Anaphylaxis: a one-year survey on Medical Emergency Service in Liguria (Italy).

Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity reaction. The diagnosis is mainly based on clinical ground. This study aimed at evaluating the records of phone calls and medical visits for anaphylaxis occurred in Region Liguria during 2013. The phone call is managed in each headquarter, and classified according to a level of care intensity and a presumed level of criticality, according to established criteria. Criticality is then re-evaluated (detected criticality) at the end of medical visit, following the same score adding the black code defining died patients. Most of the phone calls (553) to the MES were recorded in summer (37.4%). Anaphylaxis was confirmed in about half of patients. There was a fair agreement between presumed and detected criticality (k=0.322, p<0.001). In addition, 530 patients (95.8%) were transported to Emergency Room. In conclusion, the present study shows that anaphylaxis represents a serious and relevant medical problem in the general population at any age, and should always be carefully managed.

Asthma exacerbation in children: relationship among pollens, weather, and air pollution.

BACKGROUND: Asthma exacerbation is an episode of (sub)acute worsening of asthmatic symptoms. Exacerbation may depend on environmental factors. OBJECTIVE: The present study investigated emergency calls for asthma exacerbation in children, analysing: i) their trend over the course of time; and ii) their possible relationship with environmental factors, including pollen count, meteorological parameters, and air pollution. METHODS: Emergency calls for exacerbation were recorded for 10 years (from 2002 to 2011) in Genoa (Italy). Betulaceae, Urticaceae, Gramineae, and Oleaceae pollen counts were measured. Meteorological parameters and air pollutants were also measured in the same area and for the same period. RESULTS: The number of emergency calls did not significantly modify during the time studied. Two main peaks were detected: during the autumn and the spring. Wind speed significantly diminished as did most air pollutants. There were significant and relevant relationships between emergency calls and: pollens during the spring (r = 0.498), rainfall (r = 0.818), wind speed (r = 0.727), and air pollutants (r = 0.622 for SO2; r = 0.699 for NO; r = 0.58 for NO2). CONCLUSIONS: This 10-year survey demonstrates that: (i) asthma exacerbations did not diminish over the time; (ii) there were seasonal peaks (autumn and spring); (iii) pollens (mainly Parietaria), wind speed and rainfall, SO2, NO, O3 and NO2 were strongly associated with asthma exacerbations in children in this area. Therefore, asthma exacerbations may significantly depend on environmental variations.

Ketotifen treatment of adverse reactions to foods: clinical and immunological effects.

Fifteen patients with cutaneous signs and symptoms caused by adverse reactions to foods were treated in an open trial with ketotifen for 4 to 6 weeks. Seven subjects were allergic and 8 had food intolerance. Each patient was treated with a single dose of ketotifen daily: 2 mg half an hour before going to sleep. Clinical improvement was achieved in 6 out of 7 allergic patients and in 6 out of 8 patients with food intolerance. Since several drugs have been demonstrated to have an influence on immune response, the in vitro effects of ketotifen on some immunological parameters were also studied. Ketotifen showed a significant inhibitory effect on autologous mixed lymphocyte reaction responsiveness.

Two screening methods for detection of specific IgE to inhalant allergens. Comparison with skin prick test and RAST.

We analyzed the technical features of two new screening methods for detection of specific IgE to inhalant allergens. Moreover, their diagnostic accuracy was evaluated comparing the results obtained from the procedures with those from RAST and skin prick test (SPT) in a group of 30 symptomatic allergic patients. The procedures employ a classic ELISA method, where the presence of IgE is revealed by a colored reaction. These two assays appeared to be quick, inexpensive and easy to use. The results obtained showed significant correlations with both RAST and SPT, in particular for Dermatophagoides pteronyssinus, Parietaria officinalis and grasses, which are the allergens chiefly responsible for respiratory atopy in our area.

Comparative effects of terfenadine and loratadine in the treatment of hay fever.

This double-blind, double-dummy, parallel-group study was undertaken in 40 patients with seasonal allergic rhinoconjunctivitis during the 1990 hay fever season. The patients were randomized and treated for seven days with either 120 mg terfenadine or 10 mg loratadine, each drug taken once daily in the morning. The severity of nasal congestion, rhinorrhea, sneezing, nasopharyngeal itching, and itchy, watery, red eyes was evaluated before and at the end of treatment. The global severity of symptoms was ranked daily by the patient on a diary card. Both treatment groups experienced a significant improvement of symptoms after treatment (p < 0.01), without any significant difference between the two study drugs. Terfenadine and loratadine significantly improved symptom severity by 69 and 55% compared with the baseline values, respectively. Headache and fatigue were reported in three loratadine-treated patients, and sedation in one patient. No side effects were observed in patients receiving terfenadine. This study confirmed that terfenadine 120 mg once daily is a safe and effective treatment for hay fever.

Effects of an adjunctive treatment with Bacillus subtilis for food allergy.

The authors evaluated the clinical efficacy of an adjunctive treatment with spores of Bacillus subtilis in 20 adult patients with urticaria-angioedema syndrome from food allergy. The patients treated with B. subtilis showed a significant reduction in frequency and severity of clinical features in respect to the patients who received no treatment. Bacillus subtilis spores may increase S-IgA synthesis or protect gastroenteric mucosa.

Terfenadine (single or associated) treatment of adverse reactions to foods.

Six groups of patients (total 105), affected by cutaneous signs and symptoms related to food ingestion were studied with regards to the clinical efficacy of some pharmacologic treatments: blind placebo, terfenadine alone, terfenadine associated with pirenzepine or rosaprostol or ranitidine or famotidine. Pharmacologic treatment by terfenadine alone showed poor clinical results, similar to placebo, while the associations of terfenadine with both cytoprotective drugs and anti-H2 receptor antagonists revealed significant clinical improvement which is more evident in those patients treated with cytoprotective drugs combination than those who were treated with anti-H2 antagonists.

Sedation from H1 antagonists: evaluation methods and experimental results.

Sedation is the most frequent and troublesome side effect of H1-antagonists, since it can impair many psycho-motor performances of working and social life. As these drugs are largely employed for the treatment of allergic diseases, both in adults and children, an evaluation of sedation must be accurately performed by standardized tests. In the present work, authors briefly describe the most important clinical tests and summarize the results from the recent literature about the new H1-antagonists.

Theophylline and the immune response: in vitro and in vivo effects.

We analyzed the in vitro and in vivo effects of theophylline on various immunological parameters including proliferation of peripheral mononuclear cells (PMNC) in response to phytohemagglutinin (PHA), anti-T3 and anti-T11 monoclonal antibodies (MAb), PHA-induced interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) production by PMNC, interleukin-1 (IL-1) production by accessory cells, PHA-induced IL-2 production by T-cell clones, and PHA- and anti-T3 MAb-induced DNA synthesis by T cell clones. Results showed that theophylline inhibited PHA- and anti-T3-induced proliferation of both PMNC and T-cell clones, whereas the PMNC proliferation induced by MAb anti-T11 was not affected. The inhibition appeared to be dose-dependent and strictly related to the presence of the drug in the culture. Moreover, PHA-induced IL-2 production by both PMNC and T-cell clones also appeared to be reduced by theophylline. IL-1 production by accessory cells was not affected. These data suggest that the immunological inhibition exerted by theophylline is confined to the T-cell compartment, mainly by acting on structure(s) related to the T3/Ti complex, the primary site for T-cell activation. The alternative pathway of T-cell activation (i.e., via T11 site) seems unaffected. In addition, these results suggest possible clinical relations between the inhibition of the immune response and the plasma levels of the drug reached after a "once daily" or "twice daily" oral ingestion of slow-release theophylline products.

Cytoprotective drugs: a new perspective in the treatment of adverse reactions to foods.

Food allergy (FA) and food intolerance (FI) are complex syndromes caused by adverse reactions to foods. Since mucosal permeability of the digestive tract is often increased during this pathology, we evaluated the clinical efficacy of two different cytoprotective drugs in patients with urticaria-angioedema due to FA and FI. These drugs were pirenzepine, an anti-muscarinic (anti-MI) receptor antagonist, and rosaprostol, a synthetic prostaglandin. Further, the results obtained by these schedules of treatment were compared with those achieved by the previously described polyantihistaminic treatment (ie, the association of anti-H1 plus anti-H2 receptor blockers). The present investigation suggests that the cytoprotective drugs are more effective than the antisecretive ones (ie, the anti-H2). Recently, anti-H2 drugs and ketotifen were shown to be in vitro inhibitors of the immune response and cromolyn was demonstrated capable of exerting an enhancing effect on T cell proliferation. In the present study we tested the effect of pirenzepine on several immunologic parameters, such as lymphocyte proliferation (through different activation pathways) and lymphokine (interleukin-2 and interferon-gamma) production. Since we found that pirenzepine does not affect the immune response and in consideration of its clinical efficacy, we consider this cytoprotective drug a valuable tool in the treatment of adverse reactions to foods.

A multi-allergen ELISA screening method. Comparison with Pharmacia CAP system and Phazet skin prick test.

Eighty consecutive subjects, coming to our service as suffering from conjunctivitis and/or rhinitis and/or asthma, were investigated by a new multi-allergen enzymatic screening immunoassay (Profilo, Bio-Allergy, Rome, Italy) regarding to serum specific IgE for groups of inhalant allergens (Dermatophagoides, Parietaria, grasses, trees, animal danders). These groups include allergens which are most frequently responsible of allergy in our country. Indices of diagnostic accuracy of this assay were analyzed in relation to skin prick test (SPT, Phazet, Pharmacia), as in vivo reference test, and Pharmacia CAP System, as in vitro reference test, comparing the results achieved by these tests in the same group of subjects. Profilo showed high significant (p < 0.0005) correlations and satisfactory indices of diagnostic accuracy (sensitivity, specificity, predictive values of positive and negative, and efficiency) for the tested allergens with reference to both Phazet SPT and CAP System. In addition, the method appeared very rapid and simple, so that it could be performed in the physician's office.

Immunologic and clinical evaluation of a 12-month course of specific immunotherapy.

Allergen specific immunoglobulins (IgE, IgG, IgG1, and IgG4) were evaluated during the course of a 12-month specific immunotherapy (ITS) in 27 allergic subjects: 12 Dermatophagoides pteronyssinus (DP)-, 9 Parietaria officinalis (W19)-, six perennial and timothy rye grass (G5 and G6)-sensitive cases. Further, the modifications of the specific Ig levels were compared with the significant improvement in symptoms and drug consumption observed after 12 months of ITS. IgE levels significantly decreased after 6 and 12 months, while IgG1 significantly increased in the early phases of ITS (3rd month), and IgG4 significantly and progressively increased during the course of ITS. No modification was observed in specific total IgG. Regression analysis test among the various Ig levels revealed a strict correlation only between IgE and IgG4 (high levels of IgE before ITS correlated with high levels of IgG4 after 12 months of ITS). No correlation was observed between total Ig changes and improvement of clinical status or drug consumption.

A three-year double-blind placebo-controlled study with specific oral immunotherapy to Dermatophagoides: evidence of safety and efficacy in paediatric patients.

Very few double-blind trials of oral immunotherapy have been reported. The majority of these have been performed with pollen extracts and the results have often been equivocal. The major weaknesses of these studies have been the short periods of the trials, the low doses of allergen employed and inadequate evaluation of efficacy. The present study has involved a placebo-controlled double-blind trial of oral immunotherapy for three years with Dermatophagoides pteronyssinus at relatively high doses in 18 paediatric patients. Throughout the trial clinical parameters (symptom and medication scores) and immunological parameters (specific IgE, IgG1 and IgG4 levels) were monitored in order to assess the safety and efficacy of the treatment. The treatment was well tolerated by all patients and no side-effects were experienced. Clinical improvement was evident after the second year of therapy and this was confirmed by a significant reduction in conjunctival reactivity assessed by a specific conjunctival provocation test. In addition, there were significant changes in the immunological parameters with a reduction in specific IgE and increased levels of IgG4 and IgG1, results in keeping with previous studies of oral and subcutaneous immunotherapy. Although the results do not provide an explanation of the basis of successful oral immunotherapy, they clearly demonstrate the efficacy and safety of the treatment and suggest that it may be a useful and more acceptable alternative for patients than the traditional subcutaneous immunotherapy.

Cetirizine does not influence the immune response.

Antihistamines are frequently employed in the treatment of allergic rhinitis and urticaria-angioedema syndrome. We analyzed the in vitro effects of cetirizine on the immune response. To this end the proliferation of peripheral mononuclear cells induced by mitogen and by -CD3, -CD2, or -CD28 monoclonal antibodies has been studied. Since the plasma peak of cetirizine following ingestion of 10 mg is about 1 microgram/mL, the drug was tested in the cultures at the concentration of 0.1, 1, or 10 micrograms/mL. No influence of cetirizine on T cell proliferation was detected. We also evaluated the effect of cetirizine on the expression of the following markers expressed by T cells upon activation: lymphocyte markers ICAM-1, HLA-DR, and CD25 surface expression, alpha-1-acid glycoprotein has been also studied. There was no effect of cetirizine on the investigated immunologic parameters; these data acquire clinical relevance when related to previous reports showing a depression of the immunologic response exerted by other compounds such as ketotifen and theophylline and when related to the recent data about the modulation of ICAM-1 expression on eosinophils by cetirizine. Cetirizine does not affect ICAM-1 expression of lymphocyte membrane.

Nasal immunotherapy to Parietaria: evidence of reduction of local allergic inflammation.

Studies over 10 yr have demonstrated local nasal immunotherapy (LNIT) to be an effective treatment for rhinitis due to pollens and mites. The aim of our work was to investigate the effects of LNIT on the local inflammatory phenomena, employing the model of nasal allergenic challenge, since no evidence has been yet provided about LNIT effects on the events due to allergic reactions. We evaluated, in addition, the possible effects of LNIT on some systemic immunologic parameters and its clinical efficacy. The study involved a double-blind, placebo-controlled trial of preseasonal immunotherapy with Parietaria in 20 adults. A significant reduction of symptoms, inflammatory infiltration, and intercellular adhesion molecule-1 (ICAM-1) expression on epithelial cells after nasal challenge was evidence as long-lasting effect. No changes in serum allergen-specific IgE, IgG, and soluble eosinophil cationic protein were detected, whereas an unexpected increase of soluble ICAM-1 was found in the placebo group only. The treatment was well tolerated and a significant clinical improvement under natural allergenic exposure was observed in the active group. The present study provides, for the first time, evidence that LNIT is able to modulate the nasal allergic inflammation.