Shared Decision-Making in Allergen Immunotherapy (AIT) Options Using a Questionnaire for Respiratory Allergic Patients: A Delphi Consensus Study.

Purpose: The objective of this study was to develop and validate a questionnaire, through a Delphi consensus, to be used by allergists in their routine clinical practice to assess the preferences of patients starting allergen immunotherapy (AIT) treatment using an objective approach. Patients and Methods: A Delphi consensus-driven process was used. The scientific committee, composed of 15 allergists, led the study and participated in the preparation of the questionnaire. Two-hundred panelists from different Spanish regions were invited to complete a 16-item questionnaire on a nine-point Likert scale covering six topic blocks. Consensus was achieved if ≥66.6% of panelists reached agreement or disagreement. Results: Of the 200 experts invited to participate in the Delphi process, a total of 195 (97.5%) answered the questionnaire. The panel experts reached a consensus on "agreement" on a total of 12 of the 16 (75.0%) items, covering a total of six categories: (a) patient knowledge (2 questions), (b) barriers to patient adherence (3 questions), (c) patient behavior (4 questions), (d) future actions (3 questions), (e) treatment costs (2 questions), and (f) final patient preferences (2 questions). Conclusion: This Delphi consensus study validated a set of twelve recommended questions for patients objectively assessing their preferences and suitability for the most common AIT options available. The questionnaire intends to assist allergists in making an objective, unconditioned decision regarding the best AIT option for each patient, after informing them about the different routes.

Shock anafiláctico con manzana. Síndrome LTP / Anaphylactic shock caused by apple. LTP syndrome

Presentamos el caso de una paciente atendida en urgencias del centro de salud por un cuadro clínico de shock anafiláctico desencadenado tras la ingesta de manzana y realización posterior de ejercicio físico. En alergia a alimentos, hay que tener presente que en algunas personas es necesaria la presencia de determinados cofactores como el ejercicio físico o la ingesta de determinados fármacos como los AINEs para que suceda una reacción alérgica. Se sospecha que el mecanismo responsable consiste en que aceleren la absorción del alimento en el intestino y así lleguen a modular la severidad de los síntomas. Por este motivo cuando las LTP (proteína de transferencia de lípidos) están implicadas, si los cofactores no se detectan y previenen, pueden representar un serio riesgo para el desarrollo de episodios de anafilaxia severos o fatales (AU)

We report the case of a patient treated in an emergency department of a health center for a clinical picture of anaphylactic shock triggered after ingestion of apple and subsequent practice of physical exercise. In food allergy, it must be remembered that in some people the allergic reaction requires the presence of certain cofactors, such as physical exercise or use of certain prescription drugs such as NSAIDs. It is suspected that the mechanism responsible for this consists in accelerating the absorption of food in the intestine and thereby modulating the severity of symptoms. That is why when lipid transfer proteins (LTP) are involved, if the cofactors are not detected and prevented, they can pose a serious risk for developing severe or fatal episodes of anaphylaxis (AU)

Olea europaea pollen counts and aeroallergen levels predict clinical symptoms in patients allergic to olive pollen.

BACKGROUND: Allergic symptoms are commonly related to atmospheric pollen counts in sensitized allergic individuals. However, concordance between symptoms, pollen counts, and aeroallergen concentrations is not always good. OBJECTIVES: To determine the correlation between olive pollen counts, aeroallergen levels, and clinical symptoms in patients with allergic asthma or rhinitis in Ciudad Real (Spain). METHODS: Two types of samplers were used to determine pollen exposure: a Burkard spore trap to collect pollen grains and a high-volume air sampler to collect airborne particles. A total of 366 air filters were collected. After extraction, they were analyzed by specific immunoglobulin E enzyme-linked immunosorbent assay inhibition using a serum pool containing high titers of olive-specific immunoglobulin E. Twenty olive-pollen monosensitized patients were asked to record their daily symptoms before, during, and after the olive pollen season. RESULTS: Olive pollen was detected between April 21 and June 30, 2004. Symptoms showed positive and significant correlations with pollen counts (r = 0.700, P < .001) and aeroallergen levels (r = 0.803, P < .001). Using a Poisson regression model, relative changes in aeroallergen concentrations and pollen counts were found to be similar and significant. Threshold levels for the induction of symptoms were 162 olive pollen grains/m(3) and 22.7 ng of olive pollen allergen/m(3) (equivalent to 0.9 ng/m(3) of Ole e 1). CONCLUSIONS: Olive aeroallergen concentrations and pollen counts are positively associated with symptoms of rhinitis and asthma in olive-allergic patients. Both data may be used in the clinical follow-up of these patients.

Vine pollen allergy in areas with a high density of vineyards.

BACKGROUND: In Castilla-La Mancha, Spain, the area with the highest density of vineyards in the world, 2 cases of Vitis vinifera pollen allergy have been previously reported. OBJECTIVE: To determine the clinical relevance and biochemical characteristics of vine pollen in the Spanish province of Ciudad Real. METHODS: We designed a prospective study of patients treated in the allergy units from Puertollano and Ciudad Real for respiratory symptoms of 4 months' duration in the year 2000. Skin prick tests with a standard aeroallergen battery and V vinifera pollen extract were performed on all patients. We also performed conjunctival and bronchial provocation tests and serum specific IgE and sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting on the patients who tested positive for V vinifera pollen. RESULTS: We included 200 patients, 98 sensitized to any pollen and 9 to V vinifera pollen. We found 8 of 9 positive conjunctival provocation test results and a positive bronchial provocation result to vine pollen in a vine grower. Serum specific IgE against V vinifera pollen was detected in 9 of 9 patients. Immunoblotting with V vinifera pollen extract showed IgE-binding bands at 45 and 67 kDa. CONCLUSIONS: Vine pollen could be the cause of pollinosis in exposed patients living in areas with a high density of vineyards.

Exploración visual y movimientos oculares en conductores con distinta experiencia: una revisión / Visual search and eye movements in drivers with different experience. A review

Una deficiente exploración visual de la carretera y su entorno es uno de los factores que contribuyen a la siniestralidad del tráfico. Este artículo revisa los trabajos que han analizado la exploración visual de conductores con distinto grado de experiencia a partir del registro de sus movimientos oculares. Se incluyen estudios en entorno real de conducción, con simuladores y con escenas de tráfico proyectadas en vídeo. La revisión pone de manifiesto las diferencias entre conductores noveles y experimentados en medidas como la duración de las fijaciones oculares, la variabilidad de las posiciones de las fijaciones y el patrón de exploración sobre los objetos y lugares presentes en la situación de tráfico. Tomados en conjunto, los trabajos indican que la experiencia en la conducción permite desarrollar una mayor flexibilidad para obtener la información visual relevante con objeto de adaptarse a las condiciones de la situación de tráfico. Finalmente, se proponen ciertas mejoras metodológicas así como la necesidad de diseñar programas de intervención con objeto de mejorar la seguridad vial (AU)

Genetic and metabolic determinants of increased plasma plasminogen activator inhibitor-1 activity in children with renal transplants.

Recent studies have shown that activity of plasminogen activator inhibitor-1 (PAI-1), a prothrombotic protein, may be increased in transplanted patients. The aim of the present investigation was to determine PAI-1 activity in pediatric recipients of renal transplants and to establish the relative contribution of both genetic and metabolic factors. In 29 children and adolescents with stable renal transplants, we related plasma PAI-1 activity to an indicator of inflammatory status [plasma concentration of C-reactive protein (CRP)] and to elements of the insulin resistance syndrome [body mass index (BMI), fasting insulinemia, HOMA index and plasma triglyceride, HDL-cholesterol, apolipoproteins A-1 and B concentrations]. Polymorphisms of PAI-1, apolipoprotein E (apoE) and angiotensin-converting enzyme (ACE) genes were also investigated. In all patients the study was repeated 1 year later. PAI-1 activity remained constantly elevated (23.4+/-22.8 and 18.6+/-7.8 U/ml in the first and second study, respectively, P=NS). Plasma PAI-1 activity correlated positively with CRP ( P=0.001), BMI z score ( P=0.02), fasting insulinemia ( P=0.009), and HOMA index ( P=0.006). No significant correlations were found in this population between plasma PAI-1 activity and age, gender, time elapsed after transplantation and plasma homocysteine, total cholesterol, LDL-cholesterol, HDL-cholesterol, apolipoprotein B, and apolipoprotein A-1. Plasma PAI-1 activity was not related to the cumulative dose of prednisone, cyclosporin A, or tacrolimus. Plasma PAI-1 activity was significantly higher in 5 children with apoE3/apoE4 genotype. No apparent influences of the PAI-1 4G/4G and ACE I/D genotypes were observed. In a multiple stepwise regression model, fasting insulinemia and apoE3/apoE4 genotype accounted for 45% of the observed plasma PAI-1 variability. We conclude that increased PAI-1 activity in children with stable renal transplants is determined both by genetic factors and by metabolic factors, the latter mainly linked to the insulin resistance syndrome.

Hyperhomocysteinemia in children with renal transplants.

Many studies have demonstrated a strong association between elevated plasma total homocysteine (tHcys) levels and vascular disease. The aim of the present study was to determine the plasma levels of tHcys in pediatric recipients of renal transplants, to establish possible correlations with renal function, lipid profile, and folate and vitamin B12 status, and to assess whether the C677T and A1298C polymorphisms in the 5, l0-methylenetetrahydrofolate reductase (MTHFR) gene were associated with a particular risk. A total of 26 transplanted children and adolescents were investigated. tHcys levels were elevated in transplanted patients (12.9+/-4.8 micro mol/l) and 73% of these displayed values above the 97th percentile of healthy children. Plasma tHcys correlated negatively with creatinine clearance ( r=-0.58, P<0.001) and plasma vitamin B(12) ( r=-0.40, P<0.05) and positively with plasma triglycerides ( r=0.53, P<0.005). No significant correlations were found between plasma tHcys level and age, gender, time elapsed after transplantation and plasma values of glucose, insulin, folic acid, total cholesterol, low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, apolipoprotein B, and apolipoprotein A-1. Plasma tHcys level was clearly increased in 3 patients with a MTHFR 677TT/1298AA genotype. In a multiple stepwise regression model plasma creatinine and triglyceride levels and MTHFR 677TT/1298 AA genotype accounted for 60% of the observed plasma tHcys variability. The MTHFR 677CT/1298 AC genotype was not a significant predictor of tHcys plasma levels. We conclude that a moderate degree of hyperhomocysteinemia is often present in renal transplant children and that folate supplementation must be considered in this population.