Recommendations for the prevention and diagnosis of asthma in children: Evidence from international guidelines adapted for Mexico

BACKGROUND

With the availability of high-quality asthma guidelines worldwide, one possible approach of developing a valid guideline, without re-working the evidence, already analysed by major guidelines, is the ADAPTE approach, as was used for the development of National Guidelines on asthma.

METHODS

The guidelines development group (GDG) covered a broad range of experts from medical specialities, primary care physicians and methodologists. The core group of the GDG searched the literature for asthma guidelines 2005 onward, and analysed the 11 best guidelines with AGREE-II to select three mother guidelines. Key clinical questions were formulated covering each step of the asthma management.

RESULTS

The selected mother guidelines are British Thoracic Society (BTS), GINA and GEMA 2015. Responses to the questions were formulated according to the evidence in the mother guidelines. Recommendations or suggestions were made for asthma treatment in Mexico by the core group, and adjusted during several rounds of a Delphi process, taking into account: 1. Evidence; 2. Safety; 3. Cost; 4. Patient preference - all these set against the background of the local reality. Here the detailed analysis of the evidence present in BTS/GINA/GEMA sections on prevention and diagnosis in paediatric asthma are presented for three age-groups: children with asthma ≤5 years, 6-11 years and ≥12 years.

CONCLUSIONS

For the prevention and diagnosis sections, applying the AGREE-II method is useful to develop a scientifically-sustained document, adjusted to the local reality per country, as is the Mexican Guideline on Asthma.

Real life study of three years omalizumab in patients with difficult-to-control asthma

BACKGROUND

Even though there are multiple options for the treatment of asthma, there still exists a fair group of patients with difficult-to-control asthma. We describe for the first time the real-world effects of three-year omalizumab treatment on patients with difficult-to-control asthma, seen in a social security hospital in a Latin American country.

METHODS

Difficult-to-control asthmatic patients from the out-patient clinic of a regional hospital were recruited to receive a three-year omalizumab course. Efficacy parameters were asthma control test (ACT) score; FEV1; daily beclomethasone maintenance dose; and unplanned visits for asthma exacerbations (emergency room (ER), hospitalisations, intensive care).

RESULTS

52 patients were recruited, 47 completed the three-year treatment (42 female, 15-67 years, mean age 43.5). Comparing efficacy parameters of the year before omalizumab with the 3rd year of omalizumab: mean ACT improved from 12.4 to 20.5, mean FEV1 from 66.3% (standard deviation (SD) 19.1%) to 88.4% (SD 16.2%) of predicted, while mean beclomethasone dose reduced from 1750 to 766 mcg/day and there was a significant reduction in patients experiencing ER visits (from 95% to 19%, p<0.0001), hospitalisation (38% to 2%, p<0.0001) and intensive care (4% to 0, NS). Five patients discontinued omalizumab, two because of an adverse event (anaphylaxis, severe headache, both resolved without sequelae).

CONCLUSION

Omalizumab improved most clinical parameters of Mexican patients with difficult-to-control asthma. Especially the rates of ER visits and hospitalisation were significantly reduced, thus reducing costs. Omalizumab was generally well tolerated.

[Hereditary angioedema. A report of a case and literature review]

Hereditary angioedema is a congenital disorder with recurrent attacks of localized swelling of submucosal and subcutaneous tissue, or both caused by a deficiency of the plasma protein C1 inhibitor. It is caused by heterozygous defects in the C1 inhibitor gene located on chromosome 11q, and it has an autosomal dominant inheritance pattern. This disease afflicts 1 in 10,000 to 1 in 150,000 persons. Hereditary angioedema has been reported in all races, and no sex predominance has been found. Skin and visceral organs may be involved by the typically massive local edema. The most commonly involved viscera are the respiratory and gastrointestinal systems, and it can affect the upper airways resulting in severe life-threatening symptoms, including the risk of asphyxiation. There are three types of hereditary angioedema, which difference lies in the inheritance pattern and in the C1 esterase inhibitor and C4 concentrations. The treatment is complicated and it should be treated with intravenous purified C1 inhibitor concentrate; corticosteroids, antihistamines and epinephrine can be useful adjuncts but they are not effective. We report a patient with hereditary angioedema type 1 and make a review of the medical literature.

[Safety and efficacy of specific sublingual immunotherapy in patients with asthma and allergy to Dermatophagoides pteronyssinus]

BACKGROUND

First reports on sublingual immunotherapy were published in 1980.

OBJECTIVE

To compare safety and effectiveness of sublingual immunotherapy, as compared with placebo, in asthmatic patients.

MATERIALS

In a blinded randomized controlled trial asthmatic patients with positive skin prick tests to Dermatophagoides pteronyssinus, and with serum IgE at least 200 UI were included. According to GINA, asthma severity was mild persistent and moderate. All patients improved their baseline FEV1 at least by 14% after inhaled albuterol. Spirometry was performed again after three and six months after initiating treatment. Patients were randomized to receive for six months either sublingual immunotherapy with Der p 1 standardized allergens (IPI-ASAC, México) at a total dose of 10,469 UBE or identically looking and tasting placebo. Both groups received conventional pharmacological therapy.

RESULTS

Sixty four patients enter the study; four were excluded because of systemic oral steroid therapy. Sixty patients underwent randomization. Both groups (30 patients in each one) were similar in their baseline characteristics. After six months, patients that received sublingual immunotherapy had less exacerbations than those in the control group (61 vs 123, T 2.61, p<0.001, IC 1.8-7.2), better FEV1 as compared with baseline values (25% vs 9%, Z=0.66, p=0.03), and less need of albuterol (50% of initial dose, vs 21% (Z=1.4, p=0.03, IC 1.39-1.49).

CONCLUSION

Sublingual immunotherapy improves patient symptoms and pulmonary functional tests, makes exacerbations less frequent, and reduces albuterol needs. It may improve asthma related quality of life.

[Transfer factor as specific immunomodulator in the treatment of moderate-severe atopic dermatitis]

BACKGROUND

Atopic dermatitis is a skin inflammatory disease which has been associated to high levels of IgE, eosinophiles and change of T lymphocytes. The transfer factor is an immunomodulator active substance and decreases the number of inflammatory cells and the severity of the symptoms of atopic dermatitis.

OBJECTIVE

To determine the efficacy of the transfer factor as treatment of moderate and severe atopic dermatitis.

MATERIAL AND METHODS

Articles related to treatment with transfer factor in the atopic dermatitis were looked up in Medline and EMBASE, and the ones referring to controlled studies in patients with moderate and severe atopic dermatitis in accord to SCORAD.

RESULTS

We found seven articles with 121 patients and 88 controls demonstrating significant decrease in the symptoms of the SCORAD index, decreased IgE, and eosinophils in patients treated with transfer factor.

CONCLUSIONS

The transfer factor is a choice treatment for moderate and severe atopic dermatitis.

[Skin tests with high and minor determinants in patients with doubtful allergy to penicillin]

BACKGROUND

Currently, the skin tests are the most accepted methods for the diagnosis of allergy to penicillin.

OBJECTIVE

To evaluate the efficacy and diagnosis security of the skin tests with high and minor determinants of penicillin, crystalline and penicillin, in patients with hypersensitivity reaction to penicillin.

METHODS

Patients with doubtful antecedents of reaction to penicillin (problem group) and healthy patients (control group) were included. Both groups were submitted at the following tests: 1) Skin tests with high and minor determinants of penicillin, and crystalline penicillin, by prick and intradermoreaction methods. 2) In case of negativity, tests of direct challenge with penicillin were practiced. The formation of wheal with or without erythema 3 mm related to the negative control or systemic reaction, was considered positive test.

RESULTS

47 patients were included (24 for problem group, and 23 for control group), 50% of the group problem showed positive reactions with the method of prick, none patient of the control group (p < 0.001); with the intradermoreaction method, 79% in the problem group and only 13.4% in the control group showed positive reaction (p < 0.001). Cutaneous tests showed local adverse effects. Clinical history showed a sensitivity or 88%, method of prick, 50%, and intradermoreaction method, 95%.

[Comparative treatment between thalidomide and transfer factor in severe atopic dermatitis]

AIMS

The atopic dermatitis is an chronic inflammatory illness of the skin. It exists an interrelation complex of factors gene, environmental, and psychological that contribute to the development and severity of the illness. The immunol aberrations significant is the answer increased of IgE specific antibodies toward antigens common, the liberation is increased of immunol mediators by the basophils and mast cells, eosinophils peripheral and local, besides enlarges the biphasic activity Th1/Th2 with liberation of cytokines (IL-4, IL-5, IL-13), GM-C5F, and decrease of IFN-gamma by the cells Th1. Leung to report a knowledge upon the bases immunopathologies of it atopic dermatitis has immunopathologies clinical important for the diagnosis and processing. Alternatives multiples of processing by the same complexity of the illness exist.

OBJECTIVE

To compare the security and the clinical efficacy of the thalidomide and the factor of transfer in the atopic dermatitis severe.

MATERIAL AND METHOD

Were studied patient with diagnosis of atopic dermatitis severe in agreement with the criterions of Hanifin and Rajka that they entered to the service of Allergy and Immunology Clinical of the Hospital Regional Lic. Adolfo López Mateos (public hospital). They were included 19 patient (women 12 and men 7, with age average 30 +/- 4 years). They were distributed in two groups. The first group of 5 patient administration thalidomide 200 mg/d during six months. The second group am administered the factor of transfer a total of 15 units by road oral during six months. Studies of laboratory for appraisal were requested immunology and metabolic pretreatment and pretreatment.

RESULTS

In the group A dealt with thalidomide 5 patient and the group B dealt with FT, both presented a statistically significant decrease, as for the extension of the wounds (p < 0.01), and 1 am observed greater reduction in the intensity of the symptoms, the SCORAD total (p < 0.001 and p < 0.001 respectively) with statistical difference among them. None presented alterations immunologies and metabolic secondary to the use of the two drugs and not there was the need to suspend the processing. During the period of study, the patient were maintained controlled to the allergic rhinitis and the asthma.

DISCUSSION

In the atopic dermatitis by its secondary clinical complexity to the multifactors etiologic, the alternatives of processing utilized in the present study are an option the security and efficacy, I am observed better clinical.

[Asthma and gastroesophageal reflux. Diagnostic correlation between gammography and digestive endoscopy]

AIMS

Incidence of gastroesophageal reflux (RGE) in asthmatic it is considered be of the rang of 33% until 89%. RGE can be classic or atypical and 30% will be payees of silent reflux. It considers at the moment so much as standard of gold to 24 hours pH esophagus like endoscopic digestive and biopsy, being determined a smaller sensibility to gastric gammagraphic but maybe a bigger utility in relation to their readiness and access easiness.

OBJECTIVE

Comparative study is presented that reports sensibility/specificity of gastric gammagraphic, relating it with digestive endoscopic study and biopsy report.

METHOD

All asthmatic patient of difficult control and of up to 6 years, selected of the External Consultation of the Service. Gastric gammagraphic was determined and later on the panendoscopic study with taking of biopsy. It integrated sensibility specificity for gammagraphic gastric.

RESULTS

Study that understood 8 months, with a total of 44 patients, with a range of 1.4 year-old age to 6 years. Gastric gammagram was reported positive in 25 patients, (56.8%) and negative in 19,(43.18%). Endoscopic studies demonstrated incompetent hiatus in 33 (75%), esophagitis of variable degree in 20 patients, (45.4%), Gastritis in 8 (18.1%) and normal study in 8, (18.1%). Histopathologies: Esophagitis of variable degree in 33 patients (75%), chronic gastritis in 2 patients, (4.5%), Esophagus of Barrett in 2 patients, (4.5%), and normal histopathologic study in 7,(15.9%). Of the 44 patients, 81.5% showed significant reflux. It is integrated a sensibility and specificity of the gastric gammagraphic of 71.4% and 54.2%, respectively.

CONCLUSIONS

Gastric gammagraphic contributes sensibility it mediates but acceptable for diagnose of RGE. In asthmatic of difficult control, it should be considered initially endoscopic study. The probability of RGE should always take into account in all asthmatic patient.

[Cell surface markers in patients with allergic rhinitis versus Der p and Der f challenge]

The allergic condition is determined genetically and they affect of the general population's 20-30% in developed countries, in the last decade have been increased the prevalence. Inside the imbalance that is manifested in the atopic patients it is on one hand the antigen-presenting cells (monocytes and B cells) and on the other hand, the lymphocytes T CD4+. The association of molecules like CD80, CD 86 (co-stimulatory molecules) in monocytes and B cells and CD30, CD62L, ALL, CD11a, CD28, CD124 and CD152 in CD4+, they have shown to be of particular interest in allergic sufferings. However we don't find a difference statistically significant among patient and controls and among nasal challenges with saline solution with specific allergen. For what we suggest that the changes in the activation, proliferation and cooperation are given in the les ion place, without an apparent repercussion in cells of peripheral blood.

[Respiratory function tests in aspirin-induced asthma]

INTRODUCTION

Aspirin induced Asthma (AIA) is a syndrome, with typical clinical features. Aspirin and Nsaids induced Asthma is its distinctive characteristic.

OBJECTIVE

Was to determine challenge and bronchodilator test usefulness, as well as its complications, in patients with Aspirin induced Asthma.

MATERIAL AND METHODS

Prospective, open, transversal and comparative study of 20 patients divided in two groups of ten people each one group with an Aspirin induced Asthma antecedent, undertook a challenge and bronchodilator test, and the second group was composed of patients with extrinsic asthma which were exposed to a challenge test. All patients had a physical exam and laboratory test, besides paranasal and chest X-ray, allergic skin test and spirometry. Criteria used to make diagnosis of AIA were defined as a 15% decrease of FEV-1 in the both groups. Laboratory and other paraclinic studies were made in order to assess diagnosis and/or complications.

RESULTS

In the first group it was observed a 15% statistically significant decrease of FEV-1 and FEF 25-75 values (p < 0.05), on second group an statistically significant increase in FEV-1 values of more than 15% was observed in 7 patients (p < 0.05). In the control group no statistically significative changes were observed in the patients. The more frequent complications after challenge test were wheeze, dyspnea, cough and severe bronchospasm. Zero defunctions were reported.

CONCLUSION

The minimum dose to realize the diagnosis of AIA are 100 mg of aspirin. The FEV-1 decrease depend of dose of aspirin in patients with AIA. Patients with extrinsic asthma without an aspirin intolerance history, have non adverse effects with aspirin ingestion. Severe bronchospasm was the most severe complication in patients who underwent Aspirin challenge test who had an idiosyncrasy history.

[Asthma phenotype during the first six years of life]

Asthma is one of the main wheezing causes during the first years of life. In our country it is a common respiratory chronic illness but insufficient studies still exist on the asthma phenotypes during the first years of life.

OBJECTIVE

To know the phenotype of asthma in a group of children younger than 6 years old.

MATERIAL AND METHODS

185 children of both sexes were studied with antecedent of having presented wheezing (tree episodes or more) and it registered data about the antecedents of family and personal allergy, dietary habits during the first year of life, infections, data on the beginning and the evolution of the condition, and they were practiced determinations of peripheral eosinophilia, total serum IgE and gastric gammagram to discard illness for gastroesophageal reflux. All were carried out skin tests for foods and aeroallergens.

RESULTS

In the group of 185 patients of both sexes, they had data that supported the allergic process, in 137. It was correlated the atopy antecedents significantly, positive skin tests, eosinophilia (more than 300), with elevated IgE for the age (p < 0.05). The gastric gamagrama was carried out in 144 patients, of which were positive results for gastroesophageal reflux in 64 (44%) and in 79 (54%) it was reported doubtful or negative. It was related the gastroesophageal reflux presence and the positive skin tests significantly (p < 0.05).

CONCLUSIONS

The more common phenotype of asthma in our patients corresponds to a wheezing pattern that persist after the 3 years old, in relation to an allergic component. Furthermore in most of those children a positive gastroesophageal reflux was an important finding.

[Comparative study of prick and intradermal cutaneous tests in allergic rhinitis]

A prospective clinical study to compare the skin prick test method e intradermal method as a diagnostic tool in allergic rhinitis: There were 100 patients with allergic rhinitis of both sexes in the study with ages ranging from 3 to 18. All of them received skin tests by the prick method to 10 common pollen extracts in Mexico City. If the patient showed positively was included in the control group, and if negative the intradermal method to the same extracts was performed. The intradermal method was utilized in 50 patients, of which only 12 (24%) showed positivity to the tests. This result doesn't showed a significant difference with the prick method, with a value of p greater than 0.05.

[Transference factor in moderate and severe atopic dermatitis]

We did a prospective, comparative, experimental study with 30 patients with moderate to severe atopic dermatitis from the allergy section from September 1994 to March, 1995. The test laboratory examination was performed in all patients: complete blood cell count, immunoglobulins A, G, M and E determination, lymphocyte subpopulations CD3, CD4, CD8, CD4-CD8 proportion, CD25, rosette formation for B and T lymphocytes, coproparasitoscopic examination, throat and nose cultures, nasal cytology, skin tests of cellular immunity to PPD, thrichophytin, candidine, varidasa; skin prick test to poliens, fungi, inhalants and foods. All patients underwent to a sign and symptom grading score system as follows: the parameters were erythema, pruritus, eczema, papule valorated on a scale from 0 a 4+( O = no symptoms, + = mild, ++ = moderate, + ++= severe, ++ ++ = very severe). Initially all patients received one placebo unit every 15 days orally 3 times, then one after 30 days. Laboratory examination was performed and then treatment with transfer factor was initiated, initially 1 unit every 15 days three times and the fourth 30 days after. 15 days after the last dose a new immunological valoration was done. Results demonstrate a CD4 cell decrement, blood eosinophil and lgE dissemination although they're not statistically significative. There was a statistically significative improvement in the 4 clinical parameters: erythema, eczema, pruritus and populous with the use of Transfer Factor.

[Superantigens and their behavior in the immune response]

Superantigens are a group of molecules produced by bacteria, viruses and parasites that stimulate T lymphocytes in a very potent way. They join the TCR-HLA complex from the outside, not through the classical peptide-bound mechanism, so that they can easily trigger the citokyne production network and produce tissue damage, they can also lead to clonal anergy over the CD4 T cell subpopulations (Th0/Th1/Th2).

[Efficacy of a new in vitro test (Phadiatop paediatric) for the diagnosis of allergy in children]

An investigation was done to know specificity and sensitivity of one in vitro test useful for diagnosis of allergy in pediatric age (Phadiatop paediatric), in 65 children in two groups. Group 1 (35 children) with diagnosis of respiratory allergy (asthma, rhinitis, or both) based on clinical history, eosinophils, IgE and skin tests; and group 2 (control) with no allergy diagnosis. In both groups IgE was measured and Phadiatop test was done. In group 1, Phadiatop paediatric was positive in 28 children (80%) while in group 2 was positive in 2 children (6.6%) that means a 67.5% sensitivity and 88.0% specificity, for this test.