A multicenter study of sensitization profiles in an allergic pediatric population in an area with high allergen exposure

BACKGROUND AND OBJECTIVE

In areas with a high number of allergens and high allergen concentrations, it is essential to identify the main causes of allergy, especially in pediatric patients. This study was conducted in allergic patients aged 14 or less to identify sensitization profiles during an initial phase, and to then evaluate changes in these profiles after 3 years of follow-up. This article describes the first phase of our investigation.

METHODS

A total of 187 patients aged between 2 and 14 years were included by 5 allergy units; all the children had symptoms suggestive of allergic disease (rhinoconjunctivitis andlor asthma). Allergy diagnosis was confirmed by evaluation of clinical history, allergen exposure, and in vivo or in vitro tests. Specific immunoglobulin E (slgE) to major allergens was tested.

RESULTS

Patients were sensitized to both seasonal (especially grass, olive, cypress and Cynodon dactylon) and perennial allergens (Alternaria alternata) and to panallergens (especially profilin and lipid transfer protein). Almost 60% of the patients included were polysensitized. Sensitization to certain major allergens such as Cup s1, Phl p1, or Sal k1 seems to increase with age. Patients sensitized to profilin had a higher number of sensitizations than non-profilin-sensitized patients. This panallergen is a diagnostic confounding factor.

CONCLUSIONS

A high percentage of allergic pediatric patients living in an area with high exposure levels to a large number of allergens are polysensitized and have a high percentage of sensitization to panallergens. The implementation of new diagnostic tools such as component-resolved diagnosis is crucial.

Analysis of mite allergic patients in a diverse territory by improved diagnostic tools

BACKGROUND

There are few studies comparing the sensitization with mite allergens from different mite species which could potentially be the cause of allergy.

OBJECTIVE

To improve the diagnosis of mite allergic patients from a diverse territory in which D. pteronyssinus/D. farinae mites together with storage mites could be present in the environment.

METHODS

Four hundred and seventy-seven patients (both children and adults) from different regions, covering the main mite prevalent areas of Spain, were recruited. sIgE to eight allergens was measured together with SPT to whole mite extracts, level of mite allergen exposure, and specific IgG(4) . BAT and CAST was performed in a subgroup of patients.

RESULTS

D. pteronyssinus and L. destructor were more prevalent in Atlantic areas, whereas D. farinae predominate in Mediterranean areas. About 90% of patients were sensitized to group 1 and/or group 2 allergens. Group 2 was the most prevalent, and the IgE response/intensity of sensitization in BAT was higher. sIgE to Der p 2/Der f 2 was almost fully cross-reactive, but no cross-reactivity was detected with Lep d 2. Group 1 allergens were also cross-reactive, but in some patients a species-specific response was observed. sIgE to Lep d 2 was associated with SPT results to storage mites. Sensitization to Der p 1 was more frequent in children, whereas Lep d 2 sensitization was more frequent in adults. A higher ratio IgE/IgG(4) to Der p 2 was associated with the presence of allergic asthma.

CONCLUSION

An improved diagnosis algorithm has been established. Group 2 allergens seem to have a leading role in mite allergy, but as group 1 sensitization could be species-specific in some patients and its prevalence is higher in children, an adequate balance on major mite species and major allergens must be consider in the design of mite allergy vaccines.

Postmarketing study for assessment of tolerability of a grass allergen immunotherapy tablet (GRAZAX) in patients with rhinitis or rhinoconjunctivitis

BACKGROUND AND OBJECTIVE

Many patients with grass pollen allergy in Spain have concomitant sensitization to other allergens such as profilin. Since this type of sensitization is more common in Mediterranean countries than in countries where most patients were enrolled in clinical trials on GRAZAX (Phleum pratense 75,000 SQ-T/2, 800 BAU, ALK), the aim of this study was to analyze tolerability to GRAZAX under clinical practice conditions in patients with grass pollen allergy.

METHODS

A total of 155 patients were enrolled consecutively in a prospective, open-label, observational study. Adverse reactions were recorded during the first month of treatment at 3 different timepoints: after the first dose, when patients were kept under observation for 30 minutes, and on days 15 and 30 after starting treatment

RESULTS

With the first dose, 117 adverse reactions were recorded in 63 patients (40.7%). The commonest reactions (>10% patients) were oral pruritus (25.2%) and throat irritation (24.5%). Ear pruritus was recorded in 7.7%. All reactions but 1 occurred within 30 minutes of administration and all were mild-to-moderate. At the end of treatment, the percentage of patients with adverse reactions had decreased significantly (21.3%). Most adverse reactions (95.2%) were mild-to-moderate and only 3 (1.4%) were severe. No serious adverse reactions were recorded.

CONCLUSION

GRAZAX seems to be well tolerated, and most reactions were mild-to-moderate. Many of these reactions occur with the first dose. Therefore, according to the Summary of Product Characteristics, the first dose has to be administered under medical supervision.

Enhanced diagnosis of pollen allergy using specific immunoglobulin E determination to detect major allergens and panallergens

BACKGROUND

Pollen is one of the main causes of allergic sensitization. It is not easy to make an etiological diagnosis of pollen-allergic patients because of the wide variety of sensitizing pollens, association with food allergy, and increasing incidence of polysensitization, which may result from the presence of allergens that are common to different species, as is the case of panallergens.

OBJECTIVE

To compare the results of skin prick tests (SPT) using whole pollen extract with specific immunoglobulin (Ig) E determination for several allergens (purified panallergens included) in the diagnosis of polysensitized pollen-allergic patients.

METHODS

The study sample comprised 179 pollen-sensitized patients who underwent SPT with pollen extract and allergen-specific IgE determination against different allergens.

RESULTS

The level of concordance between the traditional diagnostic test (SPT) and IgE determination was low, especially in patients sensitized to the panallergens profilin and polcalcin. In the case of SPT, the results demonstrated that patients who are sensitized to either of these panallergens present a significantly higher number of positive results than patients who are not. However, IgE determination revealed that while patients sensitized to polcalcins are sensitized to allergens from a higher number of pollens than the rest of the sample, this is not the case in patients sensitized to profilins. On the other hand, sensitization to profilin or lipid transfer proteins was clearly associated with food allergy.

CONCLUSIONS

Sensitization to panallergens could be a confounding factor in the diagnosis of polysensitized pollen-allergic patients as well as a marker for food allergy. However, more studies are required to further investigate the role of these molecules.

Occupational asthma caused by turbot allergy in 3 fish-farm workers

We report 3 patients (26, 31, and 33 years) who worked at the same fish farm for several years. They experienced symptoms of rhinoconjunctivitis and bronchial asthma while classifying fish by size. Their asthma gradually worsened to the extent that it became persistent and required daily medication with inhaled corticosteroids and bronchodilators. Symptoms improved during weekends and holidays. All 3 patients could eat turbot. Our study showed that the patients were allergic and that sensitization was probably by inhalation. The allergens were parvalbumin in 1 case and a different allergen in the remaining 2 patients.

Follow-up of venom immunotherapy (VIT) based on conventional techniques and monitoring of immunoglobulin E to individual venom allergens

OBJECTIVES

To assess the efficacy of venom immunotherapy (VIT) and monitor changes in in vivo and in vitro test results after 5 years of treatment and subsequent follow-up. To study the profile of immunoglobulin (Ig) E to individual allergens prior to treatment and 1 year afterwards.

METHODS

We studied 562 patients with hymenoptera venom allergy (438 to bee, 124 to wasp), all of whom underwent immunotherapy with Apis or Vespula extract. The patients were followed up using conventional in vivo and in vitro tests, and in 51 cases, specific IgE against the main hymenoptera allergens was measured before starting and after 1 year of treatment.

RESULTS

Of the 387 patients who completed VLT, 130 sensitized to Apis and 68 to Vespula suffered spontaneous re-stings during treatment. Of these, 123 (94.6%) did not suffer any reaction and 64 (94.1%) suffered only a local reaction. Sixty-two patients sensitized to Apis and 14 sensitized to Vespula suffered spontaneous re-stings after stopping treatment. Only 3 patients suffered a systemic reaction (grade I Müller). At the end of treatment, the results of skin tests and specific IgE to whole extract improved significantly. Reductions in IgE to the main allergens were observed after 1 year of treatment (median differences in Ves v 5, -238.0, P = .0425; and in Api m 1, -183.0, P = .0024).

CONCLUSION

The high rate of spontaneous re-stings shows that efficacy is maintained for years after completing treatment in a real-world setting. Determination of IgE to individual venom allergens may offer new perspectives in the diagnosis and follow-up of these patients.

Component-resolved diagnosis of pollen allergy based on skin testing with profilin, polcalcin and lipid transfer protein pan-allergens

BACKGROUND

Allergy diagnosis needs to be improved in patients suffering from pollen polysensitization due to the existence of possible confounding factors in this type of patients.

OBJECTIVE

To evaluate new diagnostic strategies by comparing skin responses to pan-allergens and conventional allergenic extracts with specific IgE (sIgE) to purified allergen molecules.

METHODS

One thousand three hundred and twenty-nine pollen-allergic patients were diagnosed by a combination of an in vitro method with a panel of 13 purified allergens, including major allergens and pan-allergens, using a high-capacity screening technology (ADVIA-Centaur) and skin prick test (SPT) to pan-allergens and conventional extracts.

RESULTS

There was a high concordance (kappa index) between in vitro (sIgE to major allergens) and in vivo (SPT to conventional extracts) methods in patients who were not sensitized to pan-allergens, but SPT with conventional extracts failed to diagnose patients with sensitization to pan-allergens. In patients who were simultaneously sensitized to polcalcins and profilins, there was a duplication both in the number of sensitizations to major allergens and in the years of disease evolution. There was a statistical association between sensitization to profilins and/or lipid transfer proteins and food allergy (P<0.0001).

CONCLUSION

The novel diagnostic strategy has proven to be a valuable tool in daily clinical practice. Introduction of routine SPT to pan-allergens is a simple and feasible way of improving diagnostic efficacy. Patients sensitized to pan-allergens should be tested by an adequate panel of allergenic molecules in order to identify the allergens that are responsible for the allergic disease.

Understanding patient sensitization profiles in complex pollen areas: a molecular epidemiological study

BACKGROUND

Allergy diagnosis in patients exposed to multiple pollen species is complex and misdiagnosis is often a cause for unsuccessful specific immunotherapy.

OBJECTIVE

We studied the sensitization profile of individual allergens (major, minor and pan-allergens) in pollen-sensitized patients in a region with high exposure to olive pollen by investigating the influence of minor allergens on allergic disease and the association between pan- and minor allergen sensitizations.

METHODS

A panel of 13 purified allergens, which included the most relevant allergens in the area, as well as minor olive allergens and pan-allergens, were screened using a high-capacity technology (ADVIA-Centaur) in 891 patients.

RESULTS

Olive allergy as measured by specific IgE to Ole e 1 was the leading pollinosis in the area. The minor olive allergens Ole e 7 and Ole e 9 were markers of more severe allergic illness. Profilin sensitization was associated mainly with grass allergy, the second most prevalent pollinosis. Salsola kali pollen allergy was the third most common cause of pollinosis in the area. The prevalence of sensitization to the peach allergen Pru p 3, a nonspecific lipid-transfer protein, was notable.

CONCLUSION

Epidemiological analysis by component-resolved diagnosis is a new method, which elucidates the interaction between allergen exposure gradient and patient sensitization. High exposure leads to differential sensitization profiles some of which are associated with more severe allergic conditions. Profilin sensitization, related mainly to grass pollinosis, was a marker of more severe grass pollen sensitization.

Prognostic value of flow cytometry in surgically treated primary gastric lymphoma

AIM

To investigate whether flow cytometry could help to define the optimal therapeutic strategy of primary gastric lymphomas.

MATERIAL AND METHOD

Retrospective study of 46 patients having primary gastric lymphoma--according to Dawson criteria--in Ann Arbor stage IE and IIE, who were surgically treated. From selected paraffin-embedded tissue blocks of the tumor, DNA content was studied by flow cytometry (FC). Other pathological tumor features were analysed by hematoxiline-eosine and Giemsa stains as well as immunohistochemical study; any possible influence on postoperative survival was investigated through statistical analysis.

RESULTS

The DNA ploidy pattern was diploid in 40 cases (87%) and aneuploid (hyperdiploid) in 6 (13%). Postoperative survival probability (PSP) was 62.7% at 5 years. Statistical analysis showed significant prognostic value for Ann Arbor classification--with higher PSP for stage IE (p = 0.009)--and FC parameters: diploid tumors had higher PSP than aneuploid tumors. Also tumors having S-phase (p = 0.044) or G2-M phase values (p = 0.023) under the respective mean values had higher PSP. No influence on PSP was found for wall invasion, Helicobacter pylori infection, Isaacson's histologic type or resection margin involvement. No significant relationship was appreciated between Isaacson's histologic type and DNA ploidy patterns.

CONCLUSION

FC could be useful in assessing gastric lymphoma prognosis.

Absence of port-site metastases following staging laparoscopy for gastric carcinoma

BACKGROUND

port-site metastases (PSM) have been reported following oncological laparoscopic surgery. However, their frequency after laparoscopic examination in gastric cancer has not been well established.

MATERIAL AND METHODS

prospective follow-up of 41 patients having had a staging laparoscopy and a follow-up longer than 12 months. Mean age was 65 years (29-89). After staging, an open gastrectomy was performed in 33 cases. Mean follow-up was 21.4 (12-66) months. PSM was defined as a node in the former port-site wound with adenocarcinoma histology at biopsy.

RESULTS

no patient showed clinical signs of PSM or port-site recurrence, even in advanced stages. We had no morbidity or postoperative mortality attributable to laparoscopic manoeuvres, and no need for laparotomy in cases without a gastrectomy indication.

CONCLUSIONS

our results suggest that staging laparoscopy is a safe procedure in gastric carcinoma, as it is not associated with PSM after even considerable follow-up, and has a very low complication rate.

Stage- and tissue-expression of genes involved in the biosynthesis and signalling of ethylene in reproductive organs of damson plum (Prunus domestica L. subsp. insititia)

In this work, four cDNA clones (Pd-ACS1,AJ890088; Pd-ETR1 and Pd-ERS1, AJ890092, AJ890091; and Pd-CTR1, AJ890089) encoding an ACC-synthase, two putative ethylene (ET) receptors, and a putative MAPKKK, respectively, were isolated and phylogenetically characterized in Prunus domestica L. subsp. insititia. Their expression was studied by real-time PCR during flower (closed, open and senescent) and fruit (early green, late green, maturation and ripening) development of damson plum, which is climateric. While two peaks of ET production were quantified at early green and ripening stages in whole fruits, the seed was not able to produce it during maturation and ripening stages. All studied genes were differentially expressed during flower and fruit development. In general, the level of transcripts of Pd-ACS1 was higher in fruits than in flowers. However, it was noteworthy that: (1) Pd-ACS1 expression was hardly detected in closed flowers and at low levels during early green stage; and fruit development provoked a notable differential expression in seeds, and pericarp; (2) the results of Pd-ACS1 expression during fruit development suggest a preponderant role of this gene from late green stage onward. The stamen was the only floral organ in which expression of both Pd-ETR1 and Pd-ERS1 receptor genes was not significantly altered during development; however, their expression decreased concomitantly with development of pistil (only floral organ to register a net ET production when fertilized) and during first days of ovary development (the highest ET production during all fruit development). Contrary to Pd-ERS1, the level of Pd-ETR1 mRNA was temporally quite similar in the seed. With regard Pd-ETR1, even its expression was very scarce during maturation of mesocarp, was stimulated during ripening. In the epicarp, Pd-ERS1 and Pd-ETR1 were low expressed during pit hardening increasing onward and decreasing during ripening. Pd-CTR1 expression was in the seed>mesocarp>>epicarp. Spatial and temporal levels of Pd-ACS1, Pd-ETR1, Pd-ERS1 and Pd-CTR1 mRNAs described in this work demonstrate that the expression of these genes is not always constitutive and that control of its transcription may play an important role in regulating the development of reproductive organs of damson plum.

Assessment of a new brand of determinants for skin testing in a large group of patients with suspected beta-lactam allergy

BACKGROUND

Skin testing with major and minor determinants of benzylpenicillin is recommended standard practice for the evaluation of patients with immediate hypersensitivity reactions to beta-lactams. However, commercial reagents for this purpose were recently dropped from the European market.

OBJECTIVE

In the present study, we assessed a new brand of reagents for use in skin testing in patients with suspected penicillin allergy.

METHODS

Prick tests and intradermal tests were performed with benzylpenicilloyl polylysine (PPL) and minor determinant mixture (MDM). Penicillin G, amoxicillin, and the culprit beta-lactam were also tested. If skin tests were negative, a single-blind oral challenge test was performed with the culprit active principle or penicillin. If both skin tests and challenge tests were negative, the same procedure was repeated between 2 and 4 weeks later.

RESULTS

A total of 636 patients were assessed. The allergy study was positive in 69 patients. Skin tests with PPL were positive in 30 patients (46.8%) and with MDM in 28 (43.7%). Sixteen patients displayed a positive reaction to both PPL and MDM (25%), while 42 patients (65.6%) had a positive reaction to either PPL or MDM alone. Thirty-two patients had positive skin test reactions to penicillin G or another p-lactam antibiotic. Five patients in whom a negative result was obtained in skin tests had a positive reaction to oral challenge.

CONCLUSIONS

Our results indicate that a new brand of determinants that is commercially available in Europe is a reliable and useful tool for the diagnosis of beta-lactam allergy. The new reagents are a safe alternative to the previously available brand.

Do current indications for surgery of primary gastric lymphoma exist?

OBJECTIVE

To analyze the results of our series in order to assess whether surgical excision is still a valid therapeutic option in case the patient needs surgery. Secondarily, to analyze Helicobacter pylori infection rate.

PATIENTS AND METHOD

A retrospective study of 69 consecutive patients having stage IE-IIE primary gastric lymphoma; of these, 65 were treated by gastrectomy between 1974 and 1999. Mean age: 62.6 years (28-85). New staining of paraffin-embedded samples from the surgical specimen were carried out (hematoxiline-eosine, Giemsa, immunohistochemistry) and reviewed. The histological classification was performed according to Isaacson's criteria. The statistical analysis was done by Chi-squared and Fisher's exact tests, as well as Kaplan-Meier and Log-Rank tests.

RESULTS

Mortality was 9.2%. There were non-fatal complications in 10.8%. Helicobacter pylori was identified in 62.7%. Seven patients (11.9%) suffered a relapse. The 5-year survival probability was 87%. The statistical analysis did not show any influences of Ann Arbor stage, gastric wall invasion, Helicobacter pylori infection, histological type, or margin resection involvement on survival.

CONCLUSIONS

Surgical excision provides a high rate of complete remissions and excellent long-term survival with acceptable mortality. Therefore it appears to be a valid treatment in case of emergency surgery, incidental finding, or lack of histological diagnosis.

Tolerance and short-term effect of a cluster schedule with pollen-extracts quantified in mass-units

We performed a prospective, multicenter study to assess the tolerance and possible short-term effects of allergen vaccines administered according to a cluster schedule in the months immediately preceding the onset of the pollen season. The study was carried out in eight centers and included 191 patients (children and adults) with allergic respiratory disease due to sensitization to olive tree and/or grass pollen. Of these, 34 patients acted as controls and the remaining patients received immunotherapy administered in the initiation phase according to a cluster schedule of eight doses injected on four visits. After 3 months of treatment, significant differences were found between the two groups in medication consumption (antihistamines in drops and oral formulations: p = 0.045 and p = 0.001, respectively; short-acting beta2-agonist treatments: p = 0.004) and respiratory symptoms (wheezing and coughing: p = 0.035 and 0.014, respectively). The cytokine profile (interleukin [IL]-4, 5, 10 and 2, interferon [IFN-gamma], and tumor necrosis factor [TNF-alpha]) was determined before the start of treatment and at the end of follow-up (4-5 months). Levels of IL-4, 5 and 10 (Th2 profile) decreased while those of IL-2, IFN-gamma, and TNF-alpha (Th1 profile) decreased. These differences were more marked in the active group than in the control group but were not statistically significant. No severe adverse effects were recorded. This study shows that the schedule tested had an acceptable tolerance profile and produced significant changes in symptom and medication scores after a few months of treatment. A double-blind, placebo-controlled study is needed to confirm these results.

Tolerance of a Salsola kali extract standardized in biological units administered by subcutaneous route. Multicenter study

BACKGROUND

Sensitivity to Salsola kali is a frequent cause of allergic respiratory disease in various regions of Spain. However, there are very few articles in which this allergen has been studied.

METHODS AND RESULTS

In order to evaluate the tolerance of this extract, a prospective study has been performed. This study was observational, multi-centred and open, involving 88 patients with allergic respiratory disease due to sensitivity to Salsola, aged between 5 and 52 years. The administration of the extract was performed subcutaneously, through one of two treatment schedules: cluster (8 doses in 4 visits) or conventional (13 doses in 12 visits). A total of 42 adverse reactions were registered, in 26 patients (35 local reactions in 21 patients and 7 systemic reactions in 6 patients). Among the 7 systemic reactions, 4 were registered with the cluster protocol and 2 with the conventional protocol (p = 0.329). In no patients were serious adverse reactions registered.

CONCLUSION

The subcutaneous administration of a Salsola extract is safe and well tolerated, both when administered using a conventional schedule and when using a cluster schedule.

A prospective and multicenter safety-monitoring study of a short up-dosing schedule of immunotherapy with a mass-units-standardized extract of mites

A prospective, multicenter pharmacovigilance study was carried out to evaluate the safety of a new 7-dose treatment schedule of subcutaneous immunotherapy as opposed to the conventional 13 doses normally recommended. The study was carried out in 14 centers and included 261 patients (children and adults) with respiratory allergic disease due to sensitization to mites (Dermatophagoides pteronyssinus and/or farinae). A total of 2290 doses were administered under the direct supervision of the participating specialists. One hundred and ten reactions in 63 patients (24.1%) were recorded, representing 4.8% of the total doses administered. Most of the reactions (98) were local. Only 12 were systemic (0.5% of the administered doses) and occurred in 10 patients (3.8% of the sample). Ten reactions reverted quickly with rescue medication. The maintenance dose had to be lowered in one patient and another patient was withdrawn from the study after suffering two asthmatic crises after two consecutive doses. In view of the results obtained, we can conclude that the new schedule shows an acceptable tolerance profile and does not present a greater risk of reactions than the conventional scheme of 13 doses using an identical extract. Moreover, the new schedule represents substantial savings in the number of doses and visits required to reach the maintenance dose.

Epidemiological factors on hymenoptera venom allergy in a Spanish adult population

BACKGROUND

The prevalence and risk factors of hymenoptera venom allergy (HVA) have been studied in several countries. However, there are few studies on the general population and these have very variable results.

METHODS

An observational, prospective and cross-sectional study was carried out on a sample of 1064 subjects in a total working population of 7887 subjects (Ford factory, Spain) in order to know the prevalence of HVA in this population and the influence of several risk factors in its development.

RESULTS

The rate of exposure to stings was 84.1% (ci 95%: 81.8-86.3%). The prevalence of HVA was 7.6% (ci 95%: 6.1-9.4%), with local severe reactions (LSR) in 5.3% (ci 95%: 4-6.8%) and systemic reactions (SR) in 2.3% (ci 95%: 1.5-3.4%). More than 82% of individuals over 20 years had already had some exposure, a figure that did not change in the age groups of older decades. In our study, the prevalence of HVA was not dependent on either age (similar age in all groups), sex: for LSR OR 2.75 (ci 95%: 0.37-20.30), for SR OR 0.54 (ci 95%: 0.12-2.38), or atopy OR 0.96 (ci 95%: 0.50-1.83); SR being more frequent among the residents of rural habitats, with ranges approaching statistically significant levels OR 2.15 (ci 95%: 0.95-4.81). The number of stings was larger in HVA group with respect a control group. The degree of venom sensitization measure by skin test and CAP-RAST was more intensive in SR group versus LSR group. Among vespids, sensitization to Polistes was more frequent than Vespula.

CONCLUSIONS

HVA in our sample has a similar prevalence to other countries located in similar geo-climatic environments. Rural habitat and the number of stings suffered along life are risk factors of HVA development.

Immunotherapy with an extract of Olea europaea quantified in mass units. Evaluation of the safety and efficacy after one year of treatment

Sensitization to olive pollen is a frequent cause of rhinoconjunctivitis (RC) and bronchial asthma (BA) in the region of Jaén (southern Spain), where this allergen reaches atmospheric levels of almost 7000 grains/m3 during pollen season (May and June) and produces high morbidity. Specific immunotherapy (SIT) has proven very efficient in allergic RC and BA caused by grass pollen. Considering the availability of a biologically standardized extract of Olea europaea, with its major allergen quantified in mass units, we decided to investigate SIT with this extract in a group of rhinitic and/or asthmatic patients monosensitized to olive. We studied tolerance, safety, and efficacy by comparison of the active group (subjected to SIT) with a control group that did not receive SIT. A hyposensitizing dose of Olea europaea extract was administered preseasonally, establishing a maintenance dose 3.8 times higher than those administered in conventional treatments. Eighty-three percent of the patients reached the proposed maximal dose of 75 BU, equivalent to 45 micrograms Ole e 1, with a rate of 0.8% of systemic reactions. A significant decrease in cutaneous (p < 0.001) and bronchial (p < 0.001) reactivity was observed in the active group, but not in the control group. Also, a decrease in specific IgE and an increase in IgG1 and IgG4 were found in the group of patients treated with SIT. Regarding clinical evolution, the active group, but not the control group, experienced a clear statistically significant improvement both in nasal (p < 0.05) and bronchial (p < 0.05) symptoms, in addition to a significant decrease in the consumption of antihistamines (p < 0.05) and beta 2-agonists (p < 0.01). In conclusion, SIT with olive extract proved to be safe and efficacious for the treatment of asthma and rhinitis caused by this allergen.

Tolerance of a cluster schedule on the treatment of seasonal allergic respiratory disease with pollen extracts quantified in mass units

In order to evaluate the tolerance of a cluster schedule on specific immunotherapy (SIT), 306 patients were included in a multicenter study. The patients were suffering from rhinoconjunctivitis with/without asthma, caused by sensitization to olive and/or grass pollen. SIT was administered subcutaneously according to a cluster schedule in which the maintenance dose is reached after four visits (3 weeks). The extracts were biologically standardized with major allergens quantified in mass units. Local reactions appeared in 7.2% of the patients and 1.3% of the doses. Systemic reactions (SR) were recorded in 1.2% of the doses administered to 9.5% of the patients. No anaphylactic shock was registered, and all the SR responded fully and rapidly to treatment. There was no difference in SR according to diagnosis or allergen extract used. The majority of SR occurred with the administration of vial of higher concentration (Vial 2: 7 SR (22%), Vial 3: 32 SR (78%), p < 0.05). Of the 32 SR recorded with Vial 3, 13 (41%) were immediate, with no existing association between dose administered and appearance of SR. However, of the 18 delayed SR (56%), 14 occurred after the administration of the first two doses of Vial 3 and four occurred after administration of the second two doses (78% vs 22%, p < 0.05). On the other hand, this regime realized an important saving in cost and time compared to the conventional schedule (1581 fewer doses and 2754 fewer visits were necessary to reach the optimal dose). Considering all these factors, the clinical profile of the proposed regime may be qualified as good. However, future studies are necessary in order to better adjust the schedule to avoid the delayed SR that occurred after the administration of the first two doses of Vial 3.

The cost of asthma treatment in Spain and rationalizing the expense

According to Weiss et al. [12], the main providers of asthma care in the United States in 1992 were general and family medicine + internal medicine (46%), pediatrics (19%), allergy (25%), pulmonary medicine (5%), and others (5%). In an overall climate of a shift of referral from primary care to the specialties, specialists will have to provide evidence that their intervention in the control of patients provides truly better clinical and economical outcomes than that of general practitioners. In order to support this hypothesis, we estimated: (1) the development of the costs of medication for asthma in a population of 40 million people (Spain) and (2) the correlation between these costs and the intervention of a specialized attendance. In Spain the annual costs incurring from allergic diseases are estimated to be approximately 1,500 million Euros and, the cost due to asthma alone is about 900-1,200 million Euros. There are two main ways to explain the size of these figures. First, the prevalence of allergic diseases is rising year by year. Second, the relevance of allergology in the control of asthma is often greatly reduced. This has resulted in a reduction in the etiological diagnosis and treatment with specific immunotherapy (SIT). However, SIT is the only specific causal treatment of allergic asthma that is able to modify the natural history of disease or disease progression. So, it is possible to hypothesize that this reduction in a proper etiological diagnosis and treatment could be a cause (among others) of increasing costs.

Increased production of hydrogen peroxide by Lactobacillus delbrueckii subsp. bulgaricus upon aeration: involvement of an NADH oxidase in oxidative stress

The growth of Lactobacillus delbrueckii subsp. bulgaricus (L. delbrueckii subsp. bulgaricus) on lactose was altered upon aerating the cultures by agitation. Aeration caused the bacteria to enter early into stationary phase, thus reducing markedly the biomass production but without modifying the maximum growth rate. The early entry into stationary phase of aerated cultures was probably related to the accumulation of hydrogen peroxide in the medium. Indeed, the concentration of hydrogen peroxide in aerated cultures was two to three times higher than in unaerated ones. Also, a similar shift from exponential to stationary phase could be induced in unaerated cultures by adding increasing concentrations of hydrogen peroxide. A significant fraction of the hydrogen peroxide produced by L. delbrueckii subsp. bulgaricus originated from the reduction of molecular oxygen by NADH catalyzed by an NADH:H(2)O(2) oxidase. The specific activity of this NADH oxidase was the same in aerated and unaerated cultures, suggesting that the amount of this enzyme was not directly regulated by oxygen. Aeration did not change the homolactic character of lactose fermentation by L. delbrueckii subsp. bulgaricus and most of the NADH was reoxidized by lactate dehydrogenase with pyruvate. This indicated that NADH oxidase had no (or a very small) energetic role and could be involved in eliminating oxygen.

[Diarrhea associated with Clostridium difficile. One-year retrospective study at a tertiary hospital]

BACKGROUND

Diarrhea associated with Clostridium difficile is a health care problem of growing importance in the last few years specially in the hospital environment. The epidemiologic data and factors associated with this disease have not, to date, been sufficiently studied in Spain.

METHODS

The cases of diarrhea associated with C. difficile reported in 1996 in a tertiary hospital of 1,500 beds were retrospectively reviewed, collecting clinical and epidemiologic data. The technique used for the detection of the C. difficile toxin was EIA Premier.

RESULTS

One hundred thirty-two patients were included in the study, 83.3% of whom were over the age of 65 years, who had had 148 episodes of diarrhea associated with C. difficile. Most had been admitted into internal medicine (36%) or in the geriatric department (25%) and the remaining in the surgical departments (16.4%) or others (22.6%). The most frequently prescribed antibiotics were third generation cephalosporins (28.6%), clindamycin (17%), quinolones (11.1%) and macrolides (9.1%). Most of the patients received from 2 to 4 antibiotics prior to presenting diarrhea. Thirteen percent of the episodes of diarrhea associated with C. difficile were exclusively treated with withdrawal of the prescribed antibiotic, while the remaining cases were also given specific treatment which in 68.6% of the cases was with metronidazole and 31.4% with vancomycin. No significant difference was observed in the evolution of the patients according to the antibiotic prescribed.

CONCLUSIONS

Diarrhea associated with C. difficile should be taken into account as a frequent complication of wide spectrum antibiotic treatment, specially in the elderly, immunosuppressed or in patients with pluripathology. With this study the authors wish to underline the need for the judicious use of antibiotics in the hospital environment and aid in the rapid diagnosis of this entity.

IgE binding proteins in honey: discussion on their origin

Pollen proteins, most frequently from Compositae plants, and glandular enzymes from Hymenoptera insects are the only honey allergens involved in every case of honey sensitization reported so far. Surprisingly, we found three patients, all showing the same pattern of honey sensitization with clinical history, cutaneous test and specific IgE clearly positive to honey crude extract but not to the aforementioned components. IgE binding bands, mainly at 54, 46, 17 and 16 kDa, were recognized by the sera of the three patients on blots following electrophoretic separation of a local honey extract under dissociating conditions. Attempts to identify these proteins with the most common honey allergens by means of SDS-PAGE immunoblotting failed, leaving open the question on the origin of protein allergens in cases of honey allergy. Thus, if bee-derived components are not proven to be involved in honey sensitization, other protein sources, such as nectar, should not be disregarded.

Delineation of the minimal portion of the Bacillus sphaericus 1593M toxin required for the expression of larvicidal activity

The two genes of Bacillus sphaericus 1953M coding for the 51.4-kDa and 41.9-kDa proteins are both required for the expression of the active larvicidal toxin in Escherichia coli. The minimal size of the active peptide of the 41.9-kDa toxin was defined by in vitro deletion analysis of the gene and found to consist of 338 amino acids (38.3 kDa). N-terminal deletions past the Ile18 residue and C-terminal deletions past the His352 residue result in the loss of toxic activity and rapid degradation of such modified toxins by host proteases. The minimal active 38.3-kDa peptide produced in E. coli seems to mimick the stable processed form of the toxin found in larval midguts. However, it still requires the action of the synergistic 51.4-kDa protein for the larvicidal activity.

Transfer of the toxin protein genes of Bacillus sphaericus into Bacillus thuringiensis subsp. israelensis and their expression

The genes encoding the toxic determinants of Bacillus sphaericus have been expressed in a nontoxic and a toxic strain of Bacillus thuringiensis subsp. israelensis. In both cases, the B. sphaericus toxin proteins were produced at a high level during sporulation of B. thuringiensis and accumulated as crystalline structures. B. thuringiensis transformants expressing B. sphaericus and B. thuringiensis subsp. israelensis toxins did not show a significant enhancement of toxicity against Aedes aegypti, Anopheles stephensi, and Culex pipiens larvae.

On the respective roles of the two proteins encoded by the Bacillus sphaericus 1593M toxin genes expressed in Escherichia coli and Bacillus subtilis

The 3.6 kb HindIII DNA fragment of B. sphaericus 1593M chromosomal DNA bears two genes encoding two polypeptides of 41.9 kDa (protein "42") and 51.4 kDa (protein "51"). DNA fragments carrying only one of these two genes when expressed in E. coli yield products that are inactive towards Culex larvae. The larvicidal activity is recovered when Triton X-100 treated E. coli cells containing each one of the two genes are incubated together. In E. coli these two polypeptides are acting synergistically. The protein "51" appears to be involved in the maturation of protein "42" for expression of the larvicidal activity. In B. subtilis however the toxicity is expressed by cells carrying only the gene coding for protein "42". There is no need of the "51" gene product for the maturation of the "42" polypeptide, suggesting that the maturation is most likely accomplished by host enzymes.

Evaluation of four methods for the detection of streptococcal group A antigen directly from throat swabs

We have compared the sensitivity, specificity and reproducibility of four rapid tests for the detection of group A beta-hemolytic streptococci antigen directly from a throat swab. The four methods were very specific, all of them offered reproductibility and surpassed conventional culture in speed and simplicity.

Choline acetyltransferase activity in the rat brain cortex homogenate, synaptosomes, and capillaries after lesioning the nucleus basalis magnocellularis

Stereotaxic lesions of the nucleus basalis magnocellularis were made unilaterally in male Wistar rats with either kainic or ibotenic acid, using the contralateral side as control. Differences in behavior, body weight, and survival were observed between the kainic and ibotenic acid-treated rats. One week after surgery, the rats were sacrificed and the effect of the lesions on choline acetyltransferase activity was measured in brain cortex homogenate, synaptosomes, and capillaries. In kainic acid-lesioned rats, choline acetyltransferase activity decreased in homogenate and synaptosomes of the ipsilateral side with respect to that of the contralateral side; but the ibotenic acid lesion, which also reduced the ipsilateral choline acetyltransferase activity in homogenate, showed a rather different effect on the enzymatic activity of the synaptosomes. There were also differences between the effect of kainic and ibotenic acid lesions on choline acetyltransferase activity in the capillaries of the ipsilateral side with respect to that of the contralateral one. However, capillary choline acetyltransferase activity of the treated rats was in both sides three times higher than that of unoperated rats.

Expression of the larvicidal gene of Bacillus sphaericus 1593M in the cyanobacterium Anacystis nidulans R2

A 3.6 kb HindIII DNA fragment from Bacillus sphaericus 1593M was cloned and expressed in Escherichia coli and B. subtilis using pHV33 as shuttle vector and in the cyanobacterium Anacystis nidulans R2 with pUC303 as shuttle vector. The level of toxin activity of the respective recombinant plasmids pGsp04 and pGsp12 against Culex mosquito larvae was found to be the same in Escherichia coli and in the cyanobacterium.