Modification of mediators of immune reaction after general anaesthesia.

UNLABELLED: The adverse reactions that may occur during a surgical intervention are of concern to anesthesiologists and allergists due to the civil responsibility they entail and the increased demand for healthcare in allergology units. The aim of the present study was to determine the prevalence of adverse reactions in our setting (Island of Lanzarote) and modifications to immune response mediators using three types of representative myorelaxants (succinylcholine, cisatracurium and vecuronium) in order to predict and prevent adverse reactions. MATERIAL AND METHODS: We performed a prospective, cross sectional, observational study in a population of 201 patients scheduled to undergo surgery in the Surgery Department of the Lanzarote General Hospital from October 1998. Three groups were retrospectively selected: vecuronium (73 patients), cisatracurium (80 patients), and succinylcholine (48 patients). Blood was extracted from all patients before and after the intervention and the following in vitro variables were evaluated: histaminemia, eosinophil cationic protein, tryptase, IgE to latex, CD4/CD8 fractions, total lymphocytes, total IgE, C3 and C4, and also the histaminuria. CONCLUSIONS: The mean age of the patients was 41 years with a predominance of women. Sixty percent had not previously undergone surgery. The mean operating time was 2 hours. Digestive surgery accounted for the greatest number of interventions (38.8 %) and most of the patients had no personal history of atopy (91.5 %). The greatest number of perioperative reactions was produced by cisatracurium (38.8 %), followed by succinylcholine (27.4 %) and vecuronium (20 %). The reactions observed were immediate type 1 and 2 reactions. All reactions were reversible without sequelae. Histaminuria levels were significantly decreased in the cisatracurium group. Histaminemia and eosinophil cationic protein showed no significant changes in any of the three groups. Tryptase concentrations in blood did not increase in the postoperative period in any of the three groups. On the contrary, concentrations were significantly lower than basal values. In the vecuronium and succinylcholine groups, CD4/CD8 fractions decreased in the postoperative period. Total lymphocytes decreased in all three groups. Total IgE tended to decrease in the cisatracurium and succinylcholine groups. IgE to latex was negative in the three groups. Specific IgE to succinylcholine was unmodified. C3 complement fraction was unmodified in all three groups and C4 fraction was reduced in the vecuronium group. In our setting and in our patients, the three myorelaxants produced immunosuppression of immune response mediators. The present study confirms that tests for allergy to myorelaxants are not indicated in the preoperative period.

Modification of mediators of immune reaction after general anaesthesia

The adverse reactions that may occur during a surgical intervention are of concern to anesthesiologists and allergists due to the civil responsibility they entail and the increased demand for healthcare in allergology units. The aim of the present study was to determine the prevalence of adverse reactions in our setting (Island of Lanzarote) and modifications to immune response mediators using three types of representative myorelaxants (succinylcholine, cisatracurium and vecuronium) in order to predict and prevent adverse reactions. Material and methods: We performed a prospective, cross sectional, observational study in a population of 201 patients scheduled to undergo surgery in the Surgery Department of the Lanzarote General Hospital from October 1998. Three groups were retrospectively selected: vecuronium (73 patients), cisatracurium (80 patients), and succinylcholine (48 patients). Blood was extracted from all patients before and after the intervention and the following in vitro variables were evaluated: histaminemia, eosinophil cationic protein, tryptase, IgE to latex, CD4/CD8 fractions, total lymphocytes, total IgE, C3 and C4, and also the histaminuria. Conclusions: The mean age of the patients was 41 years with a predominance of women. Sixty percent had not previously undergone surgery. The mean operating time was 2 hours. Digestive surgery accounted for the greatest number of interventions (38.8 %) and most of the patients had no personal history of atopy (91.5 %). The greatest number of perioperative reactions was produced by cisatracurium (38.8 %), followed by succinylcholine (27.4 %) and vecuronium (20 %). The reactions observed were immediate type 1 and 2 reactions. All reactions were reversible without sequelae. Histaminuria levels were significantly decreased in the cisatracurium group. Histaminemia and eosinophil cationic protein showed no significant changes in any of the three groups. Tryptase concentrations in blood did not increase in the postoperative period in any of the three groups. On the contrary, concentrations were significantly lower than basal values. In the vecuronium and succinylcholine groups, CD4/CD8 fractions decreased in the postoperative period. Total lymphocytes decreased in all three groups. Total IgE tended to decrease in the cisatracurium and succinylcholine groups. IgE to latex was negative in the three groups. Specific IgE to succinylcholine was unmodified. C3 complement fraction was unmodified in all three groups and C4 fraction was reduced in the vecuronium group. In our setting and in our patients, the three myorelaxants produced immunosuppression of immune response mediators. The present study confirms that tests for allergy to myorelaxants are not indicated in the preoperative period (AU)

Las reacciones adversas que puedan ocurrir durante una intervención quirúrgica preocupan a los anestesistas y a los alergólogos por la responsabilidad civil que conlleva y el aumento de la demanda asistencial en las Unidades de Alergología. El propósito del presente trabajo ha sido valorar la prevalencia de reacciones adversas en nuestro medio (Isla de Lanzarote), y las modificaciones de los mediadores de la respuesta inmune utilizando tres tipos de miorrelajantes respresentativos como son las succinilcolina, el cisatracurio y el vecuronio, con fines predictivos y preventivos. Material y métodos: Ha sido un diseño prospectivo, trasversal, observacional, en una población de 201 pacientes programados por el Servicio de Cirugía desde octubre de 1998, en el Hospital General de Lanzarote. Se separaron en tres grupos, anestesiados con Vecuronio (73 pacientes), Cisatracurio (80 pacientes), Succinilcolina (48 pacientes). A todos ellos se les hacía una extracción sanguínea pre y post-operatoria, valorándose los parámetros siguientes: Histaminemia, proteína catiónica del eosinófilo, triptasa, IgE al látex, fracciones CD4/CD8, linfocitos totales, IgE total, C3 y C4 y además la histaminuria. Conclusiones: Edad media de los pacientes, 41 años, predominio del sexo femenino. El 60 por ciento no habían tenido intervenciones previas. Tiempo promedio de intervención: 2 dos horas. La cirugía digestiva supuso el mayor número de intervenciones (38,8 por ciento) y el 91,5 por ciento de los pacientes no tenían antecedentes personales de atopia. El mayor número de reacciones perioperatorias se produjeron por el Cisatracurio (38,8 por ciento), seguida de Succinilcolina (27,4 por ciento) y en tercer lugar el Vecuronio (20 por ciento). Las reacciones observadas fueron tipo 1 y 2 de aparición inmediata y en su totalidad reversible sin secuelas. Los niveles de histaminuria descendieron significativamente en el grupo del Cisatracurio. Ni la histaminemia ni la proteína catiónica de los eosinófilos, se modificaron significativamente en ninguno de los tres grupos. La triptasa en sangre no aumentó en el postoperatario en ninguno de los grupos. Por el contrario hay una disminución significativa con respecto a sus valores basales. La relación CD4, CD8 se modificó en los grupos del Vecuronio y Succinilcolina, disminuyendo en la situación postquirúrigica. Los linfocitos totales disminuyen en los tres grupos. La IgE total tiende a bajar en los grupos del Cisatracurio y Succinilcolina. La IgE al látex fue negativa en los tres grupos. La IgE específica a a la Succinilcolina no se modificó. La fracción C3 del complemento no se modifica en ninguno de los tres grupos, y la fracción C4 se reduce en el grupo del Vecuronio. En nuestro medio (Lanzarote) y en nuestros pacientes, los tres miorrelajantes produjeron una inmunosupresión de los mediadores de la respuesta inmune. El presente estudio corrobora la no indicación de pruebas alérgicas a miorrelajantes en pacientes en situación preoperatoria (AU)

[Latex allergy. Diagnosis and therapeutic aspects]. / Alergia al látex. Diagnóstico y aspectos terapéuticos.

In the last two decades of the 20th century, latex allergy has reached epidemic proportions. Epidemiological studies demonstrate that 3-25 % of health personnel is allergic to latex. The main risk groups are health workers, machine operators in latex factories, and children with spina bifida and urogenital anomalies. From the allergenic point of view, latex contains 240 peptides but approximately 50 are able to react to IgE. Latex elongation factor Hevdl is the relevant allergen in patients with spina bifida. Prohevein (hev B6) behaves as a major allergen, since it reacts to IgE in most of the sera of patients with latex allergy. The nature of latex is complex; it is an allergenic mixture that depends on chemical, immunological and epidemiological variables. Latex proteins show strong cross reactivity with several proteins from fruit and vegetable grains such as avocado, potato, banana, tomato, chestnut, and kiwi. In vivo studies have shown that class I chitinase from avocado and chestnut behave as major allergens in allergic patients with latex-fruit syndrome. The clinical manifestations related to the use of latex products depend on the type of exposure, the amount of the allergen, and individual variability. The most useful diagnostic method is the skin prick test. Several perioperative guidelines are recommended in patients sensitized to latex as well as various alternatives to rubber gloves. An increasing number of studies describe the efficacy of etiological treatment (immunotherapy), using different guidelines and routes of administration. These preliminary data encourage the hope that in the near future immunomodulatory therapy will be available to mitigate against the latex allergy epidemic.

Alergia al látex. Diagnóstico y aspectos terapéuticos / Latex allergy. Diagnostic and therapeutic aspects

En las dos últimas décadas del siglo XX, la alergia al látex se ha convertido en una auténtica epidemia.Los estudios epidemiológicos demuestran que del 3-25 por ciento del personal sanitario es alérgico al látex. Los grupos de riesgo principales son trabajadores sanitario, operarios de fábrica de látex y niños con espina bífida y anomalías urogenitales.Bajo el punto de vista alergénico, el látex tiene 240 péptidos componentes, pero alrededor de 50 son capaces de fijar IgE. El factor elongación del látex Hevd1, alergeno relevante en pacientes con espina bífida. La proheveína (hev B6) se comporta como alergeno mayor, ya que capta IgE en la mayoría de los sueros de alérgicos al látex.En definitiva, la naturaleza del látex es compleja y es una mezcla alergénica que depende de las variables químicas, inmunológicas y epidemiológicas.Las proteínas del látex muestran una fuerte reactividad cruzada con diferentes proteínas procedentes de frutas y granos vegetales. Como son el aguacate, patata, plátano, tomate, castaña y kiwi. Estudios in vivo, han demostrado que la kitinasa tipo I de aguacate y castaña se comportan como alergenos mayores en pacientes alérgicos con el síndrome látex-frutas.Las manifestaciones clínicas relacionadas con la utilización del producto del látex, van a depender de la vía de exposición, a la cantidad del alergeno contactado y la variabilidad individual.El método diagnóstico más útil es el prick test el más rentable. Se recomiendan diversas normas perioperatorias en pacientes sensibilizados al látex, así como diferentes alternativas para los guantes de goma.En relación con el tratamiento etiológico (inmunoterapia) cada vez es mayor el número de trabajos que describen su eficacia, utilizando diferentes pautas y vías de administración. Estos datos preliminares, alientan la esperanza de que en un futuro próximo estuviera disponible una herramienta terapéutica de naturaleza inmunomoduladora que sirviera para paliar la epidemia de alergia al látex (AU)

In the last two decades of the 20th century, latex allergy has reached epidemic proportions. Epidemiological studies demonstrate that 3-25 % of health personnel is allergic to latex. The main risk groups are health workers, machine operators in latex factories, and children with spina bifida and urogenital anomalies. From the allergenic point of view, latex contains 240 peptides but approximately 50 are able to react to IgE. Latex elongation factor Hevdl is the relevan allergen in patients with spina bifida. Prohevein (hev B6) behaves as a major allergen, since it reacts to IgE in most of the sera of patients with latex allergy. The nature of latex is complex; it is an allergenic mixture that depends on chemical, immunological and epidemiological variables. Latex proteins show strong cross reactivity with several proteins from fruit and vegetable grains such as avocado, potato, banana, tomato, chestnut, and kiwi. In vivo studies have shown that class I chitinase from avocado and chestnut behave as major allergens in allergic patients with latex-fruit syndrome. The clinical manifestations related to the use of latex products depend on the type of exposure, the amount of the allergen, and individual variability. The most useful diagnostic method is the skin prick test. Several perioperative guidelines are recommended in patients sensitized to latex as well as various alternatives to rubber gloves. An increasing number of studies describe the efficacy of etiological treatment (immunotherapy), using different guidelines and routes of administration. These preliminary data encourage the hope that in the near future immunomodulatory therapy will be available to mitigate against the latex allergy epidemic (AU)

[Sublingual immunotherapy with cat epithelial extract. Personal experience]. / Inmunoterapia sublingual con extracto de epitelio de gato. Experiencia personal.

Because cats are a common pet in many houses and tourist complexes in the Canary Islands, sensitization to cat epithelium is a frequent problem. A total of 19.2% of patients with intrinsic asthma are sensitized to cat epithelium. In the Canary Islands, the percentage of sensitization among patients with a household cat is 18.1%, which higher is higher than in the rest of Spain (11.9). Many patients with extrinsic asthma sensitized to house dust mites undergo conventional subcutaneous immunotherapy but evolution is unsatisfactory due to sensitization to cat epithelium (whether a cat is present or not). The aim of this study was to evaluate the clinical effectiveness of sublingual immunotherapy with extract of cat epithelium in monosensitized patients with perennial allergic rhinitis and/or bronchial asthma. Forty patients monosensitized to cat epithelium were selected. Of these, 20 were administered sublingual immunotherapy and another 20 received placebo. The following evaluation was carried out in both groups: in vivo and in vitro: symptom score, skin tests, nasal challenge with cat epithelium, specific IgE determination, specific IgG4 and eosinophilic cationic protein. After 1 year of treatment the cumulative dose was 3.6 micrograms of Fe ld I, equivalent to 10 ng/drop. Duration of treatment was 365 days. Our conclusions, based on our patients in the Canary Islands, were the following: 1. Sublingual Fel d I therapy is effective after 1 year of treatment. 2. There were no modifications in IgE, eosinophilic cationic protein or skin tests. 3. An increase in IgG4 occurred which was related to clinical improvement. 4. In general, tolerance was good, except in one patient who presented urticaria and sublingual pruritus. 5. In polysensitized patients, sublingual immunotherapy to cat epithelium is complementary to immunotherapy to dermatophagoides.

Inmunoterapia sublingual con extracto de epitelio de gato. Experiencia personal / Sublingual immunotherapy with cat dander extract. Personal experience

El estudio Alergológica 92 demostró que el 19,2 por ciento de los pacientes con asma extrínseca estaban sensibilizados a epitelios, con un porcentaje de mayor convivencia con gatos, 18,1 por ciento en nuestro medio que en el resto de España, 11,9 por ciento. Otros estudios epidemiológicos sobre sensibilizaciones cutáneas, comprobó cómo el 21,45 de las madres de niños atópicos estaban más sensibilizadas al epitelio de gato que las madres de niños no atópicos, 1,9 por ciento.Muchos pacientes asmáticos extrínsecos sensibilizados a los ácaros del polvo doméstico, sometidos a inmunoterapia subcutánea convencional, no evolucionan lo favorablemente deseado, por la coexistencia de una sensibilización al epitelio de gato con o sin la presencia de gato. La inmunoterapia subcutánea con Feld 1 a dosis de mantenimiento de 13,2 g ha presentado reacciones adversas en 1,9 por ciento.El motivo del presente trabajo es estudiar la eficacia clínica de la inmunoterapia sublingual con extracto de epitelio de gato en pacientes monosensibilizados con rinitis perenne alérgica y/o asma bronquial.Para nuestro estudio el diseño estadístico usado ha sido el test de Wilcoxon para comparación intragrupo y el test de Mann-Whitney, para el estudio comparativo intergrupo. Se consideraba el test estadístico comparativo con p < 0,05. Se seleccionaron 40 pacientes monosensibilizados al epitelio de gato. Veinte de ellos recibieron la inmunoterapia sublingual quedando a una dosis acumulativa de 3,6 g de Feld 1, después de 1 año de inmunoterapia. Otros 20 recibieron placebo.Hicimos una valoración clínica de los síntomas, pruebas cutáneas, provocación nasal, determinación de IgE específica, IgG4 y proteína catiónica de eosinófilo.Los resultados se pueden ver en las tablas.Mientras que la IgG4, proteína catiónica de eosinófilo y las pruebas cutáneas no se modifican en el grupo activo después de 1 año de tratamiento, sí encontramos una mejoría en la sintomatología clínica con respecto al grupo control placebo. Por otro lado, la provocación nasal fue estadísticamente significativa en el grupo activo después de 1 año, requiriendo concentración de 100 unidades HEP en el 77,8 por ciento de los pacientes, cosa que no ocurría en el grupo control.De todo lo anteriormente expuesto podemos concluir lo siguiente: 1. Inmunoterapia sublingual al epitelio de gato en nuestro medio con nuestros pacientes ha mostrado una mejoría clínica significativa basándonos en los síntomas y en la provocación nasal.2. Esta mejoría clínica se correlaciona con el aumento de la IgG4.3. En nuestros 20 pacientes solamente uno presentó una reacción urticarial con prurito nasal, lo que significa que es bastante segura dicha inmunoterapia.4. La inmunoterapia sublingual al epitelio de gato constituye un tratamiento complementario de los pacientes polisensibilizados que están con inmunoterapia subcutánea a los dermatofagoides (AU)

Because cats are a common pet in many houses and tourist complexes in the Canary Islands, sensitization to cat epithelium is a frequent problem. A total of 19.2 % of patients with intrinsic asthma are sensitized to cat epithelium. In the Canary Islands, the percentage of sensitization among patients with a household cat is 18.1 %, which higher is higher than in the rest of Spain (11.9). Many patients with extrinsic asthma sensitized to house dust mites undergo conventional subcutaneous immunotherapy but evolution is unsatisfactory due to sensitization to cat epithelium (whether a cat is present or not). The aim of this study was to evaluate the clinical effectiveness of sublingual immunotherapy with extract of cat epithelium in monosensitized patients with perennial allergic rhinitis and/or bronchial asthma. Forty patients monosensitized to cat epithelium were selected. Of these, 20 were administered sublingual immunotherapy and another 20 received placebo. The following evaluation was carried out in both groups: in vivo and in vitro: symptom score, skin tests, nasal challenge with cat epithelium, specific IgE determination, specific IgG4 and eosinophilic cationic protein. After 1 year of treatment the cumulative dose was 3.6 mg of Felt 1, equivalent to 10 ng/drop. Duration of treatment was 365 days. Our conclusions, based on our patients in the Canary Islands, were the following: 1. Sublingual Feld 1 therapy is effective after 1 year of treatment. 2. There were no modifications in IgE, eosinophilic cationic protein or skin tests. 3. An increase in IgG4 occurred which was related to clinical improvement. 4. In general, tolerance was good, except in one patient who presented urticaria and sublingual pruritus. 5. In polysensitized patients, sublingual immunotherapy to cat epithelium is complementary to immunotherapy to dermatophagoides (AU)

[Allergic reactions and pseudoallergies in surgical interventions with general anesthesia]. / Reacciones alérgicas y pseudoalérgicas en las intervenciones quirúrgicas con anestesia general.

The Spanish Societies of Allergology and Anesthesiology have established a protocol for action for the performance of allergy tests for anesthesia. The protocol was published by the General Directorate of INSALUD, along with an informed consent form for general and loco-regional anesthesia, on 30 June 1994. Despite this, demands for care and requests for allergologic and anesthetic studies have increased. This review examines the diagnostic, preventive, and therapeutic criteria for adverse reactions during general anesthesia according to the most relevant international literature. Pseudoallergic reactions are one of the most frequent and important adverse reactions that occur during general anesthesia. These reactions are caused by the release of histamine and, probably, other mediators. The histamine-releasing effect depends on the dose of the medication. The most potent medications are morphine and almost all muscular relaxants, in the following proportions (succinylcholine: 43%; vecuronium: 37%; pancuronium: 13%; alcuronium: 76%; atracurion: 6.8%; galamine: 56%). Somewhat less than 50% of all severe intraoperative allergic reactions are really anaphylactoid reactions. The mediators involved in anaphylactic/anaphylactoid responses are: IgE in type I hypersensitivity mechanisms, IgA, immunocomplexes, complement activated by an alternative pathway, tryptase, and histamine. Numerous and varied agents are involved. Table III lists general intravenous anesthetics; table IV shows muscular relaxants. According to national studies, intraoperative latex sensitization occurs in 1% to 5% of health-care personnel and 40% of children with spina bifida. More than 6% of blood donors have IgE against latex. Cross-reactions between latex and fruit proteins, such as banana and kiwi, have been reported. As many as 50% of patients with latex allergy have such cross-reactions, according to some authors. Diagnostic methods include skin tests, challenge, histamine release test, RIA, human basophil optical degranulation test, and ImmunoCAP. Skin tests are the technique most often used in Allergology Units in Spain. Risk factors are debated. Although the female sex is accepted as predominant, atopy is controversial. The only known negative factor is the insertion of an endotracheal tube in asthmatic patients. Prevention should begin with the selection of less potent drugs, such as histamine releasing agents. Slow administration of drugs, as opposed to bolus administration, has been demonstrated to be more effective. The use of combined H1 and H2 antihistamines as a preanesthetic medication can significantly reduce tachycardia/bradycardia, hypotension, skin response, and even gastric pH changes induced by histamine release.

Reacciones alérgicas y pseudoalérgicas en las intervenciones quirúrgicas con anestesia general / Allergic and Pseudo-allergic reactions in surgical interventions with general anesthesia

A pesar de que las Sociedades Españolas de Alergología y Anestesiología han establecido un protocolo de actuación, publicado por la Dirección General del Insalud sobre la realización de pruebas alérgicas en anestesia y el Documento de consentimiento informado para anestesia general y loco-regional de 30 de junio/94, la demanda asistencial en nuestro medio, sobre petición de estudios alergológicos o anestésicos ha aumentado.Con la presente revisión pretendemos aclarar e informar sobre los criterios diagnósticos, preventivos y terapéuticos, sobre las reacciones adversas durante la anestesia general, siguiendo la literatura internacional más relevante. Las reacciones pseudoalérgicas constituyen una de las reacciones adversas más frecuentes e importantes de las que acontecen durante la anestesia general, y se deben a la liberación de histamina y probablemente de otros mediadores. El efecto histamino liberador va en función de la dosis del fármaco. Los más potentes son la morfina y casi todos los relajantes musculares, siendo la proporción (succinilcolina: 43 por ciento, vecuronio: 37 por ciento, pancuronio: 13 por ciento, alcuronio: 76 por ciento, atracurio: 6,8 por ciento, galamina: 56 por ciento). Algo menos del 50 por ciento de las reacciones alérgicas graves intraoperatorias son en realidad reacciones anafilactoides.Los mediadores implicados en la respuesta anafiláctica/anafilactoide han sido: la IgE dentro de un mecanismo de hipersensibilidad tipo I, IgA, inmunocomplejos, activación del complemento por vía alternativa, triptasa e histamina.Los agentes implicados han sido múltiples y variados. En la tabla III se recogen los anestésicos generales intravenosos: en la tabla IV, los relajantes musculares. La sensibilización intraoperatoria al látex, según estudios nacionales, está entre un 1 por ciento y 5 por ciento del personal sanitario. El 40 por ciento en niños con espina bífida. En más del 6 por ciento de los donantes de sangre se encuentran IgE frente al látex. Se han descrito reacciones cruzadas entre el látex y proteínas de frutas, como la banana y el kiwi, encontradas por algunos autores en un 50 por ciento de los pacientes alérgicos al látex.Los métodos diagnósticos incluyen las pruebas cutáneas, la provocación, el test de liberación de histamina, el RIA, test de degranulación óptica de basófilos humanos, e inmunoCAP, siendo la primera la técnica de uso habitual en la mayoría de las Unidades de Alergología de nuestro país. Los factores de riesgo han sido un tema controvertido, aunque se acepta que existe un predominio del sexo femenino; la atopia es controvertida. El único factor probado que empeora es la colocación del tubo endotraqueal en pacientes asmáticos.La prevención debe comenzar con la selección de fármacos que sean menos potentes, como histamino-liberadores. También se ha demostrado que es más eficaz administrar los fármacos lentamente y no en bolo. El uso de antihistamínicos H1 y H2 combinados, como medicación preanestésica, es capaz de reducir de forma significativa la taquicardia/bradicardia, la hipotensión, la respuesta cutánea, e, incluso, la reducción del pH gástrico inducida por histaminoliberación (AU)

The Spanish Societies of Allergology and Anesthesiology have established a protocol for action for the performance of allergy tests for anesthesia. The protocol was published by the General Directorate of INSALUD, along with an informed consent form for general and loco-regional anesthesia, on 30 June 1994. Despite this, demands for care and requests for allergologic and anesthetic studies have increased. This review examines the diagnostic, preventive, and therapeutic criteria for adverse reactions during general anesthesia according to the most relevant international literature. Pseudoallergic reactions are one of the most frequent and important adverse reactions that occur during general anesthesia. These reactions are caused by the release of histamine and, probably, other mediators. The histamine-releasing effect depends on the dose of the medication. The most potent medications are morphine and almost all muscular relaxants, in the following proportions (succinylcholine: 43%; vecuronium: 37%; pancuronium: 13%; alcuronium: 76%; atracurion: 6.8%; galamine: 56%). Somewhat less than 50% of all severe intraoperative allergic reactions are really anaphylactoid reactions. The mediators involved in anaphylactic/anaphylactoid responses are: IgE in type I hypersensitivity mechanisms, IgA, immunocomplexes, complement activated by an alternative pathway, tryptase, and histamine. Numerous and varied agents are involved. Table III lists general intravenous anesthetics; table IV shows muscular relaxants. According to national studies, intraoperative latex sensitization occurs in 1% to 5% of health-care personnel and 40% of children with spina bifida. More than 6% of blood donors have IgE against latex. Cross-reactions between latex and fruit proteins, such as banana and kiwi, have been reported. As many as 50% of patients with latex allergy have such cross-reactions, according to some authors. Diagnostic methods include skin tests, challenge, histamine release test, RIA, human basophil optical degranulation test, and ImmunoCAP. Skin tests are the technique most often used in Allergology Units in Spain. Risk factors are debated. Although the female sex is accepted as predominant, atopy is controversial. The only known negative factor is the insertion of an endotracheal tube in asthmatic patients. Prevention should begin with the selection of less potent drugs, such as histamine releasing agents. Slow administration of drugs, as opposed to bolus administration, has been demonstrated to be more effective. The use of combined H1 and H2 antihistamines as a preanesthetic medication can significantly reduce tachycardia/bradycardia, hypotension, skin response, and even gastric pH changes induced by histamine release (AU)

Chronic angioedema. Three relevant cases.

Three cases of clinical angioedema are reported in which the etiopathogenetic involvement of qualitative and quantitative complement disorders was demonstrated. The first patient had a functional deficit in C1 inhibitor, the second had a decrease in CH50, and the third, a reduction in the C1q, C3, and C4 fractions. The cases are interesting because of occasional difficulties in the causal diagnosis, the severity of the symptoms, which can include laryngeal edema, and, finally, the favorable outcome achieved with correct medication, which did not include antihistamines or steroids. The clinical picture of hereditary angioedema is characterized by the familial occurrence of the process, although this apparently was absent in these cases. Two patients experienced laryngeal edema and none had abdominal manifestations. The treatment of choice for angioedema of these characteristics is antifibrinolytic agents, which achieve good results in 70% of the patients. Epsilon-aminocaproic acid and tranexamic acid inhibit the formation of plasmin and fragments of the Hageman factor, thus inhibiting kallikrein and bradykinin production. The androgens danazol and stanazolol have been used since the 1970s, and stanazolol proved to be very effective in two of our patients.

[Effect of the home environment and maternal sensitizations on the bronchial asthma of their children]. / Influencia del entorno vital y sensibilizaciones maternas en el asma bronquial de sus hijos.

The allergy diseases in our province have the characteristic of the early appearance of asthma and predominant monosensitization to the domestic dust is mites due to the climate condition. In this work we study the influence of allergic children. We selected 1,028 mothers who went to the hospital with their children for the 1st time. We divide them in 2 groups. One of 459 mothers of atopic children (MA) and another of 569 no atopic's (MC). All mothers were skin prick-tested (Phazet). The papular area was the mothers with aeroallergen sensitization were the 180 (17,5%) between (MA) 126 (274%) and (MC) 54 (95%). The 180 mothers were sensitized to: D. Pteronyssinus 66.3%, D. Farinae 65,5%., Lolium p 14.55%, Cats 11.6% (MA > MC), Artemisia V (6,25% and Cladosporium H (0,6%).

Sensitization to neumoallergens influence in mothers of asthmatic children.

Allergy diseases in our province have the characteristic of early appearance of asthma and predominant monosensitization to domestic dust mites due to the climatic condition. In this work we study the influence in allergic children. We selected 1028 mothers that brought their children to hospital for the first time. We divided them in two groups. One was comprised of 459 mothers of atopic children (MA) and another of 569 mothers of non atopic children (MC). All mothers were skin-prick tested (Phazet). The papula area, the mothers with aeroallergen sensitization, were 180 (17.5%) between MA 126 (27.4%) and MC 54 (9.5%). The diagnosis of allergic mothers was higher in MA than in MC. Asthma 8.39%, Rhinitis 4.75% and dermatitis 2%. 53.31% lived on the coast. 51.45% had house moulds. 31% had animals. 34.9% were smokers. There were more adverse drug reactions in MA than in MC. 180 mothers presented sensitization. D. pteronyssinus 66.3%, D. farinae 65.5% Lolium P. 14.55%, Cats 11.6% (MA > MC), Artemisia Vulgaris 6.25% and Cladosporium Herbarum 0.6%. There was no correlation between skin sensitization and domestic animals. There was no influence between children's IgE and mothers with skin sensitization. Skin sensitization to grass pollen correlated with the mother who was living in another country. The mothers who have been living more than five years in our province presented more skin sensitization to aero-allergens.

[Prevalence of cosmetic sensitivity among beauticians]. / Prevalencia de sensibilizaciones a cosméticos en profesionales de la estética.

Cosmetics are a frequent cause of contact dermatitis, not only in females but also in males. Men use cosmetics in the form of deodorant, hair dye and aftershave lotions. U.S.A men spent more than 6,000,000,000 million dollars in cosmetic products. Responsible substances of contact dermatitis are unidentified in many occasions, what impedes the estimation of morbidity data. It is calculated that 2-4% of dermatological consultations are due to contact dermatitis caused by cosmetics. The Spanish industry manufactures each year articles valued in several thousands of million pesetas, 14% of which are exported. Annual manufacturing is raising between 10 and 11%. The French journal Cosmetology (IMS) pointed as an example the fact that in the third trimester of 1978, the number of sold products was as follows: 87,880 units of cleansing milk; 128,020 creams; 237,200 tonics; 10,228 lip protectors. The Committee of European Unions for Perfumery and Cosmetology (COLIPA) reported in 1978 a yearly sale in Europe of 225,000,000 units of hair dyes, exclusively. Adverse reactions to cosmetics affect not only the skin in the form of irritant or contact dermatitis, but cases of conjunctivitis, asthma, urticaria, rhinitis, angioedema, pneumonitis and anaphylaxis-like reactions due to cosmetic products, mainly hair bleaching agents, perm liquids and hair spray, have been also reported. The present work studied the prevalence of sensitizations to cosmetic products on the professional staff of a beauty salon in our city of Las Palmas (SEM). Twenty people came to our Unit of Allergology to fill a questionnaire and undergo a skin test.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevalence of sensitization to Blomia in Gran Canaria]. / Prevalencia de sensibilizaciones a Blomia en Gran Canaria.

In the present study we assessed the prevalence of sensitizations to Blomia in our environment. Perennial climatological conditions in the Canarian Islands facilitates the habitat to mites. The Blomia is found in tropical and subtropical homes of Europe, USA and Asia like the Dermatophagoides. We have designed a transversal and prospective study on 100 patients who consulted our Unit for the first time. A Prick-test for the common allergens, including Blomia Kulagini, and in vitro determination of total and specific IgE to Dermatophagoides Pteronyssinus and Farinae, was performed in those patients showing the same or higher levels than class 3 CAP System RAST-Fesa against Blomia Tropicalis. Results achieved in our environment and our patients are the following: 1. Prevalence of sensitizations to BK in patients who consult for the first time is 50%. 2. The specific IgE immunologic response to BK is 56% (45 patients). 3. Scarce correlation in the papule areas and specific IgE levels between BT and DTP (p = 0.22020); BT and DFA (p = 0.09063). Table VI. Fig. I and II. 4. These results and previous studies of allergenization suggest poor crossed reactivity between Blomia and Dermatophagoides. 5. We think that Blomia is a new etilogic agent of the allergic respiratory disorders in our environment and therefore it should be included in the standard set of allergens from a diagnostic and therapeutical point of view. We keep studying its identification and count in dust samples from our homes, as well as the crossed reactivity, by RAST inhibition, with other acari.

[An integrated approach to the psychological features of the asthmatic child]. / Un abordaje integral de los aspectos psicológicos del niño asmático.

The work starts from the interrelation that occurs in asthmatic children between physical and psychical aspects. We carry out the experiment on an instructional programme as an efficient method of intervention that on one hand improves the levels of personal, social school and family adaptation and that on the other hand helps to modify the wrong attitudes about the illness, presuming that, in some way, it will be a relief in the physical aspect of the illness. The sample chosen by randomization and stratification from the Allergy Service of the Insular Hospital of Gran Canaria was tested using an experimental and control-placebo with retest design. The children were between nine and eleven years old. The results for the adaptative aspects of the subjects were similar to the ones that Doctors Hernández and Hernández from La Laguna University (Canarias) got through similar studies, though the outcomes were not as successful as we hoped in cognitive/affective and social restriction. About the modification of the more internal aspects of asthmatic problems the programme was successful though we didn't modify some attitudes. We had the improvements that we hoped in some physical aspects as secondary effects but it seems that the programme can have more influence among them.

A new method of administration of topical nasal extracts. Immunoaerosol therapy.

Topical nasal immunotherapy (TNI) is a therapeutic option in residual rhinitis. Adverse reactions are common with pollen extracts and often are related to the phenol and thimerosal conservatives. This study sought to determine the clinical effectiveness of two methods of administration of TNI. Twenty-eight patients with allergic perennial rhinitis treated for 2 years with parenteral semidepot immunotherapy were divided into two groups of 14 patients: group A receiving conventional aerosol nebulization (TNE), and group B, which received TNAI using a type F aerosol electrocompressor. Clinical response and tolerance to TNI were evaluated using scores for signs and symptoms. The conclusions were: Both group A and group B exhibited statistically significant differences between baseline and post-immunotherapy parameters (p < 0.001). There were no statistically significant differences in the degree of improvement achieved in the two groups. The main advantages of TNAI were better tolerance of the D. pteronyssinus extracts, perhaps due to the elimination of conservatives, and the guarantee of correct administration of the dose and control of minimum reactions. For these reasons it is a viable therapeutic option in allergic perennial rhinitis previously treated for two years with parenteral semidepot immunotherapy.

[Epidemiological study of asthmatic crises in a maternal-child emergency service]. / Estudio epidemiológico de las crisis asmáticas en un servicio de urgencias maternoinfantil.

In our region, allergic respiratory diseases affects over 55% of the child up to 5 years. This could be attributed to some peculiarities of our region, such as consanguinity, climate and predominant sensitisation to dermatophagoides mite. We made an epidemiologic study on the bronchospasm urgent cases attended in the Urgency Unit of our Maternal-Child Hospital in Las Palmas. We took 935 patients with a mean age of 32.36 months with acute attacks of bronchospasm, and found no significant difference between patients from the Northern and Southern zones of the island. Bronchospasm cases were more frequently observed in Autumn and Winter. We discuss here about the possible causing agents involved and want to draw attention to the need of education for our patients' parents for them to learn antiasthmatic medication and how to use it, before going to the Urgency Unit of any Hospital.

[Immunologic clinical evaluation of a biological response modifier, AM3, in the treatment of childhood infectious respiratory pathology]. / Valoración clínica inmunológica de un modificador de la respuesta biológica, AM3, en el tratamiento de la patología respiratoria infecciosa infantil.

To assess the immunoclinical effectiveness of a biological response immunomodulator, we used AM3 (glycophosphopeptide ), a glucomannan polysaccharide extracted from the cell wall of a strain of Candida utilis, in 20 children with asthmatic bronchitis. They received 2 envelopes (1 g) daily for 4 months. The results were compared with a control group of 20 untreated children with the same pathology. The following clinical and immunological parameters were assessed in all of them: cough, dyspnea, expectoration, frequency and intensity of the bronchospasm, time of administration of the symptomatic medication, and the delayed cutaneous cells response by means of the intradermal reaction of 5 antigens (Trichophyton, Candida albicans, tuberculin, E. coli and bacterial antigens). In the treated group, the immunoferon (AM3) reduced the symptoms, the intensity and frequency of the bronchospasm, and the symptomatic medication (table I, II and III). In basal conditions, the 40 children presented a state of 75% anergy; after 4 months of treatment, the treated group experienced a 45% decrease in their anergic situation, variation which was statistically significant when compared with the control group. In our 20 treated patients, AM3 behaved like and immunostimulant, improving the clinical situation and progress in patients with infectious respiratory disorders. We consider that the immunoferon constitutes a coadjuvant therapy to bacterial immunotherapy.

Skin cross-reactivity between Dermatophagoides pteronyssinus and storage mites in atopic children.

In our environment, some children with allergic respiratory pathology do not have as favorable an evolution as expected after three years of immunotherapy with D. pteronyssinus extracts. We believe this is due to the existence of other mites whose antigenic determinants are not present in D. pteronyssinus. The purpose of the present study was to evaluate skin cross-reactivity between Dermatophagoides and storage mites in children with bronchial asthma. Fifty patients were chosen, with a mean age of 7.78 +/- 2.98 years and a range of 3-14 years. There were 38 boys (76%) and 12 girls (24%) with rhinitis and bronchial asthma. All patients had skin tests and prick tests with the following extracts performed on them: house dust (HD), Dermatophagoides farinae (DFA), Dermatophagoides pteronyssinus (DPT), Acarus siro (AS), Glycyphagus domesticus (GD), Lepidoglyphus destructor (LD), Tyrophagus putrescentiae (TP), with negative and positive controls. The areas of the papulae were evaluated in crosses, according to the size of the histamine and using computerized papulometry, using the Kurta series one graphic tablet with one resolution of 200 points per inch. The data were processed with the "Image-pro" analysis image program. The following conclusions were obtained from our study: 1) No case of skin sensitization to storage mites was found in any of our 50 patients, without house dust and/or Dermatophagoides mites also being present. 2) The greatest skin response with regard to histamine was found for DFA (52%), DPT (44%), HD (22%), GD (10%), AS (4%) and GF (2%).(ABSTRACT TRUNCATED AT 250 WORDS)