The value of skin testing for penicillin allergy in an inpatient population: analysis of the subsequent patient management.

It was decided to assess the value of skin testing in a group of inpatients with a remote history of penicillin allergy, in terms of whether or not beta-lactams were subsequently given, if any adverse reactions occurred as a result of this therapy, and if labeling of the patient record was changed subsequent to skin testing and/or challenge. All patients seen in consultation with a history of penicillin allergy were assessed. When done, skin tests were performed with the major and minor determinants of penicillin and semisynthetic penicillins. Charts were reviewed after discharge in terms of the antibiotics given during admission, adverse events, and the medical record and hospital database labeling for drug allergy at discharge. Skin testing was carried out in 79% of 67 patients assessed and in all, the tests were negative. Beta-lactam therapy was recommended in 51/53 patients but was given in only 57% of these cases. At discharge, 49% of patients' records still carried the penicillin allergy label, despite negative skin testing and/or successful completion of a course of beta-lactam therapy. So, in approximately half of the patients reviewed, beta-lactams were not given despite negative skin tests and a recommendation to do so, if indicated, and 49% of patients were still inappropriately labeled as being penicillin-allergic on discharge.

Prevalence of anal human papillomavirus infection and anal cytologic abnormalities in HIV-seropositive women.

OBJECTIVE: To determine the prevalence of anal human papillomavirus (HPV) infections and anal cytologic abnormalities in HIV-seropositive and HIV-seronegative women. DESIGN: This cross-sectional study of a cohort of women with known HIV serostatus involved a standardized interview and a gynecologic examination, including a cytologic evaluation of the cervix and anus. Anal swabs were tested for HPV DNA using the Hybrid Capture assay. SETTING: Two HIV/AIDS clinics, a sexually transmitted disease clinic, a methadone clinic and women enrolled in a study of HIV heterosexual transmission in the greater New York City metropolitan area. PATIENTS: One hundred and two HIV-seropositive and 96 HIV-seronegative women were selected from an ongoing study of the gynecologic manifestations of HIV infection. MAIN OUTCOME MEASURES: Detection of anal HPV DNA and anal cytologic abnormalities. RESULTS: Anal cytologic abnormalities were detected in 27 (26%) of the 102 HIV-seropositive women and in six (7%) of 96 HIV-seronegative women. Five (5%) of the anal smears from the HIV-seropositive women and one (1%) from the HIV-seronegative women had low-grade anal intra-epithelial neoplasia. The remainder of the anal cytologic abnormalities were classified as mild squamous cytologic atypia. HPV DNA was detected in 30 (29%) of 102 HIV-seropositive and two (2%) of 96 HIV-seronegative women. Of the 33 patients with anal cytologic abnormalities, 19 (58%) had anal HPV DNA detected as compared to 13 (8%) of 160 women without cytologic abnormalities (P < 0.001). In a multivariate logistic regression analysis, HIV-seropositivity was found to be an independent risk factor for both anal HPV infection and anal cytologic abnormalities and the strength of the association was greater in women with lower CD4+ T-lymphocyte counts. CONCLUSION: The prevalence of both anal cytologic abnormalities and anal HPV infection are significantly increased in HIV-seropositive women.

Community-based strategies for immunizing the "hard-to-reach" child: the New York State immunization and primary health care initiative.

The 1989-1991 measles epidemic in New York City drew attention to the low immunization coverage rates found in urban neighborhoods. This article describes a joint initiative of the New York State Department of Health and the Columbia University School of Public Health to mobilize parents to fully immunize their children. Eleven community-based organizations (CBOs) used a variety of outreach strategies to identify and enroll underimmunized children in primary care. They enrolled 4,555 children, of whom 75% needed at least one basic vaccine dose to be up-to-date for their age. Enrolled children were followed by CBOs to ensure compliance with appointments. After nine months of program operation, 73% of children in an evaluation sample were up-to-date for age for their immunizations. Immunization coverage increases were greatest for the youngest children, for whom coverage rates more than doubled in the first nine months of program operation. Ninety-one percent of these "hard to reach" children were tracked successfully by CBOs. This article compares the strategies used by the community organizations and concludes with suggestions for improvements of future community-based mobilization programs.

The frequency of skin test reactions to side-chain penicillin determinants.

BACKGROUND: Skin testing for immediate hypersensitivity to penicillins is usually carried out with reagents prepared from benzylpenicillin, and it is believed that side-chain-specific reactions to semisynthetic derivatives are rare. Because some experimental and clinical data suggest that antibodies can be induced to immunogenic epitopes on the side chains of penicillins, we looked for side-chain-specific reactions to skin testing in patients with a history of allergy to penicillins or semisynthetic penicillins. METHODS: One hundred twelve patients with a clinical history of allergic reactions to penicillins and other semisynthetic penicillins were skin tested an average of 4.9 +/- 0.7 years after their reactions with the major and minor determinants of benzylpenicillin and minor determinant mixtures of ampicillin, amoxicillin, or cloxacillin. RESULTS: In these patients the most common clinical reactions were urticaria and angioedema (36.6%) and exanthema (48.8%). It was found that 21 cases (18.8%) still exhibited immediate hypersensitivity reactions on skin testing. But of these 21 patients, skin test reactivity was limited in 47.6% to the semisynthetic penicillin reagents derived from ampicillin, amoxicillin, or cloxacillin; that is, skin tests were negative with the benzylpenicillin derivatives. Ampicillin and amoxicillin were the semisynthetic beta-lactams causing most clinical reactions (24.1% and 33.9%, respectively), and ampicillin was the most common penicillin derivative to which skin test reactivity occurred (38.1%), other than the benzylpenicillin derivatives (52.3%). CONCLUSIONS: IgE antibodies appear therefore to discriminate between benzylpenicillin and ampicillin or other semisynthetic penicillins in a significant proportion of patients allergic to penicillin. Although it has not been proved that side-chain-specific skin reactivity implies the presence of clinically significant immediate hypersensitivity to semisynthetic penicillins, it is possible that side-chain-specific reagents may be required to exclude possible immediate hypersensitivity to the penicillins in patients who reacted to these antibiotics clinically.

Repeat skin testing for aeroallergen immediate hypersensitivity in an atopic patient population.

A retrospective study of repeat intradermal skin testing with aeroallergens carried out on atopic subjects with allergic rhinitis/conjunctivitis and/or asthma, after a mean interval of 3.5 years, showed that an increase in the number of allergens reacted to by an individual patient correlated with age or with worsening of symptoms.

Cell-mediated immune responses to artificial food additives in chronic urticaria.

In some cases of chronic urticaria it is suspected that food additives such as tartrazine and sodium benzoate or salicylates may play a role in the pathogenesis of the condition. Since, at times, chronic urticaria may appear histologically similar to a mild cell-mediated immune response, the release of the T cell-derived lymphokine leucocyte inhibitory factor (LIF), in response to incubation with these additives and with acetylsalicylic acid (ASA), was measured in vitro using cells from normal controls, from patients with chronic urticaria with or without clinically associated additive sensitivity and from patients with asthma with or without associated ASA sensitivity. It was found that significant production of LIF occurred in response to tartrazine and sodium benzoate in those individuals with chronic additive induced urticaria. In addition, tartrazine caused LIF release from mononuclear cells of ASA-sensitive asthmatics. These results may indicate a possible role for additive-induced cell-mediated immune responses in the pathogenesis of some cases of chronic urticaria and suggest a potential diagnostic test for this condition.

A dietary approach to bulimia treatment.

To determine the effect of diet on bulimia, a treatment group of 10 bulimic women were placed for 6 weeks on a nutrient-dense diet containing no fewer than 1400 calories and free of suspected blood sugar-insulin level destabilizers. Simultaneously, a control group of 10 bulimic women were placed on a Sham Food Plan which allowed unknowing duplications of their pre-study food patterns. After three weeks they were switched to the nutrient-dense diet for the remainder of the study. No subject received psychiatric counseling. The treatment group assigned to the nutrient-dense diet ceased to binge (p = (1/2)9 less than 0.002, sign test). The control group on the sham diet binged steadily until switched to the nutrient-dense diet, after which, all binging ceased. Subjects lost weight effortlessly (or maintained weight by choice) and have remained binge free for over 2 1/2 years. Evidence suggests that malnutrition and blood sugar-insulin level destabilizers may play a role in precipitating the bulimic condition.

The effect of the human menstrual cycle on nutrient intake.

The dietary intakes of eight human females were obtained by interview each day for 60 days to determine whether the menstrual cycle affected nutrient intake. Analysis showed that over the menstrual cycle there were fluctuations in carbohydrate consumption, but not in protein and fat consumption. The mean post period (preovulation) intake was between 51.6% to 56.4% of the preperiod (postovulation) consumption. The evidence indicates that women eat more carbohydrate per day after they ovulate than before.

Lymphocyte transformation studies in suspected hypersensitivity to trimethoprim-sulphamethoxazole.

In a group of patients with suspected and probable adverse skin reactions to trimethoprim-sulphamethoxazole, the lymphocyte transformation test (LTT) was positive in approximately 60% of subjects tested. Levels of stimulation in the majority of cases were low, probably reflecting either use of inappropriate stimulatory forms of the drug or lack of marked reactivity. Since there appeared to be a correlation between peak stimulatory index and duration of the rash, the latter explanation appeared more likely.