Positive Provocations Research Articles

ТЕОРІЯ ПРОВОКАЦІЇ ЗА МИРОСЛАВОМ КАРВАТОМ

The article is dedicated to the contemporary problem of provocation as a popular kind of manipulating, fundamentally developed by the Polish doctor of political sciences Miroslaw Karwat in his book “Theory of provocation. In Light of Political Science". This book contains the typology of the forms and methods of provocations and their functioning in communication. The linguistic, sociolinguistic and psycholinguistic methods of analysis are used. Positive provocation is constructive, determined as challenge and is applied in flirting, games, pedagogy, family conflicts, etc. Negative provocation is destructive, targeted at forcing something out of someone. The rude forms of the verbal provocation include strong emotional expressions and may be explained after M. Karwat by the intellectual helplessness or narrow mind. Provocation influence evokes illusions, hopes, changes behavior, to unusual, e. g., brutal, accumulates crisis tendencies. Positive and negative provocations are classified into active and passive, emotional and verbal, intentional and unintentional, planned and unplanned, etc. Provocation is the kind of manipulation and when positive it can develop thinking. Deceitful manipulations may be aimed at conflict, antagonism, shocking, destroying mind, triggering emotions, etc. Constructive provocation stimulates mentality, awakens thinking and conscience of society, and reveals the provocateurs’ intentions.

Safe De-Labeling of Patients at Low Risk of Penicillin Allergy in Denmark

Introduction: Penicillin allergy is suspected in 10% of hospital inpatients but can be disproved in 90% of cases. Direct oral provocation without preceding tests among low-risk patients has proven to be safe in studies of both children and adults and is gaining use across the world. The aims of this study were to investigate the rate of severe allergic reactions to direct oral drug provocation, without preceding tests, in penicillin allergy patients stratified to be at low risk, as well as to examine if these patients have barriers to penicillin allergy de-labeling and future use of penicillins. Methods: Adult patients referred to a university hospital allergy clinic with a suspected penicillin allergy were prospectively risk evaluated. Patients stratified to be at low risk were offered a direct oral provocation with a single-dose amoxicillin followed by 4 days of continued treatment. The same risk stratification criteria were applied to a larger retrospective cohort. Results: In the prospective study population, 202 patients had a direct oral drug provocation and 20 (10%) were positive. There were no cases of anaphylaxis or severe delayed hypersensitivity. Fifteen reactions were benign rashes with onset >1 day after initial dosing, and 13 of these were maculopapular rashes. The same low-risk criteria were applied retrospectively to patients in a drug provocation database, and 1,759 patients fulfilled the criteria; of these, 10% had positive provocations, and there were no cases of anaphylaxis or severe delayed hypersensitivity. De-labeled patients in the prospective study reported not to fear future penicillin intake, after prolonged provocation. Conclusion: The risk stratification criteria for identifying low-risk patients for the oral drug provocation test without prior skin testing were safe in terms of avoiding anaphylaxis or severe delayed hypersensitivity. Benign delayed skin reactions still occurred, and access to allergy advice and follow-up is necessary.

Clinical and diagnostic features of perioperative hypersensitivity to cefuroxime.

The Danish Anaesthesia Allergy Centre (DAAC) investigated 89 adult patients with suspected perioperative cefuroxime-associated hypersensitivity reactions between 2004 and 2013. The goals were to determine whether the time to index reaction after cefuroxime exposure could be used to implicate cefuroxime as the cause of the reactions and explore different test modalities in diagnosing cefuroxime hypersensitivity. Skin tests, in vitro tests, and titrated provocations were used to determine cefuroxime hypersensitivity. Patients were deemed cefuroxime positive on the basis of at least two positive tests and/or a positive provocation. One or more tests were positive for cefuroxime in 24 of 89 (27.0%) patients. One was only specific IgE positive and was deemed cefuroxime negative. Twenty-three (25.8%) were deemed cefuroxime positive. There were four specific IgE-, 4 histamine release test-, 13 skin test-, and 14 provocation positive patients. There were eight (34.8%) patients who were only provocation positive. Data on time to index reaction after cefuroxime exposure were available for 80 patients (22 in the positive group and 58 in the negative group), 22 of 22 (100%) of positive patients reacted in <15min vs. only 38 of 58 (65.5%) of negative patients. All patients with confirmed hypersensitivity to cefuroxime reacted within 15min of administration, but so did 65.5% of Cefuroxime negative patients, making timing of administration an unreliable predictor of causation in the perioperative setting. Provocations were always positive when carried out in skin test positive patients; however, eight patients had positive provocations only, highlighting the need for provocation in skin test negative patients.

MILK-SPECIFIC IMMUNOGLOBULIN E/TOTAL IMMUNOGLOBULIN E RATIO AS A PREDICTOR OF POSITIVE ORAL FOOD CHALLENGES IN CHILDREN WITH ALLERGY TO COW'S MILK

INTRODUCTION: Skin-prick test wheal size and serum-specific immunoglobulin E (IgE) levels are able to predict, to an extent, the presence of allergy to certain foods. Nevertheless, the predictive value of these markers is not enough to substitute for oral food challenges, which suggests the need for improvement. OBJECTIVE: The goal was to determine the prognostic value of specific IgE/total IgE (tIgE) ratio in patients with allergy to cow's milk by using receiver operating characteristic (ROC) analysis. METHODS: Thirty-four open challenges were performed in children with a mean age of 18.4 months (range: 10.3–69.2 months) who had a previously diagnosed IgE-mediated allergy to cow's milk to reintroduce milk into their diet. Specific IgE levels, assessed by ImmunoCAP fluorescence enzyme immunoassay (Pharmacia Corp, Bridgewater, NJ), were obtained, and skin-prick tests were performed just before the challenge. The specific IgE (f2)/tIgE ratio was evaluated as a potential predictor of a positive challenge and compared with f2 alone by using ROC analysis. RESULTS: Of 34 challenges, 6 (17.6%) results were positive. Prechallenge milk-specific IgE levels and the f2/tIgE ratio were significant predictors (Pf2 = .007; Pratio = .008) of a positive challenge outcome. After ROC analysis, f2 provided a discrimination (between positive and negative provocations) of 0.8601 (ROC area under the curve); however, the f2/tIgE ratio provided a significantly greater discrimination of 0.9464. Values of the f2/tIgE ratio that are &amp;gt;0.1121 provide a 100% diagnostic accuracy (probability of a positive provocation result). CONCLUSIONS: The f2/tIgE ratio may be a novel, promising predictor of positive oral food-challenge results and should be evaluated prospectively in a larger sample.

Effect of body mass index on response to methacholine bronchial provocation in healthy and asthmatic adolescents

A linkage between airway hyperreactivity and obesity could partly explain the prevalence of obesity in asthmatics. To test for such a linkage, we analyzed body mass index (BMI), pulmonary function, methacholine bronchial provocation, and asthma severity scores in 216 adolescents (aged 12-18 years), of whom 82 were healthy and 134 were asthmatic. Methacholine provocations in a subgroup of 36 subjects (healthy and asthmatic) enabled us to examine the effects of BMI on dynamic hyperinflation and ventilatory indices during induced bronchospasm. Age- and gender-specific BMI was higher in asthmatics (74 +/- 24%) compared to healthy subjects (61 +/- 28%, P < 0.002). General linear model analysis, in which baseline spirometric results were adjusted for gender, age, race, and height, showed opposing effects of BMI on expiratory flow in controls and asthmatics (P < 0.05), i.e., forced expired volume in 1 sec increased with BMI in controls (P < 0.02), but forced expiratory flow (FEF)(25-75%) decreased with BMI in asthmatics (P < 0.05). However, linear regression analysis showed no effect of BMI on the provocation dose for methacholine (PD(20)) in either controls or asthmatics, and there was no effect of BMI on asthma severity scores. Overweight (BMI >85th percentile) and nonoverweight subjects had similar degrees of dynamic hyperinflation during positive provocations, but overweight subjects had greater decreases in mean inspiratory flow (mean, 28% vs. 9%, P < 0.05). We conclude that our measurements support a relationship between overweight and baseline flow limitation, rather than a relationship between overweight and airways hyperreactivity, in the linkage between overweight and asthma during adolescence.

Allergic reactions to β-lactams – in vitro and in vivo diagnosis

Rationale Since β-lactams allergy diagnosis is important to prevent allergic reactions we evaluated in vivo and in vitro methods contribution to β-lactams allergy diagnosis. Methods Sixty patients were evaluated having immediate allergy, after penicillin or β-lactams administration. All patients were evaluated with: 1-skin tests (PPL- benzylpeniciloyl-polylysine, MDM-minor determinants mixture, penicillin G, amoxicillin, ampicillin, cephalosporins); 2-Specific IgE (penicillin G, penicillin V, amoxicillin, ampicillin; 3-CAST (PPL, MDM, penicillin G, penicillin V, amoxicillin, ampicillin, cephalosporins). Sixteen patients have performed provocation tests to the relevant drug. Correlation analysis was performed using Spearman coefficient. Results Positive skin tests to at least one drug were identified in 25 patients, CAST revealed positive results to at least one drug in 26 patients, of which 16 have already had positive skin tests. All 4 patients with positive specific IgE had positive skin tests. Positive provocations were observed in only 4 patients, all having doubtful skin tests. The other 12 provocations were negative, all in patients with negative skin tests. As to skin tests, statistical analysis has revealed a good correlation between PPL and penicillin (rho=0,522 p<0,01), amoxicillin ( rho=0,403 p<0,01) and ampicillin ( rho=0,362 p<0,005). PPL test correlates very well with PPL CAST (rho=0,439 p<0,001). Conclusions Simultaneous evaluation of skin tests and CASTs, turned up to be useful to establish β-lactams allergy diagnosis, enabling to enhance diagnosis sensitivity. As negative skin tests were associated with negative provocations, it is suggested to use provocations tests only in patients with doubtful skin tests.

Outcome of double-blind, placebo-controlled food challenge tests in 107 children with atopic dermatitis.

Little is known about late phase clinical reactions during oral food challenges and the value of specific IgE in terms of sensitivity and specificity. We therefore analysed retrospectively the clinical outcome of 387 oral provocations during double-blind, placebo-controlled food challenge tests in 107 children with atopic dermatitis. Eighty-seven (81%) children showed a positive clinical reaction to at least one challenge. The vast majority of children (94%) showed clinical symptoms to one or two allergens. One hundred and thirty-one of 259 (51%) of verum challenges and 1/128 (0.8%) placebo challenge were assessed as positive. Oral provocations with hen's egg showed the highest percentage of positive reactions (70%). Sensitivity of specific IgE to the four allergens tested was 90%, specificity 30%. Sensitivity of the parental history as a predictive factor was 48%, specificity 72%. Ninety-two of 131 (70%) children with positive verum provocations showed early reactions, 33 (25%) late and six (5%) combined early and late reactions. In 84/131 (64%) positive provocations one organ system was involved, while in 44 (34%) provocations two and in three (2%) challenges three organ systems were involved. Skin reactions were the most frequent clinical manifestation leading to positive reactions followed by gastro-intestinal and respiratory symptoms. There was no correlation between titration dose and specific IgE. The subgroup of non-sensitized children did not differ in terms of sex, age or titration dose from the total study population. Double-blind, placebo-controlled oral food challenges are helpful in distinguishing children with clinically manifested symptoms from those with food sensitization. Accurately identifying children with a clinical relevant food allergy may help to prescribe specific diets on a scientific basis, avoiding dietary limitations which may be unnecessary or even harmful.

Clinical reactions to systemic provocation with gold sodium thiomalate in patients with contact allergy to gold

In a double blind experimental study, 20 patients with a contact allergy to gold sodium thiosulphate were challenged intramuscularly with the chemically similar gold sodium thiomalate and with placebo. The most spectacular clinical reaction in the 10 patients given the active agent, was an epidermal and dermal flare up of healed patch-test reactions to the gold salts, as well as a high, but transient, rise in body temperature. Previous intradermal tests were similarly reactivated. In addition, toxicoderma-like rashes were observed in several cases, but a flare up of a previous contact dermatitis site was seen in one patient only. The specificity of the positive provocations was demonstrated.

Provocation of nonepileptic seizures by suggestion in a general seizure population.

Nonepileptic seizures (NES) are common and are often diagnosed at epilepsy centers by video-EEG recording of both spontaneous and suggestion-induced episodes, but no study has evaluated provocative testing in a general seizure population. We studied consecutive patients with a tentative diagnosis of epilepsy using saline provocation during video-EEG recording, suggesting that this could produce a typical seizure. Of 52 patients, 40% had no response, 23% had responses unlike their seizures, and 37% had typical episodes (positive test). Patients whose usual episodes resembled complex partial seizures (CPS) were more likely to have NES than were patients with a history of generalized tonic-clonic seizures (GTC). Of patients with positive provocations, the primary physician predicted NES in 68% of cases. This preliminary study suggests that NES are frequent in a general neurology setting, and that saline provocation is a sensitive method of identifying NES.

Basophil histamine release in the diagnosis of house dust mite and dander allergy of asthmatic children

The aim of the study is to compare the glass fibre-based basophil histamine release test with skin test (Phazet), RAST (Phadebas) and bronchial provocation test in children with allergic asthma. The study comprised 68 selected children with a case history of extrinsic allergic asthma to danders (cat and dog) and house-dust mite. Skin prick test, RAST, and histamine release were performed in all children and the bronchial provocation test was used as a reference of "true allergic asthma". A total of 81 allergen bronchial challenges were performed and 44 children experienced 49 positive provocations. In 2.9% (2/68) of the children histamine release could not be performed due to technical difficulties (low histamine release with anti-IgE). Concordances in the range 76-87% were observed with no significant difference between the tests. The highest concordance (87%) was found between histamine release and bronchial provocation test followed by skin prick test vs bronchial provocation (84%) and RAST vs bronchial provocation (80%). The sensitivity and specificity were calculated for each test. All tests showed sensitivities in the range 90-94% and no significant difference between them was observed. The specificity of histamine release, skin prick test, and RAST was 0.78, 0.69, and 0.63, respectively. The specificity of histamine release was better than RAST demonstrated by 95% confidence intervals. In conclusion, it was found that the histamine release test is a convenient diagnostic method and the study indicates a diagnostic value comparable to the common diagnostic methods in clinical allergy.

Immunoglobulin E and immunoglobulin G4 antibodies to cow's milk in children with cow's milk allergy.

The presence of cow's milk specific antibodies of immunoglobulin E and G4 classes were studied in 47 children with a positive clinical history of cow's milk allergy. The children were challenged with cow's milk orally. The clinical diagnosis was verified by immediate reactions in 25 patients while 22 had late reactions or were provocation test negative in spite of the clinical history. There was no relation between levels of cow's milk specific IgG4 antibodies and provocation test results, i.e. neither with immediate or late reactions. Total IgE was elevated above +1 SD for age in 31 of 41 tested patients. Of these, 29 had immediate type reactions to cow's milk, wheat flour and/or egg white, while only two of 10 children with IgE of less than +1 SD had a demonstrable allergy to any of these foods. The sensitivity of the total IgE determinations for the diagnosis of food allergy was 94% and the specificity was 80%. Specific IgE antibodies to cow's milk were demonstrated in 11 of 14 children with immediate reactions and in three of 15 who were provocation test negative or had only late reactions. This means a sensitivity of 79% and a specificity of 80%. At least one of the four patients with specific IgE but negative provocation test results had earlier shown an immediate reaction when challenged with cow's milk, indicating that the specific IgE antibodies were not truly "false" positive reactions but a consequence of previous allergy. Our results confirm an association between elevated total serum IgE and food allergy and an association between positive RAST to cow's milk and positive provocations in young children. We did not find any evidence for specific IgG4 antibodies playing a role in these patients.

The radioallergosorbent test (RAST) in the diagnosis of reaginic allergy

SummaryProvocation tests, skin tests, and RAST were performed in 156 asthmatic children, using eleven different allergens (moulds, animal danders, and pollens). A total of 305 positive and 676 negative provocation tests were performed. For positive provocations there was an overall agreement with RAST in 61% of the instances, for negative bronchial tests in 94%. The agreement was found to be allergen dependent. By combining RAST and skin tests, it was possible to arrive at a conclusive allergy diagnosis in a higher number of instances than if either skin testing or RAST was used alone, but in a considerable number of instances provocation tests were found to be necessary to secure the allergy diagnosis. The results obtained with RAST in this study were less favourable than those of other studies, probably because of the use of lower quality allergosorbent material.