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Background: Anaphylaxis is an acute generalized hypersensitivity reaction initiated by various triggers which involves the entire organism and which may be life threatening. Although international guidelines for the emergency treatment of anaphylaxis have been published, the therapeutic recommendations are implemented differently. In this study besides the etiology of anaphylaxis, we were interested in how and where the patients have been treated and whether or not this reaction did occur for the first time. Methods: From January 1 to December 31 of 2008 1,075 patients have been referred to the allergy unit of the communal hospital in Berne (Zieglerspital) for an allergological work-up. 54 (5.0%) of them had had an anaphylaxis defined as shock, drop of blood pressure or collapse. The examination consisted of a detailed history and a comprehensive allergological assessment. Results: The average age of the 54 patients ― 28 women (52%) - was 43 years. In 46 (85%) of them the cause for anaphylaxis was a Hymenoptera venom allergy. Other triggers were: drugs [3], exercise-induced [2], multi-factorial [2] and food [1]. 20/54 subjects (37%) had a recurrent systemic reaction; all of them were allergic to Hymenoptera venom. 6 of them (30%) possessed emergency medications (antihistamines/corticosteroids); none of them had an epinephrine-autoinjector. 48/54 patients (89%) have been treated in a hospital or by the emergency doctor; 2/6 were supported by family members, and 4 recovered spontaneously. For therapy most often corticosteroids (92%) and antihistamines (89%) were used; epinephrine, however, only in 9 cases (17%). Conclusion: This investigation shows that emergency treatment of anaphylaxis in the region of Bern does not concur with the advocated guidelines. Epinephrine as first-line therapy in anaphylaxis has been used rarely. More than one-third of the patients already had a previous allergic generalized reaction elicited by the same culprit (in our case hymenoptera stings). Only one-third of these carried emergency medications but none of them possessed an epinephrine-autoinjector.

Background: Approximately 20% of subjects with asthma experience an acute bronchoobstruction after ingestion of ASA/NSAID. In specialized clinics the inhalative broncho-provocation test (IPT) with L-ASA is a well-established method to confirm the diagnosis of aspirin-induced asthma (AIA). The objective of this investigation was to establish a new, short-during IPT with L-ASA as a diagnostic tool in an outpatient clinic. Method: In the years 2001 to 2005, 65 patients (35 F, 30 M, mean age 42 years (16 - 73 years), performed an IPT with L-ASS. Group 1 comprised 37 patients with asthma and nasal polyposis, Group 2 17 patients with asthma but without nasal polyposis, and Group 3 11 patients with only cutaneous symptoms after intake of aspirin/NSAID. The IPT was performed stepwise with 5, 15 and 40 mg L-ASA up to a cumulative dose of 60 mg. Patients with a negative IPT underwent an oral provocation test with aspirin. Results: In group 1 11/37 (30%), in group 2 6/17 (35%), and in group 3 none of 11 (0%) had a positive IPT. The threshold dose was in 13 out of 17 reactors (76%) ≤ 20 mg L-ASA. Except in 1 patient, the bronchial-obstructive reaction was well-reversible after the inhalation ofsalbutamol. 24 out of 48 patients with a negative IPT with L-ASA underwent consecutively an oral provocation test with aspirin. 4 of them reacted with mild clinical symptoms after a cumulative dose of> 500 mg ASA. Conclusion: Our modified schema of IPT with L-ASA up to a cumulative dose of 60 mg L-ASA is suitable for diagnosing an AIA in an ambulatory setting. The IPT with L-ASA is a sensitive and safe provocation test lasting about 3 h. A negative IPT at 60 mg L-ASA excludes a significant reaction following the intake of low-dose aspirin (100 - 300 mg), this information may be essential in the prophylaxis and treatment of cardiovascular diseases.

Intolerance reactions to local anesthetics are frequent complications in medical and dental offices, but true allergy to local anesthetics is very rare (< 1%). In this study, we aimed to characterize patients with recurrent - at least 2 - intolerance reactions to local anesthetics. All patients had negative skin tests to local anesthetics of the immediate (IgE-mediated) as well as of the delayed type (T cell-mediated), and all have been subcutaneously challenged with a local anesthetic. During the last 10 years, out of 477 patients with a history of intolerance reactions to local anaesthetics referred to us, 275 of them have been thoroughly tested for allergy, particularly to local anesthetics. Of 43 eligible patients, 36 could be interviewed and 23 of them agreed to new tests. Although many of the study patients experienced symptoms suggestive for a vagovasal reaction, they seemed not to have an overall higher tendency for psychovegetative dispositions. The clinical reaction of intolerance following local anesthetics was always of the same pattern. There was no evidence of an enhanced mast-cell releasability or tissue reactivity to specific and non-specific mast-cell stimulants, respectively, and basal serum tryptase level was within the normal range. Moreover, a negative challenge test with local anesthetics is no guarantee for recurrence of intolerance reactions to local anesthetics. Nevertheless, we are in agreement with the recommendation of other groups to do challenge tests in the diagnostic of intolerance reactions to local anesthetics. Based on our results, we consider pharmacological effects as the most likely explanation in subjects with recurrent episodes to local anesthetics resembling allergy. In contrast to allergy to local anesthetics, all patients recovered spontaneously within 30 minutes without any therapy.

The clinical impact of allergen tight mattress encasings has still been debated. Beside encasings, recommended measures include the use of HEPA filter in the vacuum cleaner, reducing the humidity by increased ventilation rate and weekly change of bed linen. Materials and methods: A double-blind, placebo-controlled crossover study was performed to evaluate the clinical efficacy of mattress covers (VarioProtect encasings, Sanders, Germany). We included 30 patients with rhinitis or asthma due to house dust mite allergy of which 26 completed the study. At an initial visit for evaluation of the inclusion criteria, patients received a hygrometer and were seen 4 additional times for blood sampling and delivery of the active cover and later the placebo cover (cotton cover) or vice versa. Both study phases lasted 9 - 11 weeks, the wash-out period in-between lasted 2 - 10 weeks to avoid any interference with pollen allergy. At the patients' homes, a study-independent person collected dust samples which were analyzed for house dust mite allergen using an immunodot assay with monoclonal antibodies against the house dust mite allergen Der p 1, Der f 1 and mite group 2. For the evaluation of allergen content, the sum of the 3 allergens was used. Serum eosinophil cationic protein was measured to define the underlying allergic inflammation. Subjective clinical complaints regarding rhinoconjunctivitis and asthma were asked using a standardized questionnaire by E. Juniper. All patients were informed to wash their bed linen weekly and to increase the level of air exchange. A score for medication intake was calculated and the sleeping comfort with the active or placebo covers was evaluated. Results: A statistically significant reduction of the allergen content from 1.43 μg/m 2 /2 min to 0.65 μg/m 2 /2 min was found after using the active cover, but not after using the placebo cover (1.49 μg/m 2 /2 min). The measurement of the relative humidity in the air revealed no change throughout the study. At the beginning of the study, 49.5% relative humidity was measured, at the end of the study in summer time 64.3% were measured. The clinical complaints did not significantly change comparing both groups (active/placebo or placebo/active). A carry-over effect could be excluded since baseline values were similar. Pooling all data for the subjective rhinitis score revealed a statistically significant decrease in all 26 patients receiving either placebo or active treatment. In 8 patients with an elevated serum ECP level (> 16 μg/l), an amelioration of rhinitis could be seen in the active phase compared to the placebo phase. In addition, 12 patients with asthma reported fewer symptoms using the active cover compared with the placebo cover. After the active cover phase, 6 of the 8 patients with elevated ECP had a lower level of ECP, while 6 patients with the placebo cover had a higher level of ECP (p < 0.025). The medication intake was reduced during the active phase as well as during the placebo phase. The general comfort using the active cover was good with the exception of some rustling. The data confirm the clinical efficacy of allergen impermeable covers: an allergen reduction as well as a clinical relieve can be achieved, whereby the patients with elevated ECP may be particularly susceptible to allergen avoidance measurements.

Whereas the efficacy of the specific immunotherapy (SIT) in pollen allergy has been established, its consequence on the pollen-associated food allergy particularly the oral allergy syndrome (OAS) is less clear. In a retrospective study, we investigated the effect of SIT with pollen extracts in pollen-allergic subjects on the OAS. In addition, we looked for factors that could be prognostic for the change of OAS. 72 subjects (39 male, 33 female with a mean age of 32 years) allergic to pollen with a concomitant pollen-associated food allergy, namely OAS, who have been treated for an average of 2,0 years by SIT were interviewed using a standardized questionnaire. For control served 40 individuals (17 male, 23 female; mean age 29 years) allergic to pollen and a pollen-associated food allergy (OAS) without SIT. 38 of 72 subjects (53%) treated with SIT had an improvement of their OAS. However, 23 (32%) claimed an unchangeable and 11 (15%) even an increase of the OAS. Of the controls, an improvement was realized in only 3 individuals (8%). 20 of them (50%) declared no change and 17 a worsening of the OAS. In conclusion, our results suggest that pollen-associated food allergy, specifically the OAS, can be reduced in more than half of the patients by SIT. On the other hand, in 15% of the SIT-treated collective an expansion of the spectrum of foods inducing symptoms was experienced. A successful development of the OAS by SIT seems to occur if patients are older than 20 years of age, have a clinical relevant birch pollen allergy and suffer from an intensive OAS. Failure regarding OAS seems more likely if SIT with birch pollen is combined with grass pollen extracts.