Strategies for the prevention of asthmatic, anaphylactic and anaphylactoid reactions during the administration of anesthetics and/or contrast media.

General anesthetics and contrast media can cause anaphylactic as well as anaphylactoid reactions. These events are of great concern to radiologists and anesthesiologists because of their relatively high prevalence, possible threat to life, and medical-legal consequences. Points discussed in this review are the critical evaluation of risk factors affecting prevention strategies, the need to be aware of pathogenic mechanisms relevant to prevention strategies, the use of alternative products if a culprit agent is known, the recognition of early signs of a reaction, the need to keep records of reactions on a patient's medical chart, the planning of prophylactic therapy, recommended actions after a reaction to an anesthetic or contrast medium, and the suggested establishment of allergy-anesthesiology centers to improve cooperation, and medical-legal issues. As any drug or contrast medium administered during general anesthesia or a diagnostic procedure can induce a potentially life-threatening or fatal event even in the absence of any evident risk factor in the patient's medical history or clinical status, we usually premedicate susceptible individuals at least to attenuate the severity of an unpredictable reaction, although we cannot rely on the efficacy of premedication to completely prevent a severe event. These recommendations, which are based on the literature and on the experience of our working group, aim to provide useful information for physicians and other specialists who operate in the absence of an allergy consultant.

The perennial pattern of clinical symptoms in children monosensitized to Olea europaea pollen allergens in comparison with subjects with Parietaria and Gramineae pollinosis.

Because the pediatric age represents a good model to study the correlation between the exposure to allergens and development of respiratory allergy, we investigated the occurrence of a perennial type of symptomatology in children monosensitized to Olea europaea (O.e.) pollen allergens compared with subjects with monosensitization to Parietaria (P) and Gramineae (G) in order to confirm our previous observations in adults. We selected a group of 52 children with rhinitis and/or bronchial asthma and a SPT positivity only to pollens (30 to P, 15 to G, and 7 to O.e.). Using commercially available allergenic extracts and reagents, the following diagnostic procedures were performed: skin prick test (SPT), specific IgE assays (RAST), nonspecific bronchial provocation test (NsBPT) and specific nasal provocation test (sNPT), respectively, in patients with bronchial asthma and rhinitis. Pollen counts and a statistical analysis using Spearman's correlation test were also carried out. Six of seven children with monosensitization to O.e. allergens showed a perennial pattern of symptoms in comparison to 7 of 23 and 3 of 12, respectively, in subjects with P and G pollinosis. All patients with perennial nasal symptoms of O.e. group exhibited a late nasal response after sNPT. Although these findings on nasal response may partially explain the occurrence of a prolonged inflammation of the nose induced by O.e. allergens, we think that other possibilities could be investigated. In our opinion, further studies are necessary using better purified and standardized diagnostic materials and, moreover, a greater number of O.e. monosensitized children living in other geographical areas need to be examined for a comparison of our results with theirs.

A double-blind, placebo-controlled trial of local nasal immunotherapy in allergic rhinitis to Parietaria pollen.

We assessed the efficacy and safety of local nasal immunotherapy (LNIT) using an extract in macronized powder form of Parietaria pollen, a very important allergenic plant in the Mediterranean and other parts of the world. Twenty-six patients aged 13-37 years, with seasonal allergic rhinitis to this pollen, were enrolled in a double-blind placebo-controlled trial, carried out from autumn 1991 to the end of June 1992. They were selected on the basis of a positive skin-prick test, radioallergosorbent test (RAST) and intranasal challenge to Parietaria antigen. Patients were randomly divided into two groups of 13; the first group was given Parietaria antigen, and the second placebo. We recorded mean weekly symptom scores and drug consumption for 17 weeks during the pollen season in the year 1992, and specific serum-IgE and IgG levels. Three patients in the active group withdrew from the study because of bronchial symptoms. A significant difference was observed in mean weekly nasal symptom scores, in drug consumption and in specific nasal threshold to Parietaria allergenic extract in the treated and control groups. No difference was observed in serum IgE and IgG levels. Serum IgE levels rose significantly only in the control group after the pollen season. This study indicates that LNIT may be a useful alternative to traditional subcutaneous immunotherapy in patients with allergic rhinitis.

Immunotherapy with Alpare in patients with respiratory allergy to Parietaria pollen: a two year double-blind placebo-controlled study.

Allergy to Parietaria judaica pollen causes significant morbidity in many areas of the world. In addition to rhinitis, patients who are allergic to this pollen have a high incidence of asthma. The pollinating season is long, making this particular allergy challenging for clinicians to treat. This study was designed to determine if immunotherapy with an alum adsorbed partially purified Parietaria extract (Alpare Parietaria) containing a targeted maintenance dose of 12,500 BUs was effective in decreasing rhinitis symptoms in patients allergic to Parietaria. Using a double-blind placebo-controlled technique 36 patients received placebo or active extract for 2 years. Twenty (11 placebo and nine active) completed the 2 year study. Efficacy of treatment was evaluated by determining changes in skin reactivity, visual analog scores, diary symptom scores and end of study assessments. Reactions were monitored as well. Skin-test suppression was marginally significant in the actively treated group after 1 year and showed even more significant suppression after the second year. Nasal block, rhinorrhoea and sneezing all were significantly decreased in the active group. The nasal provocation test did not show a significant change after 1 year, in either group, but after 2 years of treatment the active group did show significant improvement. Although almost all patients in the actively treated group experienced local reactions, the incidence of systemic reactions was not different between the two groups. In conclusion, immunotherapy with this extract at this dose was effective in ameliorated rhinitis symptoms in patients allergic to Parietaria judaica.

Antigenic activity of nonpollen parts (leaves and stems) of allergenic plants (Parietaria judaica and Dactylis glomerata).

In patients with respiratory allergy to pollen it is common to correlate the onset, duration and intensity of clinical symptoms with the count of atmospheric allergenic pollen grains. Pollen counts, however, may not reflect the total airborne allergen exposure since previous data suggest that pollen allergens may also be carried in microaerosol suspensions. These microdroplets may penetrate deeply into the airways, where pollen grains are too large to penetrate, eventually inducing asthma. The origin of these allergenic aerosols is still uncertain. We investigated whether antigenic activity is present in vegetative parts of allergenic plants. We have used extracts from leaves and stems of Parietaria judaica and Dactylis glomerata to evaluate patients with allergic sensitization to pollen allergens of these plants (19 grass-sensitive patients and 23 Parietaria sensitive). By using skin prick testing and RAST to stem and leaf extracts other than pollen extracts we observed that most patients sensitive to grass or Parietaria pollen had small responses to extracts of stem or leaf. We conclude that allergenic components are present throughout most of Parietaria judaica and Dactylis glomerata plants, most highly concentrated in the pollen but present in the leaves with a trace in the stems.

The effects of cefonicid on the pharmacokinetics of a once-a-day theophylline formulation.

The authors have explored the effects of cefonicid on the steady-state pharmacokinetics of a new sustained-release theophylline formulation in 12 adult patients suffering from chronic obstructive lung disease, by comparing the pharmacokinetic data obtained following four days of medication with theophylline alone with those found at the end of seven days of combined treatment with the same theophylline preparation plus cefonicid. Blood theophylline levels were assessed in duplicate by polarized immunofluorescence with a TDx analyser. Theophylline kinetics were totally unaffected by simultaneous cefonicid treatment, showing that the two drugs may be administered together without any need for adjustment of the theophylline dosage.

Allergenic pollens in the southern Mediterranean area.

In the Mediterranean area there are characteristic climatic conditions (mildness of winter, summer dryness, etc.) that facilitate the growing of a typical vegetation with production of allergenic pollen, such as those from Parietaria and Olea europaea, very different from that of central and northern Europe. We present in this article the results of an 8-year pollen count in the atmosphere of Naples, Italy. The pollen content was examined with a volumetric spore trap (Lanzoni VPPS-2000) like that of Hirst. The results of the pollen counts were subsequently compared with results of skin tests of patients born and still living in and around Naples to determine the pollinosis of that area. We found that the most important allergenic pollen in the Naples area is Parietaria, with very long-lasting periods of pollination. The first period, more important, occurring from March to July, and the second period of much lower intensity, occurring from the end of August to the end of October. Pollen allergy to Parietaria was found to be present in 82.02% of pollen-allergic patients. It was followed by Gramineae (32.12%), Olea (23.11%), and Artemisia vulgaris (17.08%). These data are quite different from data of the pollinosis in northern Italy and in the northern Mediterranean area, as well as the southern coast of France, where allergic sensitization to Poaceae is the most important.

Ketanserin, a new blocking agent of serotonin S2-receptors. Respiratory functional effects in chronic obstruction of the airways.

The role played by serotonin (5-HT) in the regulation of bronchomotor tone has up to now been a much debated question, although there is good evidence that it induces intense bronchoconstriction after inhalation in asthmatic patients. Serotonin has been found to contract the tracheobronchial smooth muscle of different animals. Some data suggest that tracheobronchial contraction due to serotonin is mediated by its interaction with the S2-receptor. The blockade of this receptor by ketanserin, a serotoninergic antagonist which primarily binds to S2-serotoninergic receptors, produces bronchodilation. The respiratory effects of intravenously administered ketanserin (10 mg) or placebo were compared in a double-blind crossover study in 14 patients with chronic obstruction of the airways. The forced expiratory volume in one second (FEV1) and the instantaneous forced expiratory flow after 50 percent of the forced vital capacity has been exhaled (FEF50%) did not change after placebo, but they increased significantly after administration of ketanserin. The results suggest that in patients with chronic obstructive pulmonary disease, serotonin may play a role in the development of obstruction of the airways, even if the mechanism remains undefined.