Management of angioedema without urticaria in the emergency department

Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.

Assessment of severity and quality of life in chronic urticaria

Chronic urticaria (CU) is very prevalent in the general population and, despite its low mortality, can have devastating effects on the quality of life (QoL) of those who experience it.Therefore, consensus documents on its classification, diagnosis, and treatment have become a necessity. The intensity of urticaria is currently evaluated using indices such as the Urticaria Activity Score and visual analog scales to assess itch or the degree of itch associated with the use of antihistamines. QoL is evaluated using various generic questionnaires and specific tools for skin disease and for CU. In recent years, attempts have been made to combine these evaluations to create a specific tool that would enable us to simultaneously evaluate the severity of the condition and the impact of symptoms on QoL. One such tool is the Urticaria Severity Score, which also allows us to compare global changes brought about by different treatments.

Use of Lactobacillus acidophilus and Lactobacillus casei for a potential probiotic legume-based fermented product using pigeon pea (Cajanus cajan)

The aim of the present study was to evaluate the use of pigeon pea (Cajanus cajan) as an appropriate substrate in the production of a legume-based fermented product with Lactobacillus acidophilus ATCC 314 or Lactobacillus casei ATCC 393 and then to ascertain the effects of the addition of ingredients such as powdered milk and banana or strawberry sauce. The products were analyzed for viable cell counts, pH, and sensory attributes during product manufacture and throughout the refrigerated storage period at 3, 7, 14, 21, and 28 days. Nine types of products were produced. At the end of the storage period, the viability of L. acidophilus was above 7 log CFU/g in the presence of milk and 20% sucrose fruit sauce. For products with L. casei, the lack of ingredients such as milk caused no significant loss in viability; however, a high concentration of sucrose in the fruit sauce was an important factor in maintaining a high L. casei population. L. casei had high viability and good sensory attributes. Both strains could be considered suitable for a pigeon pea-based fermented potential probiotic product and a low-cost protein source.

Expression of the basophil-specific antibodies 2D7 and BB1 in patients with cutaneous Mastocytosis

BACKGROUND

2D7 and BB1 are thought to be basophil-specific markers. In this study, we tested both antibodies in different skin and mast cell disorders with the aim of determining whether it was possible to differentiate between benign and aggressive presentations of mastocytosis.

METHODS

Using the antibodies 2D7, BB1, and c-Kit, we performed an immunohistochemical study of skin biopsy specimens from patients with cutaneous mastocytosis (15 urticaria pigmentosa and telangiectatic macularis eruptive perstans) and liver or bone marrow biopsy specimens from patients with systemic mastocytosis. A basophil leukemia cell line was used as a reference. Peripheral blood basophils from healthy donors were used as controls.

RESULTS

We observed intense expression of 2D7 and BB1 in all skin biopsy specimens from patients with cutaneous mastocytosis. Immunostaining of liver and bone marrow specimens from patients with systemic mastocytosis with 2D7 and BB1 antibodies was negative. Specimens from patients with either type of mastocytosis showed similarly strong expression of c-Kit. The basophil cell line showed a 2D7 and a BB1 profile, with intense expression of c-Kit. Peripheral blood basophils exhibited notable immunostaining for 2D7, BB1, and c-Kit.

CONCLUSIONS

2D7 and BB1 are expressed in cutaneous mastocytosis, although this expression is lost when mast cell proliferation is systemic, thus reflecting either a different cellular differentiation stage or the presence of basophils in these skin diseases.

Use of second generation H1 antihistamines in special situations

Antihistamine drugs are one of the therapeutic classes most used at world level, at all ages and in multiple situations. Although in general they have a good safety profile, only the more recent drugs (second generation antihistamines) have been studied specifically with regard to the more important safety aspects. Given the variety of antihistamine drugs, they cannot all be considered equivalent in application to various special clinical situations, so that the documented clinical experience must be assessed in each case or, in the absence of such, the particular pharmacological characteristics of each molecule for the purpose of recommendation in these special situations. In general, there are few clinical studies published for groups of patients with kidney or liver failure, with concomitant multiple pathologies (such as cardiac pathology), in extremes of age (paediatrics or geriatrics) and in natural stages such as pregnancy or lactation, but these are normal situations and it is more and more frequent (among the elderly) for antihistamine drugs to be recommended. This review sets out the more relevant details compiled on the use of antihistamines in these special situations.

ESPRINT-15 questionnaire (Spanish version): reference values according to disease severity using both the original and the modified ARIA classifications

OBJECTIVE

ESPRINT-15 is a specific and validated instrument to measure health-related quality of life in adults with allergic rhinitis. The aim of this study was to obtain new reference values based on disease severity using both the original and the modified versions of the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines.

METHODS

ESPRINT-15 was administered to a representative sample of adults with allergic rhinitis in Spain. As in a previous study by our group, means and percentiles were analyzed for 16 quotas based on gender, allergic rhinitis type (intermittent vs persistent), and 4 symptom intensity groups according to the total symptom score (TSS4). The novel aspect of the present study was our application the severity criteria proposed by both the original and the modified ARIA classifications.

RESULTS

Of the 2756 patients in our previous dataset, 2580 were included in the present analysis. In terms of symptom severity, women ha relatively more intense symptoms than men with both ARIA classifications. In fact, using only the modified ARIA classification, we were abl to determine that severe rhinitis is moderately more frequent in women (27% vs 23%), although the difference is not statistically significant.

CONCLUSIONS

The new set of reference values enables the ESPRINT-15 questionnaire to be adapted to the current severity classification Consequently, this quality of life tool (http://www.seaic.org/inicio/esprint) can be easily used and better interpreted in daily clinical practice.

Antihistamines in drivers, aircrew and occupations of risk

The most commonly occurring allergic diseases can involve a daytime drowsiness associated with the condition itself. The antihistamines used in their treatment can also have central effects and affect certain occupations concerned with risk, road safety and maritime and air navigation. Cognitive tests, experimental studies and epidemiological data recommend avoiding 1st generation antihistamines for people who must drive regularly and/or professions concerned with safety. Although there are no comparative studies on real driving between 1st and 2nd generation antihistamines, in this type of patients there should be a preference for prescribing those with least possible central effect, especially those which are a good substrate for transmembrane transporter pumps such as P-glycoprotein and therefore have a low capacity for crossing the hematoencephalic barrier, thus allowing a broader window for therapy. In this sense, bilastine is a good P-glycoprotein substrate and shows good tolerance at CNS level, in both psychometric trials and real driving test protocols, even at double the dose recommended in the technical file.

H1 antihistamines and benzodiazepines. Pharmacological interactions and their impact on cerebral function

Antihistamines (AH) have been classified into first and second generation according to their pharmacokinetic properties, structural characteristics and adverse effects. The effects on the central nervous system (CNS) are determined basically by their capacity to cross the hematoencephalic barrier and attach to central H1 receptors. Benzodiazepines (BZD) are drugs with effects on the CNS following their union to the specific location of GABA receptors type A. At low doses, the BZD have sedative and anticonvulsive effects, and as the dose increases it leads to sedation, amnesia and finally unconsciousness. Various studies have been made on the possible interaction between the BZD and the AH H1 with special attention to their effect on the CNS. In some cases these were studies to assess the safety of this association and in others, the aim was different: to see if their joint administration gives a better therapeutic result in pathology related with anxiety syndrome or insomnia. In general it can be said that first generation AH interact with the BZD increasing the sedative effects of the latter. However, second generation AH do not increase these sedative effects, which makes them the chosen drugs to treat allergic rhinitis/rhino-conjunctivitis and urticaria in patients also receiving BZD.

EAACI taskforce position paper: evidence for autoimmune urticaria and proposal for defining diagnostic criteria

An autoimmune subset of chronic spontaneous urticaria is increasingly being recognized internationally, based on laboratory and clinical evidence that has accrued over the last 20 years. This evidence has been reviewed by a taskforce of the Dermatology section of the European Academy of Allergy and Clinical Immunology. Functional autoantibodies in chronic urticaria (CU) patient sera have been demonstrated against IgE and FcεRIα by basophil and mast cell histamine release assays and by basophil activation assays. Antibody specificity has been confirmed by immunoassay, but there is a poor correlation between functionality and immunoreactivity. Approximately 25% of CU patients have a positive basophil histamine release assay and show autoreactivity (a positive autologous serum skin test), whereas 50% are negative regarding both. Functionality of CU sera appears to be complement dependent on mast cells but not exclusively on basophils. Basophil activation by CU sera is predominantly restricted to IgG1 and IgG3 subclasses. Circumstantial evidence for CU being an autoimmune disease comes from an observed association with other autoimmune diseases, a strong association between serum functionality and HLA-DR4 haplotype and the good response of CU patients to immunotherapies. It was proposed that a study should be undertaken to prospectively validate potentially relevant clinical criteria (from the history, examination and routinely available clinical investigations) against a new 'gold standard' for the diagnosis of ACU (positive autoreactivity, functional bioassay and immunoassay) to define preliminary criteria sets for the diagnosis of ACU based on clinical and laboratory features with highest individual sensitivity and specificity.

Validation of the modified allergic rhinitis and its impact on asthma (ARIA) severity classification in allergic rhinitis children: the PEDRIAL study

BACKGROUND

A modified allergic rhinitis and its impact on asthma (ARIA) (m-ARIA) criterion to classify the severity of allergic rhinitis (AR) has recently been validated in both treated and untreated adult patients; however, such information in children is lacking. The aim of this study was to validate this m-ARIA severity criterion, which allows for discrimination between moderate and severe AR, in a large pediatric patient sample population.

METHODS

The m-ARIA classification categorizes AR severity into mild (no affected items), moderate (1-3 affected items), and severe (all four affected items). We applied this modified criterion to untreated AR pediatric patients aged 6-12 years, through an observational, cross-sectional, and multicenter study. AR symptoms were assessed using the Total Four Symptom Score (T4SS), and the severity was evaluated by both ARIA severity items and visual analogue scale (VAS).

RESULTS

Allergic rhinitis pediatric patients (N = 1269) from 271 centers were included. Among them, 59.5% had intermittent and 40.5% persistent disease; 89.9% had moderate/severe AR using the original ARIA (o-ARIA) classification and 59.5% had moderate, while 30.5% had severe AR using the m-ARIA criterion. Using the m-ARIA, significantly higher T4SS and VAS scores were obtained when comparing severe with moderate AR.

CONCLUSIONS

The m-ARIA severity classification is a useful clinical tool to discriminate moderate from severe AR among untreated pediatric patients.

Predictors of weaning after acute respiratory failure

Although weaning predictors have been extensively explored in weaning research, their use is currently under debate. From all the stages of mechanical ventilation, the measurements of weaning predictors have been considered by some authors as imperative in order to progress weaning and initiate a weaning trial. However, this practice is rejected by other authors who considered that these tests are not necessary to perform a weaning trial, based in a meta-analysis study from the American College of Chest Physicians. Among all the weaning predictors, the frequency-to-tidal volume ratio (f/VT) remains the most important predictor of weaning. Other predictors have been defined, but their narrow predictive capacity or the requirement of specific technology, have limited their use. The variability of the results obtained by the efficacy of f/VT is probably explained because in most cases weaning is initiated late, when pre-test probability of weaning success is high. In order to reduce weaning duration, weaning strategies must be performed earlier, when a failed weaning trial probably is poor tolerated and the use of f/VT could have a role. New applications of weaning predictors must be clarified in future research, in order to progress in weaning in the context of new studies. Weaning is still a challenging period during mechanical ventilation.

Cortisol responses in children and adults with attention deficit hyperactivity disorder (ADHD): a possible marker of inhibition deficits

Attention deficit hyperactivity disorder (ADHD) is a heterogeneous disease whose neurobiological background is not completely understood. It has been proposed that deficits of the inhibitory function with an underactive behavioral inhibition system (BIS) may be in the core of ADHD. In this regard, this review summarizes all studies that examine the involvement of cortisol in ADHD. Differences in cortisol responses from different ADHD subtypes, hyperactive/impulsive, inattentive, and combined, are analyzed. In addition, we examine the role of comorbidities as confounding factors in the study of cortisol in ADHD, including comorbid disruptive behavioral disorder (DBD), as well as anxiety and depressive disorders. Because ADHD is a neurodevelopmental condition and approximately half of the children enter adulthood with the disorder, we review cortisol studies in adults and children separately. Two diverse patterns of cortisol have been reported both in children and adults with ADHD. Blunted cortisol responses to stress are associated with comorbid DBD, whereas high cortisol responses are associated to comorbid anxiety disorders. Nevertheless, the inhibitory deficits in ADHD do not appear to be related directly to cortisol deficits in either children or adults. This review increases our understanding of the heterogeneity of ADHD and could help in determining new strategies for the treatment of these patients. Future studies including gender and a more systematic methodology to study the cortisol response are needed.