Negative Challenge Test Research Articles

Assessment of maternal and fetal outcomes according to induction methods following negative oxytocin challenge test

Background/Aim: There is insufficient information about how long fetal well-being will last after a negative oxytocin challenge test (OCT) and the factors affecting this process. We aim to evaluate maternal and perinatal outcomes in high-risk patients who had negative OCTs and to investigate the effects of methods of induction on the development of fetal distress. Methods: The study was designed as a retrospective cohort study. Data of patients who were hospitalized in the perinatal intensive care unit due to high-risk pregnancies between January 2016 and December 2016 were reviewed retrospectively. The patient’s gestational age, gravidity, parity, and body mass index (BMI), risk factors leading to the OCT, labor induction methods used following a negative OCT, time from negative OCT to delivery, mode of delivery, and indications for cesarean section were recorded. In addition, data regarding fetal sex, birth weight, birth height, labor complications, Apgar scores at minutes 1 and 5, admission to the neonatal intensive care unit (NICU), indications for NICU admission, length of NICU stay, and stillbirth were also recorded. Results: OCT was performed on 551 patients and was negative in 447 patients. Among patients with a negative OCT, labor induction was preferred in 427 (95.5%) patients. When fetal distress development was assessed according to the induction method used following a negative OCT, fetal distress developed in 9.1% of 427 patients who underwent labor induction. Conclusion: When outcomes were considered in pregnant women with a negative OCT, it was observed that there were no fetal deaths and a limited number of newborns with low Apgar scores. Further randomized studies are needed to draw definitive conclusions.

Presence of variable extrathoracic airflow limitation in patients with a negative methacholine challenge test

PurposeDetermine whether variable extrathoracic airflow limitation (VEAL) is observed in patients with negative methacholine challenge tests (MCT).MethodsElectronic medical records of patients undergoing MCT at Jesse Brown VA Medical Center between January 2017 and December 2019 were reviewed. Only patients with negative MCT were selected. Pertinent demographic, clinical, and pulmonary function tests (PFT) and MCT data were abstracted from each record. Spirometric flow-volume loops recorded during each test were inspected by one co-author to determine the first inhaled methacholine concentration at which FEF50/FIF50 was either > 1 or further increased if baseline FEF50/FIF50 after nebulized saline (vehicle) already exceeded 1. Student’s t-test was used for statistical analysis. P < 0.05 was considered statistically significant.ResultsOne hundred and twenty-seven consecutive patients with normal baseline PFT and negative MCT were identified. Thirteen patients (10.2%) had negative MCT and FEF50/FIF50 > 1 after testing. They were predominately obese (BMI, 31.3 ± 6.6), non-smoking (10), White (8) males (9) aged 51.3 ± 14.1 years (mean ± SD) referred for symptoms suggestive of asthma (n = 7) or for chronic cough (n = 6). Five had obstructive sleep apnea, three gastroesophageal reflux disease, and two chronic rhinosinusitis. FEF50/FIF50 increased significantly from 0.72 ± 0.21 after nebulized saline (vehicle) to 1.21 ± 0.13 after inhaled methacholine (p < 0.001). Median inhaled methacholine concentration eliciting these responses was 1.0 mg/mL (range, 0.25–16 mg/mL).ConclusionsVEAL is observed in a subset of patients with a negative MCT. This phenomenon should be recognized and reported to the referring healthcare providers and its clinical significance addressed as indicated.

Twelve-Lead ECG, Holter Monitoring Parameters, and Genetic Testing in Brugada Syndrome: Insights from Analysis of Multigenerational Family with a History of Sudden Cardiac Arrest during Physical Activity.

Brugada syndrome (BrS) is an arrhythmogenic disorder increasing the risk of syncopal episodes and sudden cardiac death. BrS usually runs through families with reduced penetrance and variable expression. We analyzed the multigenerational family of a patient who died after sudden cardiac arrest with post-mortem diagnosis of BrS. We analyzed clinical history, comprehensive arrhythmic risk, genetic findings, and additional tests, including electrocardiogram (ECG), detailed 24-hour Holter ECG results, and standard echocardiography findings, and followed up the patients in the ambulatory clinic. We analyzed a pedigree of 33 members of four generations of the family (19 male and 14 female patients). In this family, we identified 7 patients with BrS (median Modified Shanghai Score and Sieira model: 4.5 (4-6) and 1 (0-4) points, respectively), including both parents of the deceased patient, and 8 relatives with negative sodium channel blocker drug challenge test. Genetic testing revealed a novel mutation in sodium voltage-gated channel alpha subunit 5 (SCN5A) c.941A>G, (p.Tyr314Cys) inherited from the father of the proband. Patients with BrS were characterized by longer P-wave duration (120 (102-155) vs. 92.5 (88-110) ms, p = 0.013) and longer PR intervals (211.3 ±26.3 vs. 161.6 ± 18.9 ms, p = 0.001), along with more frequent positive aVR sign, but did not differ in terms of QRS duration or T-wave characteristics in resting ECGs. BrS patients were characterized by lower mean, minimal, and maximal (for all p ≤ 0.01) heart rates obtained from Holter ECG monitoring, while there was no difference in arrhythmias among investigated patients. Moreover, visual diurnal variability of ST segment changes and fragmented QRS complexes were observed in patients with BrS in Holter ECG monitoring. There were no major arrhythmic events during median follow-up of 68.7 months of alive BrS patients. These results suggest ECG features which may be associated with a diagnosis of BrS and indicate a novel SCN5A variant in BrS patients. Twelve-lead Holter ECG monitoring, with modified precordial leads placement, may be useful in BrS diagnostics and risk stratification in personalized medicine.

SAT363 The Prevalence And Phenotype Of Polycystic Ovary Syndrome (PCOS) In A Community-Based Population In Sub-Sahara Africa: The Nigeria-PEP Study

Abstract Disclosure: C.C. Makwe: None. J.A. Olamijulo: None. M.R. Balogun: None. A.O. Akinkugbe: None. A. Samuel: None. K. Udenze: None. F. Bril: None. R.P. Buyalos: None. J.S. Laven: None. R. Azziz: Advisory Board Member; Self; Arora Forge. Consulting Fee; Self; Rani Therapeutics, Spruce Biosciences, Fortress Biotech, Core Access Surgical Technologies. Grant Recipient; Self; Ferring Pharmaceuticals. Stock Owner; Self; Martin Imaging. Background: Epidemiologic studies of unselected (medically unbiased) populations in many nations indicates that PCOS is clinically evident in 5%-15% of all reproductive-aged women. However, no systematic studies of PCOS have been performed in Sub-Sahara Africa, limiting the ability to develop rational screening and public health approaches to address the disorder in this part of the world. To address this deficit, we established the ‘PCOS Epidemiology and Phenotype in Nigeria (Nigeria-PEP)’ study. Objective: To determine the prevalence and phenotype of PCOS in an unselected population in Nigeria. Materials and methods: Women 18-45 yrs. were selected using multi-stage sampling from the Mushin and Surulere Local Government Areas of Lagos, Nigeria. All underwent a 75 gm, 2-hr. oral glucose tolerance test (OGTT) and a pelvic ultrasound between day 2-7 of the cycle (natural or induced with oral Dydrogesterone 10 mg/day x 5 day), or randomly for women who had a negative progesterone challenge test. PCOS was defined by the Rotterdam 2003 criteria. Clinical hyperandrogenism (CH) was defined by a modified Ferriman-Gallwey score of ≥6; menstrual dysfunction (MD) as menstrual cycle lengths &amp;gt;35 or &amp;lt;25 days; and polycystic ovarian morphology (PCOM) as an antral follicle count (AFC) of ≥20 and/or ovarian volume ≥ 10 cm3 at least in a single ovary. Results: Of the 422 participants recruited for the study, 418 participants had complete data for analysis. Mean (SD) age was 32.3 (8.6) yrs., body mass index (BMI) was 26.6 (9.2) kg/m2, waist circumference was 77.3 (11.5) cm and waist-to-hip-ratio was 0.77 (0.09). Twenty-seven (6.4%) participants were underweight (BMI &amp;lt; 18.5), 209 (50.0%) had normal BMI, 86 (20.6%) were overweight, and 96 (23.0%) were obese (BMI≥ 30 kg/m2). The mean (SD) fasting, 1-hour, and 2-hour plasma glucose were 4.9 (1.0), 6.5 (2.2), and 5.9 (2. 5) mmol/L, respectively; 14 (3.3%) had diabetes, 15 (3.6%) had impaired fasting glucose, 17 (4.1%) had impaired glucose tolerance, and 372 (89%) were euglycemic. Forty-three (10.3%) subjects had CH, 55 (13.2%) had MD, and 139 (33.3%) had PCOM. Our preliminary results, pending hormonal analysis, indicate that at least 8.6% (36/418) of unselected women of reproductive age demonstrated PCOS. Of these, 3 (8.3% of all PCOS and 0.7% of total population) of the subjects had CH, MD, and PCOM, consistent with PCOS Phenotype A; 9 (25% and 2.2%) had CH and MD only, consistent with PCOS Phenotype B; 12 (33.3% and 2.9%) had CH and PCOM only, consistent with PCOS Phenotype C; and 12 (33.3% and 2.9%) had MD and PCOM only, consistent with PCOS Phenotype D. Conclusion: These data suggest that, at a minimum, the prevalence of PCOS in an unselected Nigerian population of reproductive-aged women is 8.6%. Phenotypes C and D appear to be the predominant phenotypes. Further analysis is ongoing. Funding: Ferring Pharmaceuticals; Foundation for Research and Education Excellence Presentation Date: Saturday, June 17, 2023

Polypharmacy Interactions Impacting Methacholine Challenge Testing for Asthma Assessment in Older People.

Objective To investigate potential reasons for unusually high incidence of negative Methacholine Challenge Tests (MCT), following standardized MCT medication-hold protocol, in older people with physician-diagnosed asthma. Design An analysis of a longitudinal observational parent study of asthma. Setting Community-dwelling participants were evaluated in an outpatient clinic and at home. Participants Screening inclusion criteria for the parent study included 60 years of age or older, physician diagnosis of asthma, and a positive response to at least one of six asthma screening questions. Participants were enrolled in the study if they also demonstrate either: (1) a postbronchodilator administration response showing an increase of at least 12% and 200 mL in forced expiratory volume or an increase of at least 12% and 200 mL in forced vital capacity, or (2) an MCT result of PC20 ≤ 16 mg/mL (indicating bronchial hyper-responsiveness, MCT positive). Exclusion criteria included diagnosis of cognitive impairment or dementia, residing in a long-term care facility, more than 20 pack/ year smoking history or a history of smoking within the previous five years, inability to perform pulmonary function testing maneuvers, and a Prognostic Index score of greater than 10. Interventions Analysis of participant data for non-medication- and medication-exposure factors for association with negative MCT results. Results Anticholinergic burden and statin use were positively associated with negative MCT. Conclusion Medications not accounted for in medication-hold protocols, and concurrently in use, may impact clinical tests and outcomes.

PMON225 Androgen excess in pre-menopausal women due to Granulosa Cell tumor: A case report.

Abstract A 23-year-old nulliparous female without any significant past medical history presented for irregular menstrual cycles, amenorrhea, hirsutism and 25-pound weight loss in one year. Excessive hair growth was found on the face and chest. Prior to endocrinology visit she was started on oral contraceptives without any improvements. Of importance, she had a negative progesterone challenge test (no withdrawal bleeding). On examination in the Endocrinology clinic, she was a class II morbidly obese female, with coarse terminal hair on her chin and chest and no cushingoid features. Intra-vaginal ultrasound revealed large bilateral multi cystic masses in the ovaries. Her laboratory work up was significant for elevated DHEA-S at 826.6 ng/dl (134-407), Total testosterone 144 ng/dl(0-60) and free testosterone 4.75 ng/dl (0.06-1.08). Her 17-OH pregnenolone was also elevated at 539 ng/dl (31- 455), Inhibin B was elevated at 374 pg/ml (&amp;lt;139 premenopausal). 17 - OH progesterone was normal. Estradiol, inhibin A and FSH/LH were normal. ACTH, AM cortisol, TSH and prolactin were normal. Beta HCG and Cancer markers CA 19-9, CA 125, and CEA were negative. CT scan of the abdomen showed a right ovarian mass measuring 10.7×9.6×9.2 cm. Adrenal glands were normal. Patient subsequently underwent a laparoscopic diagnostic right salpingo-oophorectomy. Pathology was reported as an adult granulosa cell tumor (9.5 cm) of the ovary with an intact capsule. After surgery Inhibin B level decreased from 374 to 10 (normal &amp;lt;139), Total testosterone decreased from 144 to 36 ng/dl (0-60), Free testosterone decreased from 4.75 to 1.22 ng/dl (0.06-1.08) and DHEA-S from 826.60 to 687.40 ng/dl (134-407) however remained elevated. Moreover, after surgery irregular menses resolved and she noted some improvement in hirsutism. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Phenocopia of brugada syndrome: an under-diagnosed entity?

Abstract Introduction Brugada phenocopy (BSF) presents as an electrocardiographic pattern similar to Brugada syndrome (BS), however, they differ in etiology, being that it will be found in association with any identifiable condition and when said condition is resolved, the electrocardiogram does not present the characteristic pattern. Since the recognition of the FSB, 122 cases have been registered worldwide, there are reports of ischemic heart disease, secondary to fluid and electrolyte imbalance, pulmonary thromboembolism, electrocution and inappropriate electrocardiographic filters, considering multiple nosological entities with a common electrocardiographic manifestation that has a different prognosis to BS Therefore, the recognition of the FSB requires a diagnostic study in order to establish specific treatment in a timely manner. Purpose To present 3 clinical cases of this little-known entity that did not present risk factors or family history in a cardiology reference center. Methods A search was carried out, finding three cases from 2015–2021, the first case a 22-year-old patient with a history of Duchenne familial dystrophy and hydroelectrolytic imbalance at admission with Brugada type 1 pattern (A) corrected after treatment (B), A 26-year-old female with pulmonary thromboembolism with a Brugada Type I pattern corrected after treatment, a 55-year-old female in the immediate postoperative period of revascularization surgery who, after 48 hours, corrected a Brugada type I pattern (C). Conclusion The differential diagnosis is based mainly on the fact that FBS is due to: secondary etiology, which, once resolved, will normalize the electrocardiographic pattern, negative challenge test with sodium channel blockers and low pretest for congenital BS, contrary to patients with BS that do not present these characteristics, so a differential diagnosis must be made in patients with a BS pattern. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Instituto Nacional de Cardiologia Ignacio Chavez

Methods for Identifying and Reconciling Allergy Information in the Electronic Health Record

Patient allergies are documented in multiple areas of the electronic health records (EHRs) including areas beyond the allergy list (e.g., notes, laboratory tests, and flowsheets). Systematically reconciling allergy information is critical to improve the accuracy of the EHR allergy list and facilitate clinical decision support to maintain patient safety. Our retrospective study included all patients who visited Mass General Brigham (MGB) in 2018. We examined patient allergy information documented in five EHR areas (i.e., allergy list, clinical notes, laboratory tests, flowsheets, and drug-allergy alerts) and proposed approaches to reconciling discrepancies between these EHR areas. We used natural language processing to identify free-text reactions in allergy lists. We consolidated duplicate allergens in allergy lists by mapping previous entries with the same name/ingredients into a preferred allergen. We manually reviewed amoxicillin challenge tests performed where the allergy was deleted, but then later re-added. We reviewed drug-allergy interaction alerts and identified active allergies with ≥3 allergy alert overrides by a clinician to identify active allergies unlikely to be clinically relevant. Of 1,588,979 patients studied, 266,275 (16.8%) had allergy lists indicating need for review and reconciliation. Allergy issues detected included free-text reactions (n=428,770), ≥3 allergy alert overrides (n=10,896), duplicate allergies listed (n=21,051), penicillin allergy active despite negative challenge test (n=36). Incomplete and inaccurate EHR allergy lists are common. Reconciliation methods may allow for allergy information identification and reconciliation. Further work is needed to develop automated reconciliation methods to ensure the accuracy of patient allergy lists and provide safe patient care.

Food-dependent NSAID-induced hypersensitivity (FDNIH) reactions: Unraveling the clinical features and risk factors.

In up to 70%-80% of patients with a suspected non-steroidal anti-inflammatory drug hypersensitivity (NSAIDH), challenge tests with the culprit drug yield negative results. On the other hand, there could be a NSAIDH overdiagnosis when anaphylaxis is the clinical manifestation. We hypothesize that some negative NSAID challenge tests and an overdiagnosis of NSAIDH occur in patients with food-dependent NSAID-induced hypersensitivity (FDNIH). We studied 328 patients with a suspected acute NSAIDH. FDNIH was diagnosed in patients meeting all the following: (1) tolerance to the food ingested more temporally closed before the reaction, later the episode, (2) respiratory or cutaneous symptoms or anaphylaxis related to NSAID, (3) positive skin prick test to foods and/or specific IgE to food allergens (Pru p 3, Tri a 19, Pen a 1) involved in the reaction, and (4) negative oral provocation test to the culprit NSAID. 199 patients (60%) were diagnosed with NSAIDH and 52 (16%) with FDNIH. Pru p 3 was involved in 44 cases (84.6%) and Tri a 19 in 6 cases (11%). FDNIH subjects were younger (p<.001), with a higher prevalence of rhinitis (p<.001) and previous food allergy (p<.001), together with a higher proportion of subjects sensitized to pollens (p<.001) and foods (p<.001). Using just four variables (Pru p 3 sensitization, Tri a 19 sensitization, anaphylaxis, and any NSAID different from pyrazolones), 95.3% of cases were correctly classified, with a sensitivity of 92% and specificity of 96%. Evaluation of FDNIH should be included in the diagnostic workup of NSAIDH.

Improving Successful Introduction after a Negative Food Challenge Test: How to Achieve the Best Result?

Oral food challenges (OFC) confirm or exclude the presence of a food allergy. The outcome can be positive (allergic symptoms), inconclusive, or negative (no symptoms). In the case of a negative OFC, parents and children are advised to introduce the challenged food allergen into their diet. However, previous studies showed difficulties in a successful introduction at home. The aim of this prospective non-randomized intervention study is to evaluate the effect of a new strategy with more guidance regarding the dietary introduction after a negative food challenge test. We compared two cohorts: an historical (retrospective) control group of 157 children, previously described, who did not receive any special advice after a negative OFC, versus a new cohort consisting of 104 children, who were guided according to our new strategy of written introduction schemes, food diaries, and several phone calls. In the historical control group, introduction was successful in 56%, partially successful in 16%, and 28% failed to introduce at home. After introduction of our new strategy, complete introduction was found in 82%, 11% had partially introduced, and only 8% failed to introduce the allergen. In conclusion, comprehensive advice and dietary recommendation after a negative OFC results in an increase in successful home introduction. Therefore, more attention, guidance, and follow-up of children and parents are desirable after a negative OFC.

Successful introduction of milk after a negative double-blind placebo-controlled food challenge test is independent of the total dose and milk product used during the challenge test.

BackgroundFailure of milk introduction after a negative food challenge test is reported in a substantial number of patients. For this reason, guidelines recommend that the total dose of milk protein for a food challenge test should be comparable to a normal serving.ObjectiveOur aim is to compare the success rate of milk introduction after a negative double‐blind placebo‐controlled challenge test performed with different doses of milk protein and different milk products.MethodsWe conducted a retrospective chart review of 485 patients challenged with a low or high dose of milk protein. Pasteurized milk and milk protein powder were used for the low‐dose challenge tests, and condensed milk for the high‐dose challenge tests. Successful introduction was defined as regular milk consumption, and discontinuation of further introduction due to the reappearance of symptoms as unsuccessful introduction. We also evaluated the association between milk products and successful introduction.ResultsThe outcome of 288 (59.4%) double‐blind placebo‐controlled food challenge tests was negative. There were no significant differences between the low and high dose of milk protein in patient characteristics, percentage of patients lost to follow‐up (15% vs 20%), in whom introduction had not yet been performed (4% vs 3.1%), reappearance of symptoms (18% vs 17%), and successful introduction (88.0% and 83.4%). Age, gender, specific immunoglobulin E for milk, dose of milk protein, and atopy were not associated with successful introduction. Children who experienced symptoms during the introduction were less likely to consume milk (P < .001). There was a nonsignificant trend toward higher successful introduction rate if pasteurized milk was used as test material compared to milk protein powder, and condensed milk.Conclusion and Clinical RelevanceSuccessful introduction of milk after a negative challenge test is independent of the total dose of milk protein, and milk product used during the challenge test.

Baseline Plasma Aldosterone Level and Renin Activity Allowing Omission of Confirmatory Testing in Primary Aldosteronism.

Previous studies have proposed cutoff value of baseline plasma aldosterone concentration (bPAC) under renin suppression that could diagnose primary aldosteronism (PA) without confirmatory testing. However, those studies are limited by selection bias due to a small number of patients and a single-center study design. This study aimed to determine cutoff value of bPAC and baseline plasma renin activity (bPRA) for predicting positive results in confirmatory tests for PA. The multi-institutional, retrospective, cohort study was conducted using the PA registry in Japan (JPAS/JRAS). We compared bPAC in patients with PA who showed positive and negative captopril challenge test (CCT) or saline infusion test (SIT) results. Patients with PA who underwent CCT (n = 2256) and/or SIT (n = 1184) were studied. The main outcomes were cutoff value of bPAC (ng/dL) and bPRA (ng/mL/h) for predicting positive CCT and/or SIT results. In patients with renin suppression (bPRA ≤ 0.3), the cutoff value of bPAC that would give 100% specificity for predicting a positive SIT result was lower than that for predicting a positive CCT result (30.85 vs 56.35, respectively). Specificities of bPAC cutoff values ≥ 30.85 for predicting positive SIT and CCT results remained high (100.0% and 97.0%, respectively) in patients with bPRA ≤ 0.6. However, the specificities of bPAC cutoff values ≥ 30.85 for predicting positive SIT and CCT results decreased when patients with bPRA > 0.6 were included. Confirmatory testing could be omitted in patients with bPAC ≥ 30.85 in the presence of bPRA ≤ 0.6.

Elevated fasting vs post-load glucose levels and pregnancy outcomes in gestational diabetes: a population-based study.

To examine the relative association between fasting plasma glucose vs post-load (1-h and 2-h) glucose levels based on the oral glucose tolerance test in pregnancy and large-for-gestational-age and hypertensive disorders of pregnancy outcomes. All live singleton births between October 2008 and December 2014 in Alberta, Canada were included. Gestational diabetes mellitus was diagnosed using Diabetes Canada criteria. Logistic regression models were used to examine the association between fasting plasma glucose vs post-load values and large-for-gestational-age infants and hypertensive disorders of pregnancy after adjusting for maternal characteristics and pharmaceutical intervention in gestational diabetes pregnancies. Among 257 547 pregnancies, 208 344 (80.9%) had negative 50-g glucose challenge tests, 36 261 (14.1%) had negative 75-g oral glucose tolerance tests, and 12 942 (5.0%) had gestational diabetes based on either elevated fasting plasma glucose (n=4130, 1.6%) or elevated 1-h and/or 2-h oral glucose tolerance test values (n=8812, 3.4%). Large-for-gestational-age and hypertensive disorders of pregnancy rates were 8.1% and 5.1% in negative glucose challenge test pregnancies, 11.0% and 7.0% in negative oral glucose tolerance test pregnancies, 22.4% and 11.9% in gestational diabetes pregnancies with elevated fasting plasma glucose, and 9.1% and 8% in gestational diabetes pregnancies with elevated post-load levels, respectively. Among gestational diabetes pregnancies, those with elevated fasting plasma glucose were at higher risk of large-for-gestational age (adjusted odds ratio 2.66, 95% CI 2.39-2.96) and hypertensive disorders of pregnancy (adjusted odds ratio 1.51, 95% CI 1.33-1.72) outcomes relative to pregnancies with post-load glucose elevations only. Fasting plasma glucose remained significantly associated with adverse outcomes in gestational diabetes pregnancies with and without pharmacological intervention. Elevated fasting plasma glucose in women with gestational diabetes is a stronger predictor of large-for-gestational-age and hypertensive disorders of pregnancy outcomes than elevated post-load glucose.

Atropine Challenge Test in Screening the Organophosphorus Poisoning Cases with Atypical Presentation; a Brief Report.

Atropine is not recommended in organophosphorus (OPs) poisoning cases without any obvious clinical signs. This study aimed to evaluate the clinical utility of Atropine challenge test in screening OPs poisoning cases with atypical presentation. In this prospective cross sectional study, after primary supportive care, patients with atypical pretentions of OPs poisoning underwent Atropine challenge test (1 mg intravenously) and demographic parameters, clinical presentations, and serum level of cholinesterase enzyme were compared between cases with positive and negative test results. 20 patients with the mean age of 47.60 ± 13.25 years were studied. The mean time since exposure and initial symptoms was 6.17 ± 2.99 hours. The most common clinical presentations were tachycardia (55%) and flushing (35%). The atropine challenge test was positive in 3 (15.00%) cases. The two groups were the same regarding gender distribution (p = 0.582), mean age (p = 0.957), clinical presentation (p > 0.05), and mean PR interval (p = 0.729). The level of cholinesterase was 220.00 ± 15.52 U/mL and 332.17 ± 143.99 U/mL in patients with positive and negative Atropine challenge test, respectively (p = 0.006). Patients with positive Atropine challenge test had a significantly lower level of serum cholinesterase and response to Atropine in their therapeutic management. Hence, Atropine challenge test could be considered as a useful clinical test in the setting of acute OPs poising.

The correlation of adenosine challenge test results with subsequent clinical course among young children with suspected asthma: a retrospective cohort study

Our aim was to evaluate the correlation of Adenosine monophosphate challenge test (AMP-PCW) results with the patients' subsequent clinical course. We performed a 6-year retrospective cohort study of young children with suspected asthma who underwent AMP-PCW test. Fifty four children were included in the study (median age, 50.5 months; range, 26-90). AMP-PCW was positive in 35 (65%) children. During the 3-year follow-up period, among 22 of 35 patients in the positive AMP-PCW group and among 17 of 19 in the negative AMP-PCW group-prophylactic therapy was not changed. Prophylactic therapy was initiated or its dose was escalated in 12 of 13 (92.3%) of the children with a positive AMP-PCW test compared to none of the children with a negative challenge test (P < 0.001). Prophylactic therapy was discontinued in only one (7.6%) of the children with a positive test as compared to two (100%) of the children with a negative test (P < 0.001). There were significantly fewer severe asthma exacerbations during a 3-year follow-up period after the challenge test as compared to the preceding 3-year period both in children with a positive (from 34 to 9 total events, P = 0.01) or a negative challenge test (from 16 to 0 events P = 0.01). The severity of airway hyper responsiveness was found to associate with the number of severe asthma exacerbations (P = 0.04) and with a diagnosis of asthma during the following 3 years (P = 0.02). AMP-PCW test results correlates with the subsequent clinical course of young children with suspected asthma performing the test.

Efficacy and Safety of Omalizumab (Xolair) for Cholinergic Urticaria in Patients Unresponsive to a Double Dose of Antihistamines: A Randomized Mixed Double-Blind and Open-Label Placebo-Controlled Clinical Trial

Cholinergic urticaria (UCOL) is a highly disabling inducible urticaria triggered by an increase in core body temperature. To explore the safety and efficacy of omalizumab in controlling UCOL. We conducted a multicenter randomized mixed double-blind and open-label (first 4 months blinded followed by 8 months open-label) placebo-controlled clinical trial in 22 patients suffering from UCOL who were unresponsive to a double dose of antihistamines. We performed an exercise challenge test during each visit as our main outcome variable. The overall rate of exercise challenge test negative at week 48 was 31.3%, with an average increase in exercise challenge test negative rate of 2.9% points (95% CI, 1.5-4.2) per visit. Statistically significant differences in the negative exercise challenge test rate between the placebo and active intervention groups were not observed during the blinded period (first 4 months of the study). However, from the fourth dose, a progressive improvement was observed. When comparing before and after treatment, statistically significant improvements in all secondary outcome measures were noted after 4 doses (UCOL score: P= .0015; visual analog scale score: P= .0108; days with symptoms: P= .0125) and after 8 doses (UCOL score: P= .0005; chronic urticaria quality of life questionnaire: P= .0105; visual analog scale score: P= .0008; and days with symptoms: P= .0144). In the follow-up visit after the cessation of treatment, the symptoms reappeared, with positive exercise challenge test result and significant increases in all variables. Only 4 of 22 patients remained asymptomatic after 3 months of no treatment. No adverse effects were reported. This randomized mixed double-blind and open-label placebo-controlled trial showed evidence of the safety and potential efficacy of omalizumab in patients with UCOL.

Anaphylaxis due to proton pump inhibitors: current understanding and important clinical considerations

ABSTRACTIntroduction: Proton pump inhibitors (PPIs) are one of the most prescribed drug classes. PPIs are remarkably safe, with minimal side effects, most of which are related to drug’s pharmacokinetic interaction profiles. However, hypersensitivity reactions can occur and anaphylactic reactions to PPIs have been described.Areas covered: A literature search in PubMed was performed to review the evaluation and management of anaphylaxis to PPIs. Clinicians should have a high level of suspicion and a drug allergy workup should be carried out by allergists, in a proper facility. Skin tests with PPIs are the only accurate methods to identify the culprit drug; they are also quite specific to solve cross-reactivity problems among drugs of this group.Expert commentary: A label of hypersensitivity to the whole group is generally not correct and tolerance to PPI with negative skin tests should be established with a negative oral challenge test. When an alternative drug among the whole group cannot be found, anti-H2 can be prescribed or a PPI desensitization protocol can be applied.

Relationship maternal subcutaneous adipose tissue thickness and development of gestational diabetes mellitus.

ObjectiveWe investigated whether the ultrasonographic measurement of maternal subcutaneous adipose tissue (SAT) thickness in the second trimester played a role in predicting gestational diabetes.Materials and methodsThis was a prospective cross-sectional study in which 223 women were classified as healthy (n = 177) or as gestational diabetes (n = 46) on the basis of a negative or positive two-step oral Glucose Challenge Test (GCT), respectively. The depth of the abdominal SAT was evaluated by two-dimensional ultrasonography. Body mass index (BMI), waist circumference (WC), and waist/hip ratio were determined.ResultsThere was a positive strong significant correlation between a 50-g GCT level and BMI, WC, and SAT thickness (p < 0.001). Receiver-operating characteristic curve analysis showed SAT thickness above 16.75 mm predicted gestational diabetes mellitus (GDM) with a sensitivity of 71.7%, a specificity of 57.1%, a positive predictive value of 32.3%, and a negative predictive value of 87.6%. There was a good correlation between SAT, BMI, and WC.ConclusionIncreased SAT, BMI, and WC measurements may be helpful in predicting the risk of the development of GDM in pregnant women.

Hematochezia caused by eosinophilic proctocolitis in a newborn before oral feeding: a case report

BackgroundHematochezia is a frequent symptom in early infancy. However, it occurs very rarely within the immediate neonatal period, and its occurrence before any oral intake is particularly rare. Because of the “congenital” presentation of hematochezia in our patient, we initially considered our case to be a non-classical, potentially severe type of food protein-induced allergic proctocolitis. This diagnosis needs to be confirmed by an abnormal oral challenge test once the hematochezia has disappeared. If such a challenge cannot demonstrate an allergic origin, then the etiology of the hematochezia could be a neonatal transient eosinophilic colitis. Only two similar cases have been described so far.Case presentationWe report the case of a black baby boy of African origin born at 36 weeks 5 days of gestational age who presented with massive hematochezia immediately after birth. A rectosigmoidoscopy revealed a severe inflammation associated with diffuse eosinophilic infiltration on biopsy. His clinical outcome was favorable after introduction of an amino acid formula diet. We initially considered our case to be a non-classical, potentially severe type of food protein-induced allergic proctocolitis but reintroduction of standard formula milk at the age of 3 months was successful. So, our patient is the first newborn in Europe who fits the diagnosis of “neonatal transient eosinophilic colitis.”ConclusionsWe discuss the possible etiology of “congenital” eosinophilic inflammation of the distal colon and conclude that hematochezia in well-looking neonates, in the absence of negative challenge tests later on, is more likely to be a neonatal transient eosinophilic colitis than an allergic proctocolitis. This new entity could be more frequent than previously thought, changing our medical care strategies for this kind of neonatal symptom.

Food allergy in children with refractory gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) and food allergy are frequent disorders of childhood. The purpose of this study was to determine the frequency of food allergy in children with refractory GERD. A total of 151 children resistant to pharmacologic GERD treatment underwent skin prick test, specific immunoglobulin E, eosinophil count, atopy patch test (APT), and oral food challenge, and were then divided into three groups according to the results of oral milk challenge and allergy work-up: group A1, positive oral milk challenge and positive IgE-mediated allergy test; group A2, positive milk challenge and negative IgE-mediated allergy test; and group B, negative oral milk challenge and negative allergy tests. There were 35, 30 and 86 patients in group A1, group A2 and group B, respectively. A total of 28 of 35 patients in group A1 had cow's milk allergy and the other seven patients had egg allergy. APT positivity was more common in group A2. Endoscopic esophagitis was observed in six group A1 patients and in four group A2 patients. Bloody stools, atopic dermatitis and recurrent wheezing episodes were significantly more common in group A1 than in group A2 and group B (P < 0.001, for both). Cow's milk allergy was observed frequently in children resistant to pharmacologic GERD treatment. Combined skin prick and specific IgE tests, APT and oral food challenge is essential for avoidance of unnecessary elimination diet.