylactic reactions occur in some patients only after certain foods have been eaten before exercise. We describe a patient in whom hazelnuts were a triggering factor for exercise-induced anaphylaxis. Skin tests and RAST were positive for nuts and grass and weed pollen. The exercise challenge test after hazelnut ingestion was positive. Food hypersensitivity should be investigated in all cases of exercise-induced anaphylaxis.

Lung function and bronchial response to methacholine in young adults who had asthma in childhood.

Lung function and bronchial response to methacholine were studied in 47 young adults who had had childhood asthma, and after a period of 14-21 years, showed a different clinical evolution. At present, these subjects have been classified in four clinical groups: asymptomatic, rhinitic, asthmatic only due to exercise, and asthmatic. The same study was performed in 23 healthy individuals without personal histories of respiratory or allergic pathology. We found low spirometric basal values in both the asthmatic group (FEV1 and FEF25-75) and in the group with asthmatic responses to exercise (FEF25-75). No significant differences were found among asymptomatic, rhinitic, and control groups. While airway hyperreactivity was observed in patients who still had asthma, the bronchial response to methacholine in asymptomatic and rhinitic groups was not different from the control group. We conclude that both lung function and bronchial response to methacholine in most of the adults who had asthma in infancy and had been without asthmatic symptoms for many years are similar to those observed in the general population.

Asthma with sulfite intolerance in children: a blocking study with cyanocobalamin.

Sulfites have been implicated as the cause of bronchospasm in some subjects with asthma. However, there is still no universally accepted explanation of the pathogenesis of these reactions. We have studied five children with asthma with metabisulfite intolerance confirmed by oral challenge testing. The challenge test with metabisulfite was repeated after premedication of all the patients with 1.5 mg of oral cyanocobalamin. In four of the five patients treated with cyanocobalamin, bronchospasm did not develop in the second metabisulfite challenge. The possible mechanisms are discussed.

Nephrotic syndrome and respiratory allergy in childhood.

The etiology and pathogenesis of idiopathic nephrotic syndrome remain obscure. Several investigations have reported a role for allergy in the development and maintenance of this disease, especially in childhood. We have studied 20 pediatric patients with relapses of nephrotic syndrome related in time to respiratory symptoms. Sensitization was demonstrated to one or more allergens in 7 patients with episodes of proteinuria of seasonal tendency. Preventive management with disodium cromoglycate was successful in preventing new relapses in 3 patients; specific immunotherapy was assayed in another 2 without beneficial outcome. There appears to be a pathogenic relationship between respiratory allergy and proteinuria in some cases of nephrotic syndrome.

A possible consequence of long-term elimination diet in IgE mediated subclinical food hypersensitivity.

IgE-mediated sub-clinical food hypersensitivity is recognized, but the hypersensitivity indicated is not always in accord with the observed symptoms. Study of 2 cases shows the inefficacy of a prescribed exclusion diet, without confirmation of the relationship between symptomatology and the food allergy. In addition, elimination of the foods aggravated the sensitivity of the patients and symptoms after provocation tests. Further studies must be made to decide whether there is a sound basis for long-term exclusion diets in sub-clinical food hypersensitivity.

[Food allergy in children. II. Prognostic factors and long-term development]. / Alergia a alimentos en el niño. II. Factores pronósticos y evolución a largo plazo.

The evolution of 109 allergic children with 129 IgE-mediated food sensitizations has been evaluated. The follow-up period was from nine months to 14 years. The period up to clinical tolerance was analyzed, together with the influence of two possible prognostic factors: specific IgE antibody levels at the beginning of symptomatology and the sensitizing food. Moreover, when clinical tolerance was achieved, the presence of specific IgE antibodies was again assessed. Probability estimations indicated that 30% of food-allergic children become clinically tolerant before 3 years of evolution, 40% before 6 years, 50% before 9 years and 53% before 12 years. Onset of clinical tolerance varies in dependence with the offending food: clinical tolerance to cow's milk seems to be far earlier and easier to reach than those to egg and fish (p less than 0.001, at 9 years' evolution); allergy to egg disappears also earlier and easier than fish allergy (p less than 0.01). Levels of specific IgE antibodies at the onset of the disease show significant difference (p less than 0.01) between the patients which will become tolerant and those with persistence of clinical sensitivity, being higher in the last group. However, a high number of patients who become clinically tolerant (67.5%) remained positive at skin prick testing or had elevated specific IgE serum antibodies against the offending food.