Milton Gold

Intraoperative anaphylaxis: An association with latex sensitivity

Latex products have recently been identified as the cause of severe intraoperative anaphylactic reactions. We have identified a group of pediatric patients who appear to be at increased risk for such reactions. Fifteen patients with either spina bifida or congenital urologic abnormalities experienced 19 intraoperative anaphylactic reactions. All patients had frequent previous exposures to rubber materials since infancy as part of their management and/or investigative procedures. Seven of 15 patients had a previous history of local skin reactions to rubber. Only four patients were atopic. All patients had undergone multiple (two of 26) operative procedures before their reactions, the onset of which ranged from 40 to 290 minutes after induction of anesthesia. The reactions varied in intensity from urticaria to severe cardiorespiratory collapse. All these patients subsequently had positive allergy skin tests and positive RAST to latex antigen. We conclude that this group is at risk when they are exposed to latex intraoperatively as a result of frequent past exposure to these materials. Allergic evaluation for latex allergy may assist in the preoperative evaluation of similar patients. In sensitized patients, appropriate prophylactic measures, particularly the avoidance of latex, is required.

Intraoperative anaphylaxis to latex

This case report describes intraoperative anaphylaxis occurring in a fourteen-year-old female with spina bifida in which latex surgical gloves were incriminated as the aetiologic agent. The patient was non-atopic but since eight years of age she had developed localized angioedema and urticarial skin reactions on exposure to rubber. She had previously undergone several uneventful surgical procedures. Forty-five minutes following induction of anaesthesia and during laparotomy for elective cholecystectomy she experienced sudden onset of increased airway pressure, oxygen desaturation, tachycardia, profound hypotension and erythema consistent with an anaphylactic reaction. Resuscitation with manual ventilation and oxygen, intravenous fluids and an epinephrine infusion was successful. Subsequent investigations for allergies demonstrated a strongly positive skin prick test and RAST to latex antigen, with negative results to anaesthetic agents, antibiotics and inhalant allergens. During two later operations prophylaxis consisting of diphen-hydramine, ranitidine and hydrocortisone appeared to prevent further reactions. Latex should be considered as a cause of life-threatening intraoperative allergic reactions in patients with a history of rubber allergy or frequent exposure to latex products.RésuméLe latex des gants du chirurgien semble responsable de l’anaphylaxie intra-opératoire survenue chez une fille de quatorze ans atteinte de spina-bifida. La patiente, sans autre histoire d’atopie, manifestait depuis l’âge de huit ans un urticaire avec angioedème local lors de contacts avec du caoutchouc mais elle avail subi sans probléme, diverses interventions chirurgicales. Approximativement 45 minutes après l’induction de l’anesthésie pendant une laparotomie pour cholecystectomie, il y eut chez elle une augmentation soudaine de la pression des voies respiratoires avec désaturation artérielle, hypotension grave et un érythème, le tout compatible avec un choc anaphylactique. La réanimation consista en une ventilation manuelle l’oxygène, du liquide par voie intraveineuse et une perfusion d’adrénaline. Une cuti-réaction et un test de radioallergosorbent (RAST) s’avérerènt fortement positifs pour l’antigène du latex, ralors que la réponse aux anesthésiques, antibiotiques et autres allergénes en inhalation était négative. Lors de deux interventions subsé-quentes, une prophylaxie base de diphenhydramine, de ranitidine et d’hydrocortisone fut utilisée avec succés. On devrait considerér le latex comme un agent pouvant potentiellement declencher une réaction allergique intra-opératoire sérieuse chez ceux qui sont fréquemment en contact avec lui ou qui sont allergiques au caoutchouc.

Intranasal fluticasone propionate versus loratadine in the treatment of adolescent patients with seasonal allergic rhinitis

Fluticasone propionate (FP) is a topical corticosteroid with minimal systemic activity. We examined safety and compared the efficacy of FP aqueous nasal spray, 200 micrograms every day with loratadine tablets, 10 mg by mouth every day in 240 adolescents with ragweed pollen-induced seasonal allergic rhinitis for 4 weeks in a randomized, double-blind, parallel-group study. Nasal and eye symptoms were recorded daily on a 4-point (0 to 3) scale. A higher percentage of symptom-free days was observed for nasal blockage on waking during treatment with FP (p < 0.0001). Significant results were also obtained for all other nasal symptoms when analyzed for both symptom-free days and symptom scores. No differences were found for eye irritation symptoms (p = 0.14). Morning and evening nasal peak inspiratory flow (PIF) was recorded daily by 57 subjects. FP treatment was associated wit significantly higher PIF values than loratadine both morning (p = 0.0051) and evening (p = 0.0036). A greater improvement over 4 weeks was observed for PIF morning values in the FP group (p = 0.008) but not for evening values (p = 0.358). Statistically significant correlations were found for nasal blockage and PIF in the morning (r = -0.54, p = 0.0001) and in the evening (r = -0.46, p = 0.008).

Adrenal suppression in two patients with asthma treated with low doses of the inhaled steroid fluticasone propionate

Site-directed mutagenesis has been used to generate variants of rDer p 2 with significantly reduced skin test reactivity.3, 4 In vitro, proliferation assays showed comparable T-cell responses to rDer p 2 and C73-78 in the 10 subjects with positive responses to allergen, suggesting that the T-cell epitopes are intact in the modified allergen. Similar results have recently been reported for a different cysteine variant of Der f 2.5 Variants with significantly reduced binding to IgE antibodies may provide an alternative strategy for immunotherapy. They would be expected to have a reduced risk of anaphylaxis and may make it possible to use accelerated immunization protocols and higher allergen doses. This strategy is now being extended to other dust mite allergens with the aim of evaluating these reagents in Phase 1 and Phase 2 clinical trials.

Highly atopic children: Formation of IgE antibody to food protein, especially peanut

Highly atopic infants often form IgE antibodies toward multiple food protein in the first 2 years of life. They begin producing IgE antibody to inhalant allergens between the first and second year of life. We hypothesized that highly atopic children would be at significant risk of sensitization to peanut. We defined high atopy as serum IgE greater than or equal to 10 times 1 SD from normal plus multiple positive RASTs. In this study we have characterized the immunologic status of 141 patients by measuring total serum IgE and specific IgE to several allergens, including peanut. These data demonstrated that, independent of clinical history, a positive RAST to peanut was more common in the highly atopic category compared to the low atopy category. Significantly more patients who were highly atopic and had a positive peanut RAST had a positive RAST for egg or milk compared to low atopic patients. More significantly, 33 of the patients had never knowingly received peanut, yet 21 (63.6%) had a positive RAST for peanut, whereas seven (21.2%) had a peanut antibody in the highest RAST category. All these seven patients were considered highly atopic according to the definition above, and three were younger than 2 years of age. These results suggest that highly atopic infants are at special risk for sensitization to peanut, even when they have never received peanut, and that characterization of immunologic sensitization to milk, egg, and peanut will identify the highly atopic infant.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of once- with twice-daily dosing of fluticasone propionate in mild and moderate asthma

OBJECTIVES Two 12-week, randomized, double-blind, parallel-group studies were performed to compare the efficacy and safety of once- and twice-daily dosing of fluticasone propionate (FP) in the treatment of mild to moderate asthma, considered to require the equivalent of either 200 or 500 microg of FP daily. PATIENTS AND METHODS In study A, 461 patients with asthma received FP either 200 microg once daily or 100 microg twice daily. In study B, 443 patients with asthma received FP, either 500 microg once daily or 250 microg twice daily. RESULTS In both studies, regardless of the treatment regimen to which patients were randomly assigned, small improvements over baseline were observed in morning peak expiratory flows (PEF) and forced expiratory volume in 1 s (FEV1) following 12 weeks of treatment. In study A, the mean morning PEF improved by 2.4% and 4.3% (once daily versus twice daily, P=0.008). In study B, the mean morning PEF improvement was 0.2% and 3.7% (once daily versus twice daily, P<0.001). For both studies, the increases observed in FEV1 were not significantly different between the two groups (P = not significant). The incidence of exacerbations of asthma and related events was 13% and 5%, respectively, in the patients with mild asthma for the once-daily group versus the twice-daily group; these exacerbations were 12% and 10%, respectively, in patients with moderate asthma. Otherwise, the incidence and types of adverse events were comparable for the two treatment regimens. Although twice-daily dosing demonstrated small but statistically significant improvements over once-daily dosing, patients of both groups generally maintained a good level of asthma control on both regimens according to current treatment guidelines. CONCLUSIONS Twice-daily dosing of FP is more effective than once-daily dosing, although the latter can maintain asthma control in most patients.

Anaphylaxis during Insertion of a Ventriculoperitoneal Shunt

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Comparison between the prevalence and treatment of wheezing and coughing in Brampton and Mississauga children

An analysis of hospital discharge data showed that Brampton children 4 years and under had higher rates of hospital admissions for asthma, bronchitis and upper respiratory infections than children in the same age group living in Mississauga and other Ontario municipalities. The present study was done to compare the prevalence and treatment of wheezing and coughing between Brampton and Mississauga children 4 and 5 years of age. The study showed that increased use of pediatricians on the part of Mississauga children in comparison to Brampton children resulted in a higher proportion being placed on anti-asthmatic medications even though the underlying prevalence rate of wheezing and coughing was the same in the two samples. Further study is required to determine whether differences in primary care between the two samples can explain a two-fold increase in hospital admission rates for lower respiratory illness among Brampton preschool children in comparison to their counterparts in Mississauga.