Specific Provocation Test Research Articles

Sublingual desensitization in children with congenital malformations and latex allergy

The frequency of latex allergy in children requiring multiple surgery ranges from 16.7% to 65%. The aim of this study was to investigate the safety and efficacy of latex desensitization in a group of 10 patients with a history of multiple surgical procedures and clinically manifested allergy to latex. We selected 10 children (female-male ratio = 5:5), aged 4-16 yr (mean +/- s.d.: 9 +/- 4), with a history of multiple surgical procedures, adverse reactions to latex and positive skin test to latex and/or specific immunoglobulin E (IgE). Latex allergy diagnosis was confirmed by specific provocation tests (cutaneous, sublingual, mucous, conjunctival tests). Rush (4-day) sublingual desensitization was performed with increasing doses of latex extract (ALK Abellò) under patients' tongue until the highest dose of 500 microg of latex. A maintenance therapy (10 drops of undiluted solution three times a week) was recommended. During the 2-yr follow-up mean values of specific IgG4 and IgE, eosinophilic cationic protein and total IgE did not show significant variations. Patients did not manifest any adverse effect during the rush phase and only two patients manifested mild local symptoms during the maintenance therapy. All the challenges showed a reduction in terms of percentage of positivity and mean scores. All the patients showed a reduction of the mean individual score (p < 0.001). Furthermore patients who needed dental examination or surgery underwent such procedures without the occurrence of symptoms. Our preliminary results show sublingual desensitization to latex can be an important therapeutic tool in the management of young allergic patients requiring multiple operations.

MARKERS IN BREATH CONDENSATE IN PATIENTS WITH OCCUPATIONAL ASTHMA AND RHINITIS

PURPOSE: Specific provocation tests are used to confirm diagnosis of occupational asthma or rhinitis. Decreases of FEV1 or nasal flow are considered to be main markers of positivity. Analysis of breath condensate brings more information for monitoring processes in airways during these tests.

L-arginine ameliorates the abnormal sympathetic response of the dysfunctional human coronary microvasculature.

A nitric oxide (NO)-related defect may contribute to abnormal coronary sympathetic responses that can cause ischemia in patients with endothelial dysfunction. Because L-arginine, the NO synthase (NOS) precursor, augments NO bioactivity, we hypothesized that L-arginine would improve dysfunctional coronary sympathetic responses. Eleven patients with atherosclerosis or its risk factors were challenged with the cold pressor test, a specific provocative test of cardiac sympathetic activity, after 3 separate and sequential intracoronary infusions, as follows: 1) Normal saline; 2) L-NMMA, a competitive inhibitor of NOS; and 3) L-arginine. Study patients exhibited abnormal microvascular responses with coronary vascular resistance (CVR) increasing by 22.3 +/- 9.7% (mean +/- 1 SEM), p < 0.01. In addition, the change in coronary blood flow (CBF) did not correlate with the change in rate pressure product (RPP), r = -0.29, p = NS, suggesting an uncoupling of CBF from cardiac work. In the presence of L-NMMA, the CVR response, 10.3 +/- 9.8%, did not differ from the baseline response, and there was no relationship between the changes in CBF and RPP, r = 0.13, p = NS. In contrast, L-arginine ameliorated the CVR response, -3.2 +/- 3.1%, p < 0.05 vs baseline response, and restored the normal correlation between the changes in CBF and RPP, r = 0.74, p < 0.01. L-arginine not only improved abnormal microvascular responses to sympathetic activation, but it also restored the coupling that normally exists between coronary blood flow and cardiac work. L-arginine warrants further investigation as a therapy for coronary artery disease.

Diagnóstico laboratorial do carcinoma medular de tiróide: calcitonina basal e testes de estímulo

A calcitonina é um hormônio secretado pelas células parafoliculares tiroideanas. O diagnóstico de carcinoma medular de tiróide (CMT) pode ser suspeitado a partir do encontro de níveis aumentados de calcitonina basal ou após testes de estímulos específicos. Neste sentido, a calcitonina caracteriza-se como um importante marcador tumoral para o diagnóstico e seguimento de pacientes portadores de CMT. Neste artigo, revisamos alguns tópicos referentes à utilidade da dosagem de calcitonina basal em pacientes portadores de nódulos de tiróide para rastreamento de CMT. Comentamos a respeito dos principais testes de estímulo para secreção de calcitonina disponíveis e finalizamos com algumas observações sobre os ensaios para dosagem de calcitonina.

Ulcerative Colitis, Seronegative Spondyloarthropathies and Allergic Diseases: the Search for a Link

Background: Allergic diseases and seronegative spondyloarthropathies are frequently observed in ulcerative colitis (UC). In this report we have investigated possible relationships between IgE-mediated allergic disease (AD), allergic contact dermatitis (ACD) and seronegative spondyloarthropathy (SpA) in UC patients at different grades and extensions of mucosa inflammation. Methods: Forty-five UC consecutive outpatients were graded according to clinical, endoscopic and histologic activity scores. SpA was diagnosed according to the European Spondyloarthropathy Study Group criteria. AD was detected by skin prick tests and confirmed by specific provocation tests, while ACD was diagnosed using the European standard series of patch tests. Thirty-seven patients' spouses or partners served as controls. Results: Fourteen patients and 1 control subject showed SpA ( P = 0.001). Diagnosis of rhinitis, conjunctivitis or asthma was made in 19 patients and in 5 controls ( P = 0.004), while ACD was found in 10 and in 4 ( P = 0.17), respectively. In UC, AD coexisted with SpA in 2 cases ( P = 0.01), AD with ACD in 1 case ( P = 0.03) and ACD with SpA in 5 ( P = 0.24). Conclusions: Notwithstanding the high frequency of AD and SpA found in UC, the concurrence of AD with SpA or ACD is an unusual finding, while SpA and ACD may coexist. These data suggest that, in UC, atopy and seronegative arthritis, as well as atopy and delayed-type allergy, are strongly polarized conditions tending to mutual exclusion. In UC, the presence of AD without SpA or ACD, and of SpA or ACD without AD may indicate subgroups of patients in which T-helper-2 cell or T-helper-1 cell responses predominate.

Allergy and Mucosal Eosinophil Infiltrate in Ulcerative Colitis

Background: Data on allergy in ulcerative colitis (UC) have led to conflicting conclusions without proving any causal association. In this report we have investigated the presence of allergy and its possible relation with chronic colonic inflammation in patients with UC. Methods: Fifty UC patients underwent clinical, endoscopic, and histologic evaluations. The allergologic study included family/personal history; prick/patch exposition to airborne, food, and contact allergens; total serum IgE; and quantification of eosinophils in peripheral blood and intestinal mucosa. Diagnosis of rhinitis, conjunctivitis, and asthma was confirmed by specific provocation tests. Fifty healthy subjects were studied as control group. Results: A higher prevalence of allergic symptoms was found in patients (56%) and their first-degree relatives (52%) than in controls (18% and 26%) (P < 0.0001; P = 0.008). In patients skin tests showed increased rates of immediate (54%) and delayed-type (20%) hypersensitivity compared with controls (30% and 6%) (P = 0.01; P = 0.03). Diagnosis of allergic IgE-mediated disease was made in 19 cases and 6 controls (P = 0.01), and allergic contact dermatitis in 10 and 3, respectively (P = 0.03). IgE levels were higher in UC patients than in controls (P = 0.02). No dose-response relationship was found between degree of colonic tissue eosinophilia and clinical, endoscopic, and histologic disease severity. The degree of colonic tissue eosinophilia was higher in the presence of skin reactivity to food allergens. Conclusions: UC patients frequently show several markers of allergy. In particular, our data suggest an association between ulcerative colitis, tissue eosinophilia, and type-I allergy.

Alvéolite allergique extrinsèque

Extrinsic allergic alveolitis (EEA) is a lung disease mediated by immunologic mechanisms and induced by repeated exposure to organic dusts. EAA in children are mostly observed around 10 years of age. Subacute clinical presentation is the most frequent. Diagnosis is based on simultaneous presence of most of the following arguments: exposure to a known risk factor, spontaneous improvement after cessation of the exposure, identification of specific precipitins, demonstrative aspects on X-ray and tomodensitometry, and CD8+ lymphocytosis in bronchoalveolar lavage. Lung biopsy and specific provocation test are rarely necessary for diagnosis. Treatment is based on total eviction from inhaled antigen and on oral corticosteroids in acute and subacute forms.

Cetirizine Reduces the Priming Capacity on Neutrophilic Polymorphonuclear Leucocytes of Lacrimal Fluid from Subjects with Allergic Conjunctivitis after Specific Challenge

The priming capacity on neutrophilic polymorphonuclear leucocytes (PMNs) of lacrimal (tear) fluid obtained from subjects with allergic conjunctivitis after a specific allergic challenge was investigated using a chemiluminescence technique before and after a 10-day treatment period with oral cetirizine (10mg twice daily). Lacrimal fluid was obtained at time 0 and 30 minutes after a specific conjunctival provocation test with ryegrass allergen from 12 subjects with allergic conjunctivitis. PMNs were obtained from healthy volunteers. Luminol-amplified chemiluminescence of PMNs activated with N-formyl-methionyl-leucyl-phenyl-alanine (fMLP) or phorbol myristate acetate (PMA) were evaluated in the absence or presence of lacrimal fluid. Lacrimal fluid induced a significant increase in the chemiluminescence response of fMLP-stimulated PMNs (p 0.5). Cetirizine treatment significantly reduced the effect of lacrimal fluid on PMNs. These data suggest a priming potency on PMNs of lacrimal fluid obtained from subjects with allergic conjunctivitis after a specific challenge, probably due to the presence of inflammatory mediators. Cetirizine treatment significantly reduces this priming capacity. This may be attributed to an inhibition of cellular recruitment and/or to a reduction in the release of mediators at the site of the inflammation.

Asthma and rhinitis in wooding workers.

We present some cases of rhinitis and asthma in wooding workers exposed to hard or soft woods. The specific provocation test confirmed the diagnosis of rhinitis in three patients and of asthma in four. Rhinitis was caused by oak, beech, and pine, while asthma was caused by obeche, chestnut, acacia, and iroko. Occupational exposure to the specific wood, before onset of symptoms (symptom latency) was shorter for patients with asthma. All seven patients with respiratory symptoms were nonsmokers; three were atopics and four, all with asthma, had nonspecific bronchial hyperreactivity. Twenty-four hours after the test, PD20FEV1 had decreased in two cases with rhinitis and two with asthma, although the data did not reach statistical significance (Wilcoxon matched-pairs test: NS). After the SBPT, blood eosinophils increased in two cases with rhinitis and three with asthma, and the data were at the limit of statistical significance (P = 0.046). The study confirms that not only hard essences, but also soft woods can cause respiratory symptoms, although the pathogenetic mechanisms are still unclear. A specific provocation test is still the best and sometimes only means of diagnosing wood asthma; standardized protocols with repeated measurements of nonspecific airway responsiveness and of eosinophils in the blood may be helpful for a better understanding of the pathogenetic mechanism and predisposing factors.

Mechanical tension in the median nerve. The effects of joint positions

Stretch tests are attractive in the diagnosis of nerve root or peripheral nerve lesion. Interpretation of the test results is often difficult since the distribution of tensile forces along the nerve caused by the test manoeuvre is not known. In this study the effect on median nerve tension of 22 positions of the arm was measured with ‘buckle’ force transducers. With the elbow in full extension and the hand in neutral position, altering the position of the shoulder significantly influenced tension in the proximal part of the median nerve; tension in the distal part was not influenced. With the shoulder in 90 ° abduction, dorsiflexion of the hand combined with an extended elbow resulted in an increased tension in both distal and proximal parts of the median nerve. Dorsiflexion of the hand combined with flexion of the elbow caused an increase in tension only in the distal part. At all sites of the median nerve the median nerve upper limb tension test caused a significantly higher tension than the radial and ulnar nerve upper limb tension tests. This study provides insight in the normal distribution of tensile forces along the median nerve and can have clinical consequences. For differentiating nerve root from peripheral nerve lesions a specific provocative tension test for the median nerve is advocated. The results of this study provide a theoretical basis for differentiating between lesions in the proximal and distal parts of the median nerve.

Asthma Management: Don't Forget Occupational Asthma-Reply

Donoghue emphasizes the importance of recognizing occupational asthma in the initial assessment of adult patients with airway hyperresponsiveness. The frequency of this disorder, its economic impact on both the employee and the employer, its resolution with proper diagnosis, and change in exposure to the substance(s) involved, demands consideration in any patient whose asthma may be associated with the workplace. His comments about diagnosing and, therefore, more properly treating patients with occupational asthma actually draw into focus the importance of uncovering any etiologic factor that is involved in acute or chronic asthma. This is the approach of allergists who are trained to take a detailed history, emphasizing provocative factors, whether at home, school, work, or play. In certain patients, appropriate tests, such as determining the presence of specific IgE antibodies and/or provocative tests with antigens, exercise, or cold air, can clarify or confirm a diagnosis. These evaluations can be important not

Allergic subjects express intercellular adhesion molecule — 1 (ICAMA or CD54) on epithelial cells of conjunctiva after allergen challenge

Background: Allergic inflammation can be experimentally reproduced in vivo in humans, by means of the conjunctival provocation test with allergen. The allergen stimulation triggers an early clinical response and an almost simultaneous cellular infiltrate. Among the factors that can contribute to the local cellular recruitment, we postulate a possible early involvement of CD54 in the development of inflammation caused by the allergic reaction. Methods: We used a sensitive immunocytochemical immunoenzymatic alkaline phosphatase-monoclonal antialkaline phosphatase technique to detect the possible expression of CD54 molecule on epithelial cells of conjunctiva in 15 allergic subjects and in 15 healthy individuals in basal conditions and after allergen challenge ( Parietaria judaica) during the off-pollen season. Results: At baseline all studied individuals did not evidence CD54 expression on epithelial cells; 30 minutes after allergen challenge, all the allergic individuals showed a marked expression of CD54 on conjunctival epithelium, whereas none of healthy subjects showed any CD54 expression. First, CD54 expression on conjunctival epithelium after specific provocation test appeared as a specific phenomenon occurring only in sensitized subjects; moreover, it is an immediate event concomitant with the local inflammatory infiltrate. Therefore conjunctival epithelium unexpectedly appeared to be more than a bystander in the allergic reaction; it may be perceived as an active participant interacting with the inflammatory infiltrate. Conclusions: These findings indicate that CD54 may play a central role in the allergic inflammation and strongly support the concept that maneuvers designed to interact with the adhesion machinery expressed on inflammatory cells and epithelium may be a helpful therapeutic approach.

Salbutamol plus beclomethasone dipropionate, but not salbutamol alone, completely prevent early and late asthmatic responses to allergen

The effect of a week treatment with inhaled salbutamol plus placebo (S+P) vs. salbutamol combined with beclomethasone dipropionate (S+BDP) on early and late asthmatic responses to inhaled allergen was studied in ten atopic patients in a randomized, double-blind, cross-over study. All patients had previously shown a dual type response to the specific bronchial provocative test (sBPT). Each patient performed two periods of treatment for a week, with a 15 day interval between them: (a) salbutamol 0.3 mg, tid + placebo; (b) salbutamol 0.3 mg+BDP 0.2 mg, tid; at the end of each treatment period, sBPT was performed and the last treatments were given 1.5-2 h before and 3-4 h after allergen challenge. S + BDP completely prevented both early and late responses to allergen, while S + P reduced but did not completely inhibit early and late responses. The difference between the two treatments was significant for early and late asthmatic responses. Non-specific bronchial hyperresponsiveness to methacholine was performed before each treatment period, after 6 days of treatment before sBPT and the day after sBPT at the end of the treatment period; there was only a mild increase in PD15FEV1 methacholine after 6 days of treatment with S + BDP in comparison with S + P treatment. These results suggest that salbutamol plus beclomethasone may be used effectively in the prophylaxis of early and late asthmatic reactions induced by allergen in sensitized subjects.

Pattern of Airway Response to Allergen Extract of &lt;i&gt;Phleum pratensis&lt;/i&gt; in Asthmatic Patients during and outside the Pollen Season

In order to evaluate the pattern of airway response to a specific bronchial provocative test (sBPT) with an extract of Phleum pratensis standardized in biological units (BU), we studied 27 patients with seasonal asthma due to grass pollen by means of allergologic evaluations, methacholine inhalation test and sBPT, outside the pollen season in all patients and, in 10 of them, also during the pollen season. We used a DeVilbiss 646 nebulizer with a dosimeter, giving increasing doses (0.01-2.5 BU) of the allergen solution and we monitored FEV1 to assess early (EAR) and late (LAR) airway responses. Outside the pollen season sBPT elicited an isolated EAR in 16 and a dual asthmatic response (DAR) in 11 patients. We observed no significant difference between EAR and DAR patients as regards the provocative dose causing a 15% fall in FEV1 (PD15FEV1) methacholine, EAR (expressed by PD15FEV1 allergen) or allergologic data. There was a significant relationship between PD15FEV1 allergen and PD15FEV1 methacholine (r = 0.43, p less than 0.05). The reproducibility of sBPT was assessed in 11 patients outside the pollen season. The correlation coefficients between the two tests were: r = 0.91, p less than 0.001 for the total delivered dose of allergen during sBPT; r = 0.79, p less than 0.01 for PD15FEV1 allergen; r = 0.95, p less than 0.001 for the maximum percent fall in FEV1 during LAR. Ten patients repeated all tests during the grass pollen season. PD15FEV1 methacholine and baseline FEV1 decreased significantly during the pollen season, but PD15FEV1 allergen did not change significantly during the season.(ABSTRACT TRUNCATED AT 250 WORDS)

Laboratory Diagnosis of Hypopituitarism

Hypopituitarism can be caused by failure or loss of one or more of the eight identifiable hormones in the anterior lobe of the pituitary gland. The endocrine manifestations of hypopituitarism are related to the type and degree of hormonal deficiency and the stage in life during which the deficiency occurs. In patients with suspected hypopituitarism, the diagnostic approach consists of determining the extent and the cause of the hormonal loss. Specific provocative tests for the diagnosis of hypopituitarism are reviewed in detail in this article.

Clinical significance of specific IgE determination on nasal secretion.

The clinical use of RAST on the nasal secretions was investigated in seventeen atopic patients, with asthma or rhinitis, who had shown at a first diagnostic screening, some difficulties in the identification of the responsible allergen(s). The results of the skin tests, of the RAST on the serum and on the nasal secretions and of the specific provocation test (bronchial or nasal) were compared. In some cases the basophil degranulation test was performed. The results of the RAST on the nasal secretions were in perfect agreement with the provocation test. The skin tests and the RAST on the serum showed many discrepancies, particularly for Dermatophagoides, epidermal derivatives of cat and dog and moulds, and less frequently for Graminaceae and other pollens. It is concluded that RAST analysis on nasal secretions is useful in clinical diagnosis of allergy especially for Dermatophagoides, epidermal derivatives and moulds. Most false positive results were observed with the RAST on serum; in fifteen cases it was positive, while all the other tests, basophil degranulation test included, were negative. The data suggest that IgE may have a low affinity for basophil receptors.