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Background: The skin prick test (SPT) is the cheapest, most widely used and practical method for the diagnosis of allergic diseases. The results of repeat test might show variations due to aging. Objective: To perform repeat SPTs to determine possible changes in the atopy rate in general as well as changes in the allergen spectrum of atopic patients occurring over time and to identify the factors that could affect this change. Methods: A total of 222 patients who received a diagnosis of bronchial asthma and/or persistant rhinitis in our Adult Allergy Unit and who attended follow-up visits in the outpatient unit over a 2-year period were enrolled. SPT with 10 visit common aeroallergens were performed at the first and the second test was performed after an interval of at least 2 years. Results: The mean age was 36.4 ± 11.4 years and 77.5 % of the patients were women. The mean interval between the two tests was 43.4 ± 20.0 (minimum = 24-maximum = 105) months. Repeat tests showed that the atopy rate decreased from 58.6 % to 47.7 %; sensitivity rates to 10 allergens also decreased. These differences were statistically significant (p < 0.05). Conclusion: The atopy rate determined by SPTs tends to decrease over time. The most important factor affecting this decrease is time itself.

Background The aim of the study was to investigate the prevalence of food allergy in patients referred to our Allergy Unit and to evaluate the diagnostic methods used. Methods We selected 674 patients referred to the Allergy Unit of our hospital from May 2002 to October 2004. The prevalence of symptoms was determined by a standardized questionnaire, prick-prick test, and serum specific IgE. In a second phase, double- blind oral challenge tests were administered. Results Food allergy was found in 106 patients (15.7%): 71 adults (67 %) and 35 children (33 %). The prevalence of food allergen sensitization was 14 % in adults and 20.8 % in children. A total of 89.6 % of the patients experienced symptoms immediately. Only 29.2% the patients of sought medical attention and adrenaline was administered to five (16.1 %). The foods most frequently involved in allergic reactions were fruits (56.6%) and tree nuts (22.6%).The most common symptoms were oral allergy syndrome (46.2 %), urticaria (32.1 %), and anaphylaxis (14.2 %). Combining the results of the questionnaire with those of prick-prick tests in patients whose allergy was confirmed by double-blind, placebo-controlled food challenge (9.1 %) showed a sensitivity of 95.5 %, a negative predictive value of 96 %, a specificity of 75 % and a positive predictive value of 73%. Conclusions 1. The prevalence of food allergy in our sample was 9.1 %. 2. The foods most frequently involved in allergic reactions were fruits and tree nuts. 3. The most common symptoms were oral allergy syndrome, urticaria, and anaphylaxis. 4. Combining our questionnaire with in vivo tests allowed us to diagnose 75-96% of patients with no food allergy and 95 % of food allergy patients.

Background In the 1990s, the Japanese Society of Allergology (JSA) standardized Japanese cedar pollen allergen vaccines. In the present study, the task force for house dust mite (HDM) allergen standardization of the Committee for Allergens and Immunotherapy of JSA reports the standardization of HDM allergen vaccines in Japan. Methods In vivo allergenic potency was determined by intradermal testing of 51 Japanese adults with positive serum specific IgE to HDM allergens. In vitro total IgE binding potency was analyzed by competition ELISA using a pooled serum, with sera obtained from 10 allergic patients. The amounts of HDM group 1 (Der 1) and group 2 major allergens in eight HDM allergen extracts were measured by sandwich ELISAs. Correlation between the in vitro total IgE binding potency and major allergen levels was analyzed. Results We selected a JSA reference HDM extract and determined its in vivo allergenic potency. The in vitro total IgE binding potency significantly correlated with Der 1 content, group 2 allergen content, and their combined amount, indicating that measurement of major allergen contents can be used as a surrogate in vitro assay. Conclusions The task force determined the in vivo allergenic potency (100,000 JAU/ml) and Der 1 content (38.5 μg/ml) of the JSA reference HDM extract, selected the measurement of Der 1 content as the surrogate in vitro assay, and decided that manufacturers can label a HDM allergen extract as having a titer of 100,000 JAU/ml if it contains 22.2–66.7 μg/ml of Der 1.

The frequency of allergies to particular foods in adults has never been documented over time. Therefore, it is not possible to give evidence about a possible shift in the spectrum of food allergens over the years. There are periodic analyses of the patients of the Allergy Unit of the Department for Dermatology at the University Hospital of Zurich that were diagnosed with food allergies between 1978 - 1998. Detailed data about food allergens are taken from previous published data. In order to detect trends in food allergens, the yearly frequency of food, responsible for systemic allergic reactions among food allergic patients diagnosed in these publications, is calculated for the observation period. Between 1978 - 1982: 173, between 1983 -1987: 229, between 1990 - 1994: 383 and in the year 1998: 87 patients have been evaluated to have a food allergy. Over the entire observation period of 20 years, celery root was the most frequent allergen. The frequency of carot allergy was stable, but - in respect to celery - over all relatively low. Since the 90s, a marked increase of the following food allergies can be observed: allergies to peanuts and soy, which are both "legumes", as well as to nuts (hazelnuts and almonds), exotic fruits (kiwis and bananas), and, in the year 1998, to crustaceans. The possible explanations for these findings, for example an increase of pollen allergies and, consequently, of pollen-associated food allergies (birch fruits vegetables nuts syndrome, mugwort celery spices syndrom), the "latex fruit syndrome", the fast advancing and globalization of the American fast food culture (peanuts), among others are discussed.

Background Although subjects with a positive history of immediate allergy to penicillin and negative skin test are traditionally considered to tolerate penicillin, current evidence indicates that they may develop an immediate reaction despite negative skin and serum specific IgE tests. It is thought that these patients require additional tests to confirm the diagnosis. Objective To assess in a large group of patients with a history of immediate allergy to penicillins but with both skin test and CAP-FEIA-negative to classical and side chain penicillin determinants, the role of controlled administration of betalactams as a diagnostic test. Methods A group of 330 patients with a history of immediate allergic reactions to penicillins was studied by two evaluators from the same allergy unit using the following protocol: skin tests with major and minor determinants of benzylpenicillin (benzylpenicilloyl-poly l-lysine and minor determinant mixture), amoxicillin and ampicillin, and determination of specific IgE antibodies to penicillins, by CAP-FEIA, in serum. If both tests proved negative, a controlled administration of the drug was then carried out. Results A total of 89 (27%) patients were skin test and CAP-FEIA-negative and therefore required controlled administration of the drug. Of these, 49 developed an immediate response and were therefore considered allergic, and the remainder had good tolerance after administration of both benzylpenicillin and amoxicillin. The clinical characteristics of this group were similar to the other allergic patients who were skin test or CAP-FEIA-positive, except that they were younger (P

Background The drug provocation test (DPT) is the gold standard to rule out drug hypersensitivity. There are standardized DPT protocols to diagnose immediate reactions to drugs, but not for nonimmediate reactions. Objective The aim of this study was to show the sensitivity and specificity of an allergy work-up that included a 5-day DPT in children with histories of nonimmediate reactions to amoxicillin through focusing on a pediatric population with histories of immediate and nonimmediate reactions to amoxicillin. Methods Two hundred consecutive patients with histories of amoxicillin reactions referred to the Allergy Unit of Anna Meyer Children's Hospital for suspected drug allergy from 2008 to 2011 underwent in vivo tests with the culprit drug according to European Academy of Allergy and Clinical Immunology guidelines. Moreover, most of those children, regardless of the skin tests results, were challenged with amoxicillin for a total of 5 days. Results In 4 years, 200 patients were evaluated for a history of drug hypersensitivity to amoxicillin. The majority of patients (76%) had a history of mild nonimmediate reactions. All 200 patients underwent skin tests, and 9 of 200 tested positive. A total of 177 DPTs were performed with amoxicillin for 5 days in each child. Diagnosis of amoxicillin allergy was confirmed by a DPT in 17 patients (9.6%); 14/17 had history of nonimmediate reactions; 4/14 (26.6%) reacted on day 5. Conclusion According to our results, a long-term DPT protocol increases the sensitivity of the allergy work-up, and it should be recommended for patients with a history of amoxicillin nonimmediate reaction.

Objective The diagnostic work-up of a drug hypersensitivity reaction is indeed difficult. In general, medical documentation of allergic reactions in medical reports is usually highly deficient or non-existent. The aim of this study was to analyse the prevalence of self-reported drug allergies in the surgical population as well as the criteria used in the diagnosis of drug hypersensitivity reactions. Methods A prospective study with the consecutive participation of 1439 patients, following surgical intervention, attended the Post-Operative Care Unit. Previously, as a routine process during the pre-anesthesia consultation, all patients were questioned about whether they had any drug allergies to report and diagnostic work-up. Results The prevalence of self-reported drug allergies was 8.3% (119/1439): 3.6% considered themselves allergic to β-lactams and 2.4% to non-steroidal anti-inflammatory drugs. Approximately one-third of the subjects (40 out of the 119) had not been subjected to any allergy diagnostic procedure and with 79 (66.4%), the only diagnostic test used by the Allergy Unit had been the skin prick-test. None of those participating in the study had tryptase, methylhistamine, specific IgE or intradermal tests carried out to characterize the diagnosis of the allergic reaction. Conclusions These results show that self-reported drug allergies are highly prevalent and as yet little explored. It is an important prevalence which should bring about modifications to the prescription of certain medicaments. The medical personnel must be made aware of the need to make an accurate diagnosis of allergies to medicaments.

ABBREVIATIONS AAAAI: American Academy of Allergy, Asthma and Immunology AU: Allergy Unit BAU: Bioequivalent Allergy Unit BU: Biologic Unit CBER: Center for Biologic Evaluation and Research EAACI: European Academy of Allergy and Clinical Immunology EU: European Union IAACI: International Association of Allergy and Clinical Immunology IU: International Unit IUIS: International Union of Immunological Societies PNU: protein nitrogen unit

S A T U R D A Y Inmaculada Do~ na, MD, PhD, Francisca G omez, MD, PhD, Tahia D. Fernandez, PhD, Adriana Ariza, PhD, Arturo Ruiz, MD, Maria Isabel S anchez Rivas, Cristina De Leyva, Maria Isabel Monta~nez, Antonio Guzman, Miguel Blanca, MD, PhD, Maria J. Torres, MD, PhD; Allergy Service, IBIMA-Regional University Hospital of Malaga-UMA, M alaga, Spain, Allergy Unit, IBIMA-Regional University Hospital of Malaga, M alaga, Spain, Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Malaga, Spain, Allergy Unit, Regional University Hospital of M alaga-IBIMA, UMA, M alaga, Spain, Allergy Unit, Regional University Hospital of Malaga-IBIMA, UMA, Malaga, Spain, Research Laboratory, IBIMA, Regional University Hospital of Malaga, UMA, Malaga, Spain, Pharmacy Unit, Regional University Hospital of Malaga-IBIMA, UMA, M alaga, Spain, Allergy Unit, Regional University Hospital of M alaga, IBIMA, UMA, M alaga, Spain. RATIONALE: Pyrazolones are the most common cause NSAIDs hypersensitivity. We studied a large group of patients with immediate and nonimmediate selective responses (SR) to dipyrone. METHODS: Patients with suspiction of hypersensitivity to dipyronewere evaluated. We verified acetilsalicilic acid-tolerance and classified patients as immediate or non-immediate responders if they showed symptoms less or more than 1hour after dipyrone administration. Skin tests were performed and if negative, basophil activation test (BAT) for immediate responders. If negative results, we performed drug provocation test (DPT) with dipyrone. RESULTS: A total of 137 patients were included: 114 reacted within one hour (single NSAID-induced urticaria/angioedema/anaphylaxis; SNIUAA); 23 after one hour (single-NSAID-induced delayed hypersensitivity reactions; SNIDHR). More specifically, 73.72% reacted within 30 minutes; 9.48% 30-60 minutes; 6.56% 1-2 hours; 3.64% 2-8 hours and 6.56% after over 24 hours. Most SNIUAA patients developed anaphylaxis (66.66%, p50.0001); for SNIDHR urticaria was more frequent (52.17%, p50.014). Skin testing was positive for 62.04% of all cases and BAT for 35.89% of SNIUAA patients with negative skin tests. In 5.1% cases DPT with dipyrone was needed. In 22.62% of cases DPT was not indicated, being diagnosed by repeated allergic episodes in spite of negative skin and BAT. CONCLUSIONS: SNIUAA to dipyrone is the most frequent group with anaphylaxis being the most common clinical entity. It may occur with interval longer than 1hour. The SNIDHR occur in a very low percentage. The low sensitivity of diagnostic tests may be due to incomplete characterization of the chemical structures of dipyrone and its metabolites.

S A T U R D A Y Inmaculada Do~ na, MD, PhD, Francisca G omez, MD, PhD, Tahia D. Fernandez, PhD, Adriana Ariza, PhD, Arturo Ruiz, MD, Maria Isabel S anchez Rivas, Cristina De Leyva, Maria Isabel Monta~nez, Antonio Guzman, Miguel Blanca, MD, PhD, Maria J. Torres, MD, PhD; Allergy Service, IBIMA-Regional University Hospital of Malaga-UMA, M alaga, Spain, Allergy Unit, IBIMA-Regional University Hospital of Malaga, M alaga, Spain, Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMA, Malaga, Spain, Allergy Unit, Regional University Hospital of M alaga-IBIMA, UMA, M alaga, Spain, Allergy Unit, Regional University Hospital of Malaga-IBIMA, UMA, Malaga, Spain, Research Laboratory, IBIMA, Regional University Hospital of Malaga, UMA, Malaga, Spain, Pharmacy Unit, Regional University Hospital of Malaga-IBIMA, UMA, M alaga, Spain, Allergy Unit, Regional University Hospital of M alaga, IBIMA, UMA, M alaga, Spain. RATIONALE: Pyrazolones are the most common cause NSAIDs hypersensitivity. We studied a large group of patients with immediate and nonimmediate selective responses (SR) to dipyrone. METHODS: Patients with suspiction of hypersensitivity to dipyronewere evaluated. We verified acetilsalicilic acid-tolerance and classified patients as immediate or non-immediate responders if they showed symptoms less or more than 1hour after dipyrone administration. Skin tests were performed and if negative, basophil activation test (BAT) for immediate responders. If negative results, we performed drug provocation test (DPT) with dipyrone. RESULTS: A total of 137 patients were included: 114 reacted within one hour (single NSAID-induced urticaria/angioedema/anaphylaxis; SNIUAA); 23 after one hour (single-NSAID-induced delayed hypersensitivity reactions; SNIDHR). More specifically, 73.72% reacted within 30 minutes; 9.48% 30-60 minutes; 6.56% 1-2 hours; 3.64% 2-8 hours and 6.56% after over 24 hours. Most SNIUAA patients developed anaphylaxis (66.66%, p50.0001); for SNIDHR urticaria was more frequent (52.17%, p50.014). Skin testing was positive for 62.04% of all cases and BAT for 35.89% of SNIUAA patients with negative skin tests. In 5.1% cases DPT with dipyrone was needed. In 22.62% of cases DPT was not indicated, being diagnosed by repeated allergic episodes in spite of negative skin and BAT. CONCLUSIONS: SNIUAA to dipyrone is the most frequent group with anaphylaxis being the most common clinical entity. It may occur with interval longer than 1hour. The SNIDHR occur in a very low percentage. The low sensitivity of diagnostic tests may be due to incomplete characterization of the chemical structures of dipyrone and its metabolites.

Background The constant increase in the elderly population worldwide has led to a greater interest in immunologic responses during aging. Thus, special attention to allergic diseases in elderly people has begun to emerge, but little is known about the effect and features of allergic rhinitis in elderly people. Objective To evaluate the clinical and cytologic characteristics of respiratory allergy and its impact on the quality of life in elderly people. Methods Elderly patients with rhinitis referred to our allergy unit during a 3-month period underwent clinical evaluation and responded to the Rhinasthma Questionnaire. All patients also underwent skin prick testing, measurement of total IgE level, and nasal cytologic analysis. The data were compared with a control group of young adults. Results Fifty-four patients older than 65 years (mean age, 69.3 years) and 89 young adults (mean age, 26.3 years) with allergic rhinitis were studied. The elderly patients had a less positive family history of atopy ( P =.02) and had rhinitis plus conjunctivitis more frequently ( P =.002) than young adults, whereas the difference between groups in total IgE level was not statistically significant. On nasal cytologic analysis, the differential count of inflammatory cells did not differ between groups, but in the elderly patients the epithelial-goblet cell ratio was decreased. The quality of life in elderly people was more impaired than in young adults ( P =.01). Conclusion In elderly people with allergic rhinitis, the clinical characteristics are different and quality of life is more heavily impaired compared with young adults.

Hymenoptera venom allergy is a growing problem in Spain. This problem has a special relevance in areas where population is frequently exposed to hymenoptera stings, being paediatric patients a high risk population. Immunotherapy with hymenoptera venom is an effective and safe treatment for these patients. However, there is a lack of data on the role of this treatment on paediatric population. For this reason, from the data base of the Allergy Unit from Hospital Xeral (Lugo, Spain) which includes 560 patients, have been analyzed the 21 paediatric patients, all of them treated with venom immunotherapy. Eighteen patients completed the treatment. The maintenance dose administered was 100 microg. Two systemic reactions (both with an Apis extract) were registered. Cutaneous test and specific IgE shown a statistical significant reduction at the end of treatment (p =.0004 and p.0001 respectively). Seven patients (33 %) suffered a spontaneous re-stung during maintenance phase or after immunotherapy was completed. In 4 patients there was no allergic reaction and the other 3 children suffered a mild local reaction. In conclusion, venom immunotherapy is a safe and effective treatment in paediatric patients with hymenoptera venom allergy, being necessary to increase the experience on this specific segment of the allergic population.

Allergy to fruits belonging to the Rosaceae family is common in the adult population of the Mediterranean area, with peach and apple being the fruits more frequently responsible. The main allergenic proteins involved are Bet v 1 omologues, profilins, and lipid transfer proteins (LTPs) (1, 2). Plant LTPs are basic polypeptides of 9 kDa (91–95 amino acid), which have been identified as relevant allergens in several foods and pollens (3). Of note, LTPs are highly resistant to both gastric digestion and heat, and seem therefore to be associated to more severe and/or systemic symptoms, and capable of inducing sensitization in fruit-allergic patients without an associated pollinosis (4). This study was aimed to verify whether the severity of the clinical reactions to peach fruits is associated to sensitization towards allergenic LTP molecules, namely the LTP Pru p 3, the Bet v 1-related protein Pru p 1, and the profilin Pru p 4. Among outpatients referred to our Allergy Unit, subjects with adverse reactions due to the ingestion of fresh peaches and/or peach juices were identified. Those patients were divided, according to the severity of reaction into: subjects with systemic symptoms including urticaria, angioedema, asthma rhinitis or anaphylaxis and subjects with oral allergy syndrome (OAS) only. A control group of patients with respiratory allergy and no symptom of food allergy was also included. All patients underwent a complete diagnostic work-up including skin prick tests with a panel of common food/ inhalant commercial extracts and CAP assay (Phadia Diagnostics, Milan, Italy). The CAP assay was carried out with the following recombinant (r) or natural (n) allergens: rBet v 1, rBet v 2, rBet v 4, rPhl p 1, 2, 5b, 6, 7, 11, 12, nPhl p 4, rArt v 1, rPar j 2, rAmb a 1, rAlt a 1, rFel d 1 and Dermatophagoides pteronissinus extract. A statistical analysis was carried out in order to verify if the three groups of patients displayed significant differences in the LTP-specific IgE. Forty-six patients were studied, according to the criteria mentioned above. Seventeen patients (mean age 25.8 years, 7 male, total IgE 722 ± 101 kU/l) had systemic symptoms with peach, 12 patients (mean age 26.9 years, 8 male, total IgE 408 ± 280 kU/l) had OAS, and 17 subjects (mean age 29.1 years, 6 male, total IgE 311 ± 180 kU/l) suffered from respiratory allergy. Only the concentrations of Pru p 3 specific IgE were significantly higher in the 17 patients with systemic reactions after fruit or fruit-juice ingestion, than in patients with OAS and patients with respiratory allergy, as shown in Fig. 1. Six patients of the OAS group and four of the systemic symptoms group had measurable specific IgE to Pru p 4 (profilin), whereas a co-sensitization to Pru p 1 was present in four patients of the OAS group and three of the systemic symptoms group. Specific IgE to Par j 2 (another LTP) were detected only in three patients, two of whom were controls. A complementary observation was that specific IgE against Bet v 1 were detected in four of the patients with OAS. Those patients, in fact have had OAS also with cherry, apple or pear. LTPs are potent panallergens, and their biological activity is favoured by the resistance to heat and gastric digestion (5), since they can persist in the native form even in processed food such as fruit juices. Pru p 3, a compact protein stabilized by four disulfide bonds, has been identified as the major allergen of peaches (6), capable of inducing clinical symptoms in sensitised subjects. In the AL LERGY 2 0 0 9 : 6 4 : 1 7 9 5 – 1 7 9 8 • a 2009 JOHN WILEY & SONS A/S • CONTRIBUT IONS TO THIS SECT ION WILL NOT UNDERGO PEER REVIEW, BUT WILL BE REV IEWED BY THE ASSOCIATE EDITORS •

Two adult patients are described with severe intractable back pain of eight and 20 years standing, together with other musculoskeletal and systemic symptoms, including lethargy. Both had been extensively investigated and had had repeated admissions without alleviation. They were admitted to an allergy unit and investigations there found them to be allergic to a number of foods, chemicals and inhalants. Both improved rapidly on fasting and were discharged on oligoantigenic diets with neutralization therapy. On this they remained well, apart from infrequent reactions due to lapses from dieta

Methods This study was a retrospective analysis of cases of patients referred to the Allergy Clinic of Rio de Janeiro General Policlinic with records of suggestive of AR to BL, in the period between February 2011 and July 2014. All the patients observed ENDA protocol: specific questionnaire of adverse drug reactions, IgE specific for penicillin G and V, amoxicillin and ampicillin, followed by skin prick tests (SPT) and intradermal (ID) with penicillin and amoxicillin. Finally, the provocation test (DTP) was carried out with Amoxicillin, each step being followed from the previous negative result.

U E S D A Y 861 Efficacy and Safety of Chitosan Coated Garments on Atopic Dermatitis Management: A Randomized Controlled Trial Cristina Lopes, MD, Jose Soares, Freni Tavaria, Milton Severo, Ana Duarte, MD, Osvaldo Correia, MD, Manuela Pintado, Luis Delgado, MD, Andre M. Moreira, MD; Laboratory of Immunology, Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Portugal, Porto, Portugal, Allergy Unit, Pedro Hispano Hospital, Matosinhos, Portugal, Biology and Fine Chemistry Unit, Biotechnology Faculty, Catholic University, Porto, Portugal, Biology and Fine Chemistry Unit, Biotechnology Faculty, Catholic University, Portugal, Medical Faculty , Porto University, Porto, Portugal, Epidermis Dermatology Center , Instituto Cuf, Porto, Portugal, Epidermis Dermatology Center , Instituto Cuf, Portugal, Laboratory of Immunology, Basic and Clinical Immunology Unit, Faculty of Medicine, University of Porto, Porto, Portugal, Allergy and Clinical Immunology Department, Centro Hospitalar S~ao Jo~ao, EPE, Porto, Portugal. RATIONALE: Patients with atopic dermatitis (AD) may benefit from using textiles coated with antiseptic and skin repairing compounds. Chitosan, a natural biopolymer with inhibitory activity against Staphylococcus aureus and immunomodulatory properties has been considered potentially useful in AD management. METHODS: Patients with AD (were randomly assigned in a 1:1 ratio to receive either chitosan coated or placebo cotton long sleeved pyjamas for 8 weeks. Primary efficacy outcome was the change in severity scoring for atopic dermatitis index (SCORAD). Secondary outcomes were the number of patients withminimal clinically detected difference, change in quality of life, daily score of pruritus and sleep loss, need of rescue medication, number of exacerbations, of totally and well-controlled weeks and of adverse events . Microbiological outcomes from five skin regions included changes in number of colony forming units of total staphylococci, Staphylococcus aureus and respective ratio. Analyses were done on an intention-to-treat basis. RESULTS: Of the 102 patients screened, 78 were included aged 30613 years (mean 6SD), 61% female, 77% atopic, with AD for 16610 years . After intervention, patients in chitosan group had a mean relative reduction in SCORAD of 43.8% (95%CI: 30.9 to 55.9), compared with 16.5% (-21.6 to 54.6) in placebo (p5 0.82). Changes in secondary clinical outcomes were similar in both groups. No major imbalances in microbiological profile were observed after the intervention. CONCLUSIONS: Chitosan coated garments are safe for adolescents and adults with atopic dermatitis and reduceAD severity but with no significant differences from placebo.

Data in literature seem to show that, in patients with contact allergic dermatitis, dietary nickel might be a cause of systemic dermatitis, but little information exists in literature about the role of nickel sensitization and dietary nickel in patients with allergic-like chronic dermatitis syndromes. The prevalence of nickel sensitization in patients with chronic allergic-like, non-IgE-mediated skin diseases, and the possible impact of dietary nickel on symptom provocation and persistence has been assessed in the present retrospective study on a case series of 1726 patients referred to our allergy unit for chronic allergic-like skin diseases. IgE-mediated pathogenesis and other differential diagnoses excluded, patients were patch tested. Nickel-positive patients underwent an elimination diet and double-blind placebo-controlled nickel challenge (DBPCNC) test. A total of 339 (20%) tested nickel-positive. Fifty-two patients (15%) recovered by avoiding sources of nickel contact and 29 (10%) dropped out. Out of the remaining nickel-sensitized patients, 277 (80%) achieved complete or near complete recovery with low-nickel content diet, and 185 of them (89%) were positive to DBPCNC. We conclude that nickel sensitization and dietary nickel seem to be the chief trigger for provocation and persistence of symptoms in an important part (~11%) of patients with chronic allergic-like dermatitis syndromes.

Objective: This study aims at exploring the variance in resources used for management and treatment of asthma disease and analyzing the impact of patient and physician characteristics on total test expenditures and the number of drugs prescribed as resource utilization variables. Study setting: The study was undertaken in Hacettepe University Chest Diseases Polyclinic and Allergy Unit. 387 asthma patients visiting the unit between August 2000 and March 2001, were included in the study. Results: The regression analysis showed that patient characteristics did not have a statistically meaningful impact on total test expenditures (p > 0.05). The laboratory test expenditures for patients who referred to academicians (professors and associate professors) were higher compared to patients who referred to their counterparts (p < 0.05). Similarly, the laboratory test expenditures for patients referred to two physicians in the allergy unit were higher and statistically meaningful (p < 0.05) than patients who referred to 8 physicians in the chest diseases polyclinic. When factors affecting the number of drugs prescribed is analyzed it was found that duration of treatment, severity of disease, quality of life, frequency of referral to a physician in the last 6 months were meaningful (p < 0.05). Conclusions: The variances in total test expenditures for different academic careers and specialties indicate the need to standardize the treatment process for asthma and to reconsider medical education.

When a child presents with an allergic symptom, the general pediatrician needs to discriminate which patient has to be sent to the specialist for an allergologic evaluation. If referred, the child will undergo not only skin-prick test, but also more complex specialistic evaluations that we define here as "the march of allergic children." The objective of this article is to overview the clinical evidence about possible diagnostic interventions to avoid unuseful referrals of children reported with allergy from the general to the specialist level. Data sources include PubMed, using a search algorithm selecting for diagnostic studies of respiratory and food allergy in all children to August 2005. Also included are commentaries based on the authors' clinical experience in the allergy unit of a University Hospital in Italy. No study prospectively assessed the rule-out efficacy of clinical history, physical evaluation, and skin-prick test panels on the allergic disease. Three prospective studies on in vitro panels of specific IgE sensitization matched entry criteria. Diverse trial designs and diagnostic criteria precluded meta-analytic methods. The use of in vitro panels proved effective in ruling out the allergic condition in children. The screening efficacy of panels of food and respiratory skin-prick tests remains to be evaluated. With sensitivities and negative predictive values exceeding 90%, in vitro panels can inform the decisions of pediatricians in their capacity as gateway to specialist care. Avoiding the march of allergic children from the GPs to the secondary level is a more realistic goal than preventing the allergic march.

Objective: This review summarizes the research and clinical evidence in favour of dietary intervention aimed at eliminating allergenic foods in the management of atopic eczema/dermatitis syndrome (AEDS). Data sources: The data source was PubMed, using a search algorithm selecting for clinical studies of AEDS, diet therapy and food allergy in all children to October 2003. Also included is a commentary based on the authors' clinical experience in the allergy unit of a university hospital in Italy. Results: Fourteen prospective studies matched the entry criteria. Diverse trial designs, diagnostic criteria, types of dietary intervention and length of observation periods precluded meta-analytic methods. Allergenic food exclusion claimed efficacy in 13 of the 14 studies and was most useful in infants, in patients with elevated immunoglobulin E levels and/or multiple food sensitization and in patients with a diagnosis of food allergy. Conclusion: Dietary intervention in the form of an elimination diet is efficacious in children with AEDS when a specific diagnosis of food allergy has been made. Diagnostic evaluation of food allergy should be performed in all children with eczema, particularly in younger children and those with severe forms of the disease.

Objective: There is limited available literature on the incidence of allergic diseases in ED. The objective of this study was to investigate the clinical records of patients admitted to the ED with a suspected allergic reaction. Methods: A 1 year retrospective study was carried out and data were collected from the patients’ computerized medical reports. Results: A total of 324 patients were admitted for an allergic event. Of those, 165 patients (50.9%) were female and their mean age was 55 ± 18.5 years. Diagnoses included: asthma in 100 patients (30.9%); hymenoptera allergy in 78 patients (24.1%); food allergy in 31 patients (9.5%); drug allergy in 25 patients (7.7%); and allergic conjunctivitis in 12 patients (3.7%). No diagnosis was found in the medical records of 78 patients (24.1%). Anaphylactic shock was observed in 12 patients (3.7%) with a diagnosis of food allergy (six cases), drug allergy (three cases) and hymenoptera allergy (three cases). Ninety patients (27.7%) were hospitalized in the following units: 38 in allergy unit (42.2%); 20 in intensive care unit (22.2%); 10 in pulmonary unit (11.1%); eight in the dermatology unit (8.9%); six in the internal medicine unit (6.7%); and eight in other units (8.9%). Overall, 42 patients (12.9%) were evaluated by an allergologist after ED discharge with positive allergy results in 28 cases (66.6%). Conclusions: Acute allergic diseases are not rare in ED, representing 1% of the annual visits in our series. A low rate of allergologist referral was observed. Emergency physicians must work closely with allergologists to ensure a better evaluation, long-term care and preventive management of patients with allergic diseases admitted to the ED.

Objective To present research and clinical evidence on the use of primary dietary prevention in food allergy management. Data Sources We conducted MEDLINE searches for pertinent articles published between January 1986 and October 2001 with use of the following keywords or phrases: prevention and diet and allergy, food allergy and prevention, and dietary prevention and food allergy or allergens . Also included are information and commentary reflecting the authors' cumulative clinical experience in an allergy unit of a city hospital. Results We define as "proactive" those strategies centered on "success factors," such as the early postnatal environment, prolonged breast-feeding, and use of formula and probiotic supplementation, in contrast to earlier "prohibitionist" approaches to prevention of food allergy. These two approaches are not antagonistic and may even be synergistic. We introduce this distinction in light of epidemiologic evidence and out of concern about compliance and the quality of life for patients. Conclusions Inasmuch as nutritional and immune maturation are implicated, the prohibitionist measures that are most effective in primary prevention of food allergy are exclusive breast-feeding for at least 6 months (for lifelong immunity and other benefits), delayed (after the sixth month) introduction of solid foods, and on-indication use of "hypoallergenic" formulas. Whether proactive strategies can be contemplated remains a debatable issue. Evidence for and against the scientific use of probiotics as well as microbiologic, epidemiologic, and clinical data are discussed. Review of published epidemiologic studies and randomized clinical trials is essential before planning dietary intervention or prevention.

Objective: To examine the occurrence of adverse reactions to measles vaccine given as a single dose to children with egg allergy, and to determine if the administration of single dose to children with a positive result in an intradermal skin prick test with the vaccine is associated with adverse reactions. Design: Review of results of immunisation and prospective study of 96 consecutively presenting children given intradermal skin testing with the vaccine. Setting: Children9s allergy centre. Subjects: 410 children sensitive to egg referred to the allergy unit for advice about measles immunisation. Main outcome measures: Nature and severity of reactions associated with the administration of measles vaccine. Results: All children had a positive result in a skin prick test with egg white, and five had a positive result in a skin prick test with vaccine. Of 96 consecutive children, 46 had a positive result in an intradermal test with vaccine. After immunisation with a full dose (0.5 ml) of vaccine adverse reactions were associated with a mild reaction in four children, none of whom required treatment. Only one of the 46 children with a positive result in an intradermal vaccine skin test had a reaction associated with vaccine administration. None of the children with a positive result in a skin prick test with measles vaccine reacted to the vaccine. The rate of minor reactions to the vaccine not requiring treatment was 0.98% (95% confidence interval 0.27% to 2.48%) and serious reactions requiring treatment was 0% (0% to 0.9%). Conclusion: Children with IgE mediated allergic reactions to egg protein should be investigated and managed by practitioners with special knowledge in this subject. Measles immunisation should be performed in a setting where any adverse reactions can be dealt with appropriately. Skin tests and measles vaccine and desensitisation are not necessary.

We report a case of an eleven years old girl who was referred to our Allergy Outpatient Clinic for the revaluation of a hazelnut allergy. During her infancy she was successfully desensitised to milk and egg. Afterward she had been followed by another Allergy Unit where, according to skin prick test and specific IgE dosage, it had been suggested to strictly avoid peanut and all treenuts, although clinical history was not suggestive of treenuts allergy. She was also provided with an auto-injectable adrenaline, due to the high risk of severe reactions to treenuts. No oral provocation test was performed to validate diagnosis and adrenaline prescription.

The correlation between non-specific hyperreactivity of upper and lower airways in pathologic conditions has not been studied extensively.To investigate the occurrence of nasal and bronchial hyperreactivity in patients with allergic rhinitis studied out-of-season.From patients admitted to the Allergy Unit at Stockholm Söder Hospital, 12 individuals with allergic rhinitis due to grass or birch pollen were selected. The nasal mucosa was exposed to increasing concentrations of histamine chloride and the response was recorded by rhinostereometry, an optical method that exclusively measures changes in nasal congestion. Bronchial histamine challenge was performed in connection with the nasal tests, but on different days.The nasal histamine response was significantly greater than in a reference group of healthy volunteers (P.01). Nasal hyperreactivity was demonstrated in 9 of 12 patients. No clear relation between the magnitude of nasal and bronchial histamine responses was seen in the study group.In allergic rhinitis studied out-of-season, airway hyperreactivity is common in both upper and lower airways, but does not necessarily occur together in the same individual.

This is the first report on inhalative and ingestive allergy to the common edible mushroom Boletus edulis (Be) (English, edible boletus; German, Steinpilz, French, bolet; Italian, porcino or boleto) belonging to the class Basidiomycetes. Four cases observed in our allergy unit are presented, showing different clinical manifestations of this rare allergy: as an occupational problem or life-threatening anaphylactic reactions after eating Be. In all cases, skin prick-to-prick tests with raw Be were strongly positive; in three cases, specific IgE against Be could be found. The symptoms were reproducible after an inhalation challenge test. It is noteworthy that not only can Basidiomycetes cause airborne allergy but also that edible mushrooms from this class can cause inhalative and intestinal allergy. The two patients with strong anaphylactic reactions demonstrate that Be may have great allergenic potential.

Allergy Unit. Deparltnettt of Dettnatology. University Hospital, /.i'trich. Switzerland and * Pharmacia Diagnostic.Uppsala. SwedenSummaryBackgrowul Two patients experienced itching eonjunctivilis. rtinning nose, tightnessof ihc throat and coughing during preparation of fresh asparagus. Eating asparagusafter cooking did not provoke atiy allergie sympioms. Both patients were aiopic.sensitized additionally to pollens of grasses and trees as well as to onion.Objective To assess the hyperscnsilivity reactions to Iresh and heated asparagus andto investigate any crossreactivilies among the allergens.Methods Skin-prick tests were perfonned with commercial allergens and nativeasparagus and the patienls were lesled with Pharmacia CAP system for specific IgEantibodies against asparagus, onion, garlic, birch pollen, mugwort pollen and tworecombinani birch pollen allergens. Bet v \ and profilin. Inhibition of IgE antibodybinding lo solid phase homologous and unrelated allergens by increasing doses ofliquid allergens (inhibitors) was studied.Results Skin-prick tests with native green and white asparagus were strongly positive,but negative with cooked asparagus. Both patients had measurable levels of IgEantibodies against asparagus (3,0 and fi.2kU/L respectively) and several other aller-gens. One patienl was highly sensitive to birch and Bet v I. Both were positive toprofilin. mugwort and onion. In all cases ihe antibody uptake could be extensi\ety andspecifically inhibited by homologotts allergen. The asparagus-spccilic IgE antibodies ofthe two patienls could only be inhibited by asparagus. No inhibition was obtained afterheating of the asparagtts extract to 100 C.Ctmclu.sions The patients were speeitieally sensitized by asparagus. No immunologi-eal erossreaetions could be observed. The measurements of IgE antibodies to otherallergens were also specific, representing parallel multiple sensitivity. Profilin inhibitedprofilin-spccitic IgE binding but did not react with the asparagtis-spCLilic IgE anti-bodies of these patients. The asparagus allergen recognized by the specific IgEantibodies of these patients was thcrmolabile.Keywords: fresh asparagus, inhalant allergy. IgE antibodies. RAST inhibition, proiilinClinieal and E.xperitnental Allergy. Vol. 26. pp. 330 334. Submitted 12 January 1995:revised 10 June 1995; accepted 14 September 1995., , . diuretic effect, asparagus was widelv used in medicineIntroduction ., . ... , ,, ,until the 19th Century.Asparagus (/f.v/ji/rc/^^».v(;/'//(7/j(;//.v). a member of the Z,///V/- There have been several reports describing contactceae family, is cultivated worldwide as a vegetable. There dermatitis as a delayed hypersensitivity reaction, whichare different species with either white or green germs. usually presents as occupational hand eczema in grocers,depending on their ehlorophyll content. Due to their food handlers and workers in canneries deahng withasparagus |1.2]. To our knowledge. IgE-mediated inha-„ 1 n r n »y .i i MI 11 . I-» , , r hint allernies to asparagus. howevcr. are not reported. We

We were interested to read the article by Shaheen et al on the relationship between paracetamol and asthma.1 We have been interested in patients with analgesic induced asthma (AIA) since 1991 and now have a total of about 238 patients who have been followed up in our allergy unit. We have previously reported some related allergic conditions and risk factors for AIA, one of which was cumulative life long analgesic consumption.2-4 After reading the paper by Shaheen et al we re-analysed our data and compared the …

The results of a controlled trial of hyposensitization with intradermal EPD (beta-glucuronidase and food antigens) in 40 children with the hyperkinetic syndrome are reported from the Universitatskinderklinik, Lindwurmstrasse, Munchen, Germany and The Allergy Unit, London, UK.

With the increasing demand for vegetarian food the consumption of vegetable burgers as an alternative to beef burgers has now become widespread. Since products of this kind are often not provided with a clear description of their components or ingredients, potential allergens generally cannot be identified by the consumer. Their ingestion, however, may lead to severe allergic reactions in sensitized individuals. Here we describe nine systemic allergic reactions to sesame seeds that were diagnosed at the Allergy Unit, Department of Dermatology, Zurich, Switzerland between 1978 and 1991. In 1991 alone, we registered three cases of anaphylactic reaction to falafel vegetable burgers in patients allergic to sesame seeds. A falafel is an oriental specialty consisting of a wheat flour bun filled with chickpea balls. It is served together with a white sauce containing freshly ground sesame seeds. Our cases highlight the potential danger of vegetarian food and underline the importance of a proper allergologic assessment to recognize food allergy promptly so that the patient can eliminate the causative allergen and use suitable medication in the event of a dietary indiscretion.

In recent years, several organizations have made concentrated efforts toward standardization of allergenic extract materials. A variety of standard extracts are now available for use by commercial manufacturers who, upon preparing new extracts, can calibrate their product to the standard of reference extract. There are several advantages to the use of standardized extracts, such as more accurate administration of extracts in treatment by immunotherapy and the ability for physicians to compare different individual extracts. Standardized extracts will most likely be more expensive, but they will also be more cost effective because of consistent potency. It appears that this is a small price to pay for quality control, which, until the onset of standardized extracts, has been lacking in the manufacture and use of allergenic extracts.

Background Treatment of allergic disease can be done by pharmacological intervention by allergen avoidance – in the following called standard care (SC), or by specific treatment with allergy vaccination; Specific Immunotherapy (SIT). The aim of this study were to evaluate the effects of subcutaneously administrated SIT compared to SC by objective (clinical/medical records) and subjective parameters (patient's opinion) in a before/after SIT study. Methods The study included retrospectively all grass- and mite allergic 16-60 year old patients (N = 253) who had started SIT for grass pollen or mite allergy during the period 1.1.1996-1.1.2002 at The Allergy Unit, Aarhus University Hospital, or at a specialist practice in Aarhus. Relevant data were collected before/after treatment from medical records and from a specific designed questionnaire. The following indicators for effect were applied: Success of immunotherapy expressed as completion of up dosing phase, change in symptoms, a comparison of overall rhinoconjunctivitis symptoms, number of symptom free days per year, effect of pharmaceuticals, change in physical and psychological wellbeing and number of lost days from work/education and leisure activities. Results Compliance for completed up dosing for SIT was 94 % (95 % CI 90-97). The questionnaire revealed that after SIT there were a significant reduction in degree of symptoms, 84 % (95 % CI 79-89) of the respondents achieved a reduction in over all rhinoconjunctivitis score, there were an increase in symptom free days per year, a decrease in days off/incapacity from work/education and leisure activities, an improved effect of the pharmaceuticals used for allergic symptoms and an improvement in physical and psychological wellbeing. The study also showed that SIT was more effective treating rhinoconjunctivitis symptoms than lung symptoms. Conclusion The study revealed great advantages of SIT compared to SC and a high compliance for SIT during the up dosing period.