A structured graduated protocol with heat denatured eggs in the treatment of egg allergy.

BACKGROUND: Most children with egg allergy (EA) can tolerate extensively heated and baked egg (EHBE). Consumption of EHBE may promote faster resolution of EA; however, no consensus exists as to the required amounts and treatment protocols. OBJECTIVE: To evaluate the efficacy and safety of a structured graduated exposure protocol (SGEP) with EHBE in promoting tolerance to eggs in EA children under 2 years of age. METHODS: In a case-control study, EA children aged < 2 years who were treated with SGEP including EHBE were compared to children treated with strict avoidance. Data were collected from records and telephone questionnaires. Analysis was performed using non-parametric Kaplan-Meier and Cox proportional hazard regression models. RESULTS: Thirty-nine egg-allergic children with a median age at intervention of 16 months (interquartile range: 13-19) were treated with SGEP and followed to a median age of 39 months (26.8-50.0). The median age at resolution of EA was compared to a matched group of 80 children treated with strict avoidance at least until 2 years of age or earlier natural resolution and followed to a median age of 69 months (46-104). The median estimated age at EA resolution in the SGEP group was 24 months (95% CI, 19.5-28.5 months), compared to 78 months (95% CI, 53-102) in the control group, P < .001. At last follow-up, 82% of treated children were tolerant to lightly cooked eggs vs 54% of controls, P = .001. CONCLUSION: A structured protocol with EHBE appears to promote faster resolution of EA.

A Structured Gradual Exposure Protocol to Baked and Heated Milk in the Treatment of Milk Allergy.

OBJECTIVE: To evaluate the efficacy and safety of a structured gradual exposure protocol (SGEP) with extensively heated and baked milk in promoting allergy resolution in children with cow milk allergy (CMA). STUDY DESIGN: In a case control study, children with CMA aged 1-4 years who were treated with SGEP including extensively heated and baked milk, were compared with children treated with strict avoidance. Data were collected from medical records and from validated telephone questionnaires. Data analysis was performed using a nonparametric Kaplan-Meier and proportional hazard Cox regression model, after evaluation of the adequacy of the case control matching. RESULTS: There were 43 children with milk allergy-26 (62%) males with a mean age at intervention of 21 months (range, 12-47 months)-who were treated with SGEP and followed to a mean age of 40 months (range, 20-82 months). The median age at resolution of CMA was compared with a matched group of 67 children treated with strict avoidance at least until 4 years of age or followed until earlier resolution, with a mean age at follow-up of 71 months (range, 11-176 months). The median estimated age at CMA resolution in the SGEP group was 36 months (95% CI, 34.5-49.7) compared with 98 months (95% CI, 82.4-114.1) in controls (P < .001). At last follow-up, 86% of treated children were tolerant to unheated milk proteins vs 52% of controls (P = .003). CONCLUSION: A structured protocol with extensively heated and baked milk seems to promote faster resolution of CMA.

Antihistamines do not inhibit the wheal induced by the intradermal injection of autologous serum in resistant chronic idiopathic urticaria.

Some patients with chronic idiopathic urticaria (CIU) are resistant to conventional doses of antihistamines (AHs). This study was designed to check whether the skin wheal and flare reaction produced by the intradermal injection of autologous serum (AS) and by histamine differs in AH-resistant and AH responder CIU patients. CIU patients with treatment failure under fexofenadine at 180 mg q.d. increased their daily dose of AH to 4 tablets daily. Those with significant improvement of urticaria activity score under fexofenadine at 180 mg were included in the CIU group. Subjects with treatment failure despite a full 8-week fourfold fexofenadine treatment were included in the resistant CIU (R-CIU group). The control group consisted of sex- and age-matched patents with allergic rhinitis. The AS skin test and intradermal histamine-induced wheal and flare reaction were performed at baseline (without AH), after 8 and 16 weeks (under AH treatment). Forty-six subjects were included in the CIU group, 21 were in the R-CIU group, and 44 were in the control group. Under AH therapy, the skin reaction to intradermal histamine injection was significantly diminished in all study groups. In the R-CIU group, fexofenadine at 180 mg did not suppress AS-induced wheal reaction (5.96 ± 2.25 mm; p = 0.85), and with a fourfold AH dose some reduction of AS-induced wheal (3.79 ± 1.74 mm; p = 0.008) was observed but remained larger than in the CIU (2.31 ± 1.12; p = 0.006) and control groups (2.52 ± 1.36; p = 0.037). AHs do not inhibit the wheal induced by the intradermal injection of AS in R-CIU.

Clinical and laboratory features of antihistamine-resistant chronic idiopathic urticaria.

Chronic idiopathic (spontaneous) urticaria (CIU) is sometimes resistant to the conventional and high doses of antihistamines (AHs). This study compares the clinical and laboratory characteristics of AH responsive and AH-resistant CIU subjects. Clinical and laboratory data were retrospectively collected from 385 CIU patients. Urticaria activity score (UAS), concomitant angioedema, dermatographism, positive autologous serum skin (ASST), and laboratory data were collected. The control group consisted of 44 sex- and age-matched healthy individuals. Two hundred forty-five CIU patients controlled with AH medications were included in the CIU group. Forty-six patients failed to show clinical improvement during 8 weeks of treatment with fourfold AH doses and were included in the resistant CIU (R-CIU) group. The R-CIU group was characterized with a higher incidence (58.7%) of angioedema than the CIU group (28.5%; p < 0.001), more cases concomitant physical urticaria (23.9% in R-CIU versus 12.2% in CIU; p = 0.014), more positive ASST (73.9% in R-CIU versus 45.4% in CIU; p < 0.001), and higher baseline UAS (5.28 ± 0.81 in R-CIU versus 3.32 ± 1.25 in CIU; <0.001). R-CIU was characterized with more severe basopenia (0.04 ± 0.07 cell/mm(3) versus 0.16 ± 0.13 cell/mm(3); p < 0.001), higher mean platelet volume (10.87 ± 2.21 femtoliter (fl) versus 8.65 ± 1.74 fl; p < 0.001), higher levels of C-reactive protein (8.62 ± 3.91 mg/L versus 2.49 ± 1.34 mg/L; <0.001), and higher levels of serum C3 (1.66 ± 0.36 g/L versus 1.19 ± 0.35 g/L; p < 0.001. R-CIU is a clinically more severe disease with laboratory features of low-grade inflammation and platelet activation.

Increased mean platelet volume and C-reactive protein levels in patients with chronic urticaria with a positive autologous serum skin test.

INTRODUCTION: Activation of the coagulation cascade resulting in thrombin production is a prominent feature of exacerbations in chronic spontaneous urticaria (CU). Autologous serum skin test (ASST) causes wheal-and-flare reactions in 30% to 50% of CU cases. OBJECTIVE: The aim of this study was to evaluate the clinical and laboratory data in patients with CU with positive and negative ASST. To understand the role of platelets in CU, we investigated the relation between CU clinical severity, platelet count and their mean platelet volume (MPV). METHODS: Clinical and laboratory data were prospectively collected from 373 patients with CU who attended our Allergy and Clinical immunology Clinic during the period 2003 to 2007. The laboratory data were compared with 46 healthy subjects. RESULTS: There were no significant differences in platelet counts between the groups, nevertheless the platelets in ASST-positive CU patients were characterized by a higher MPV (9.12 +/- 1.25 fl), than that in ASST-negative patients (7.95 +/- 1.08 fl; P = 0.039) and control group (7.72 +/- 1.04 fl; P = 0.007). There was a significant positive correlation between CU severity score and MPV in ASST-positive patients (r = 0.44; P < 0.001) but not in ASST-negative patients. Higher levels of C-reactive protein (5.31 +/- 2.74 mg/L) were measured in the ASST-positive CU group compared with the ASST-negative CU group (2.53 +/- 1.27; P = 0.029) and the control group (2.34 +/- 1.38; P = 0.003). CONCLUSION: CU with positive ASST is characterized with higher clinical severity, increased MPV and C-reactive protein.

Pulmonary function correlates with arterial stiffness in asthmatic patients.

BACKGROUND: At the population level, asthma has been associated with chronic systemic inflammation as well as adverse cardiovascular outcomes. OBJECTIVES: The aim of this study was to investigate peripheral vascular hemodynamic variables of arterial stiffness (AS) and their relationship to pulmonary function tests in asthmatic patients. METHODS: Young asthmatic patients from the tertiary center for pulmonary diseases at the Barzilai Medical Center underwent pulmonary function evaluation and non-invasive radial artery hemodynamic profiling, pre- and post-exercise. Results were compared to age matched, non-asthmatic controls. RESULTS: 23 young asthmatics and 41 controls, completed all evaluation points. Pulmonary flow parameters were significantly reduced in the asthma group at all points. There were no differences between groups in BMI, blood pressure, pulse rate or measurements of AS at baseline or after bronchodilation. The % predicted forced expiratory volume in the first second at baseline (FEV1%) in asthmatics was positively correlated with the small arteries elasticity index (SAEI) and negatively correlated with the systemic vascular resistance (SVR) in these patients. These correlations were not observed in non-asthmatic controls. In multifactorial regression FEV1 remained the major factor associated with measurements of AS in asthmatic patients, while gender was the only significant factor in non-asthmatic controls. CONCLUSIONS: Significant correlations between measurements of AS and FEV1 in young asthmatics, suggest the presence of a common systemic, most likely inflammatory pathway involving both the cardiovascular and respiratory systems.

Impact of specific allergen sensitization on the prevalence of asthma in patients with allergic rhinitis from adjacent distinct geographic areas.

BACKGROUND: Patients with allergic rhinitis (AR) and perennial allergen sensitization are at increased risk for asthma. OBJECTIVES: To determine the allergic profile of patients with clinical AR in regions of the coastal Mediterranean compared with the inland southern desert area of Israel and the impact of specific allergen sensitization on the prevalence of asthma in these patients. METHODS: Retrospective evaluation of medical records from patients referred for evaluation during 2002 and 2003 to the allergy clinics of 3 medical centers located in different geoclimatic areas. RESULTS: A total of 479 patients with AR were included (64% from the humid Mediterranean coast and 36% from the arid desert area), with a mean age of 32.8 years (range, 6-84 years). Sixty percent of the patients were male, and 33% had an additional diagnosis of asthma. Mite sensitization was 84%; cockroach, 34%; trees, 43%; weeds, 40%; grasses, 53%; and fungi, 30%. There were no significant differences in the prevalence of sensitization to any of the evaluated allergens except for weeds, which was higher in the arid region. A diagnosis of asthma was significantly associated with mite sensitization in the Mediterranean area (odds ratio, 2.24; 95% confidence interval, 1.14-4.4; P = .02) and mold sensitization in the arid climate zone (odds ratio, 2.18; 95% confidence interval, 1.05-4.6; P = .04). CONCLUSION: Although sensitization to mites is high in the coastal areas and in the Negev desert-like environment, the presence of asthma in patients with AR is associated with mite sensitization in the humid environment but with fungal sensitization in the more arid environment.

Safety and efficacy of allergen immunotherapy in the treatment of allergic rhinitis and asthma in real life.

BACKGROUND: Subcutaneous allergen immunotherapy is effective in treating allergic airway disease. Disadvantages include immediate local and systemic adverse reactions and poor compliance. OBJECTIVES: To obtain real-life efficacy and safety data through a prospective observational study of SIT in the allergist's office. METHODS: We prospectively collected data from all patients with a diagnosis of allergic rhinitis and/or asthma and a specific immunoglobulin E-mediated sensitization to one or more aeroallergens who began SIT during the 2 year period 1 January 2005 to 31 December 2006. As part of the routine immunotherapy care patients were asked to complete a disease activity questionnaire before and yearly during the treatment. The primary outcome measure was the combined rhinitis and asthma symptoms scores. Data from patients completing at least 1 year of immunotherapy were analyzed. RESULTS: Altogether, 133 enrolled patients with a mean age of 22.7 years completed at least 1 year of SIT. The allergic rhinitis and asthma disease activity score decreased from a mean of 8.1 to 3.3 (rhinitis) and from 4.8 to 2.4 (asthma) on a 10 cm visual analogue scale after 1 year of SIT (P < 0.001 for all comparisons). Rhinitis medication use in all patients and asthma medication use in asthmatics decreased significantly. Mild local adverse reactions were almost universal. There were 11 patients (8%) who developed 14 immediate systemic, mild to moderate reactions. All reactions were successfully treated in the clinic; none required additional observation or hospitalization. CONCLUSIONS: In the hands of experienced allergists subcutaneous allergy immunotherapy is a safe and efficacious option for patients with allergic rhinitis and asthma.

[The prevalence of positive allergy skin tests among children with asthma in the Ashkelon Region, Israel].

BACKGROUND: Asthma is the most common chronic disease amongst children. OBJECTIVE: To find the prevalence of positive allergy skin tests amongst children having asthma attending the asthma clinic in Barzilai Medical Center in Ashkelon Israel. STUDY DESIGN: Retrospective study. All medical files of the asthmatic children attending the asthma clinic in Barzilai Medical Center in Ashkelon, Israel, were reviewed. Data regarding their clinical status, past medical history, socioeconomic and familial medical history were collected. RESULTS: One thousand three hundred and fifty three medical files including all the information necessary for the study were reviewed. Amongst the children 1,238 lived in urban areas and towns and 115 lived in rural areas. It was found that most of the children have positive allergy skin tests for house dust mite and mold. Among the urban children 86.2% were found to have positive allergy skin tests for house dust mite compared with 48% of the rural children (P < 0.02). Positive allergy skin tests for mold were found among 63.1% of the urban children compared with 44% of the rural children (p < 0.04). Positive allergy skin tests for most allergens were found to be more prevalent amongst the children living in urban areas compared with the children living in rural areas. The positive allergy skin tess are not related to parental smoking habits or house pets amongst these findings. CONCLUSION: Most of the children living in the Ashkelon region and positive allergy skin tests for house dust mite. This tendency is more common among the children living in urban areas as compared with children living in rural areas. The reason for this difference has to be studied.