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 β-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

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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.

Enfermedad neuromuscular: evaluación clínica y seguimiento desde el punto de vista neumológico / Neuromuscular disease: Respiratory clinical assessment and follow-up

Los pacientes con enfermedad neuromuscular constituyen un grupo de riesgo importante para sufrir con frecuencia situaciones de fracaso respiratorio agudo o crónico. Desde que nacen o son diagnosticados requieren un seguimiento por parte del neumopediatra para diagnosticar y tratar las complicaciones respiratorias, que son su principal causa de fallecimiento, dentro de un contexto multidisciplinar. El soporte ventilatorio y la asistencia a la tos han mejorado la calidad de vida y el pronóstico a largo plazo de muchos de estos pacientes. En este artículo los autores repasan la fisiopatología, evaluación de la función respiratoria, trastornos del sueño y complicaciones respiratorias más frecuentes en las enfermedades neuromusculares. En un próximo artículo se analizarán los diversos tratamientos utilizados desde el punto de vista neumológico

Patients with neuromuscular disease are an important group at risk of frequently suffering acute or chronic respiratory failure, which is their main cause of death. They require follow-up by a pediatric respiratory medicine specialist from birth or diagnosis in order to confirm the diagnosis and treat any respiratory complications within a multidisciplinary context. The ventilatory support and the cough assistance have improved the quality of life and long-term survival for many of these patients. In this paper, the authors review the pathophysiology, respiratory function evaluation, sleep disorders, and the most frequent respiratory complications in neuromuscular diseases. The various treatments used, from a respiratory medicine point of view, will be analyzed in a next paper

[Neuromuscular disease: respiratory clinical assessment and follow-up]. / Enfermedad neuromuscular: evaluación clínica y seguimiento desde el punto de vista neumológico.

Patients with neuromuscular disease are an important group at risk of frequently suffering acute or chronic respiratory failure, which is their main cause of death. They require follow-up by a pediatric respiratory medicine specialist from birth or diagnosis in order to confirm the diagnosis and treat any respiratory complications within a multidisciplinary context. The ventilatory support and the cough assistance have improved the quality of life and long-term survival for many of these patients. In this paper, the authors review the pathophysiology, respiratory function evaluation, sleep disorders, and the most frequent respiratory complications in neuromuscular diseases. The various treatments used, from a respiratory medicine point of view, will be analyzed in a next paper.

[Bacteremic pneumococcal pneumonia]. / Neumonía neumocócica bacteriémica.

BACKGROUND: Streptococcus pneumonia is the most common bacterial cause of community-acquired pneumonia in children. The reference standard for etiological diagnosis is isolation of S. pneumoniae from blood Since the advent of conjugate vaccines, disease caused by this organism can now be prevented. Many studies have been performed of the global incidence of invasive pneumococcal infections and of pneumococcal meningitis but few studies investigated bacteremic pneumococcal pneumonia and its complications in children. OBJECTIVES: To determine the incidence, patient characteristics, clinical signs, laboratory data, percentage and days of hospitalization, response to antibiotic treatment, antibiotic resistance, complications and causal serogroups of bacteremic pneumococcal pneumonia in our environment in order to estimate requirements for systematic vaccination programs. MATERIAL AND METHODS: From January 1990 to May 2001, data on all pediatric cases of invasive pneumococcal infections diagnosed in our hospital were collected. Several characteristics of patients with bacteremic pneumococcal pneumonia were analyzed. Bacteremic pneumococcal pneumonia was diagnosed in patients with positive blood or pleural fluid cultures for S. pneumoniae and radiographically evident pulmonary infiltrate. The incidence of both types of pneumonia were determined according to population census data. All S. pneumonia strains were sent to the Pneumococci Reference Laboratory of the Instituto Carlos III in Madrid for serotyping. We estimated the serotype coverage of the pneumococcal 7-valent conjugate vaccine according to the serotypes included in this vaccine and their distribution. RESULTS: Forty cases of bacteremic pneumococcal pneumonia were diagnosed, yielding an incidence of 17,10 and 5 cases per 10(5) children aged less than 2, 4 and 15 years old respectively. The mean age was 50 months and 43% were aged less than 4 years. Peaks occurred in January, March, April and May. A total of 77.5% of the patients were admitted to hospital and the mean length of stay was 9.2 days. The mean duration of fever was 2 days and was 4.2 days in patients with pleural empyema. All patients presented fever and its mean duration before admission was 4 days. Fifty-eight percent of the patients had cough. Thirty-nine percent appeared generally unwell, vomiting was present in 47% and abdominal pain in 28%. Respiratory auscultation detected rales in 30% of the patients, hypophonesis in 28% and polypnea or dyspnea in 35%. Most patients showed alveolar bilateral infiltrations and 20% had pleural empyema. Seventy-eight percent had WBC counts > 15,000 and 93% showed neutrophilia of > 60%. Erythrocyte sedimentation rate and C-reactive protein were elevated in 77% and 85% of the patients, respectively. Overall, 40% of the isolates showed intermediate susceptibility to penicillin and 5% were resistant. Eighteen percent showed intermediate susceptibility to cefotaxime and 18% were resistant to erythromycin. Thirty-four strains were resistant to erythromycin. Thirty-four strains were serogroups and in children < or = 59 months, 34% of the serogroups were included in the pneumococcal 7-valent pneumococcal conjugate vaccine. CONCLUSION: The significant morbidity of bacteremic pneumococcal pneumonia and the implicated serogroups supports the use of the new heptavalent vaccine in the pediatric age group.

Neumonía neumocócica bacteriémica / Bacteremic pneumococcal pneumonia

Antecedentes: Streptococcus pneumoniae es el primer agente causal de neumonía bacteriana adquirida en la comunidad en la infancia. Para su diagnóstico el aislamiento en sangre de S. pneumoniae es el único método válido. Con la aparición de las nuevas vacunas conjugadas antineumocócicas se pueden prevenir estas infecciones. Existen estudios sobre la incidencia global de la enfermedad invasiva neumocócica (EIN) y sobre sus formas más graves como la meningitis, pero muy pocos la neumonía neumocócica bacteriémica (NNB) y sus complicaciones en la infancia. Objetivos: Conocer la incidencia, forma de presentación clínica y analítica, porcentaje y días de ingreso, respuesta al tratamiento antibiótico y resistencia a éstos, complicaciones y serogrupos causales de la NNB en nuestros medio para estimar la necesidad de una vacunación sistemática. Material y métodos: Desde enero de 1990 hasta mayo de 2002 se han recogido todos los casos pediátricos de EIN diagnosticados en nuestro hospital. Del total de estos casos se analizaron diversas características en los pacientes con NNB. Se consideraron NNB los casos con radiología torácica compatible con neumonía y hemocultivo o cultivo de líquido pleural positivo para S. pneumoniae. Se calculó la incidencia, tanto de la EIN como de la NNB, según los datos de población censales. Todas las cepas de S. pneumoniae fueron enviadas para serotipificación al Laboratorio de Referencia de Neumococos del Instituto de Salud Carlos III en Majadahonda (Madrid). Se estimó la cobertura vacunal de la nueva vacuna antineumocócica conjugada heptavalente según los serotipos incluidos en ella y la distribución de los serotipos. Resultados: Se diagnosticaron 40 casos de NNB, lo que representa una incidencia de 17, 10 y 5 casos por 105 niños menores de 2, 4 y 15 años, respectivamente. La edad media fue de 50 meses, siendo el 43% menores de 4 años. El mayor número de casos se dio en enero, marzo, abril y mayo. Ingresaron el 77,5% de los casos y la estancia media fue de 9,2 días. La duración media de la fiebre fue de 2 días y en los pacientes con derrame pleural fue de 4,2 días. Presentaron fiebre todos los casos, siendo su duración media antes del ingreso de 4 días. El 58% de los pacientes tenían tos. El 39% presentaban afectación de su estado general, vómitos el 47% y dolor abdominal el 28%. En la auscultación respiratoria se detectaron estertores en el 30% de los casos, hipofonesis en el 28% y polipnea o disnea en el 35%. En la mayoría de los pacientes se observó un infiltrado alveolar unilateral y el 20% de los casos tenían un derrame pleural. El 78% de los casos tenían una leucocitosis superior a 15.000 y el 93% una neutrofilia mayores de 60%. La velocidad de sedimentación globular y la proteína C reactiva fueron elevadas en el 77 y 85% de los casos, respectivamente. El 40% de las cepas tenían una sensibilidad disminuida a la penicilina y el 5% eran resistentes. El 18% tenían una sensibilidad disminuida a cefotaxima y el 18% eran resistentes a eritromicina. Se serogruparon 34 cepas y en los menores de 59 meses, el 84% de los serogrupos eran los incluidos en la vacuna heptavalente. Conclusión: La importante morbilidad de la NNB y la distribución de los serogrupos implicados apoyaría la utilización de la nueva vacuna heptavalente en esta edad (AU)