Which adjuvant treatment for patients with BRAFV600-mutant cutaneous melanoma?

Treatment of patients with melanoma has considerably improved over the past decade and more recently with adjuvant therapies for patients with American Joint Committee on Cancer (AJCC) stage III (loco-regional metastases) or IV (distant metastases) totally resected melanoma, in order to prevent recurrence. In the adjuvant setting, two options are available to patients with BRAF^V600-mutant AJCC stage III totally resected melanoma: anti-PD-1 blockers (nivolumab or pembrolizumab) or BRAF plus MEK inhibitors (dabrafenib plus trametinib). In the absence of comparative studies, it is difficult to determine which of these options is best. Our aim was to review published studies focusing on the management of patients with BRAF^V600-mutant melanoma in the adjuvant setting. We also reviewed the main clinical trials of BRAF plus MEK inhibitors and immunotherapy in advanced (i.e. unresectable metastatic) BRAF-mutant melanoma in an attempt to identify results potentially affecting the management of patients on adjuvants. More adverse events are observed with targeted therapy, but all resolve rapidly upon drug discontinuation, whereas with immune checkpoint blockers some adverse events may persist. New therapeutic strategies are emerging, notably neoadjuvant therapies for stage III patients and adjuvant therapies for stage II patients; the place of the adjuvant strategy amidst all these options will soon be re-evaluated. The choice of adjuvant treatment could influence the choice of subsequent treatments in neo-adjuvant or metastatic settings. This review will lead clinicians to a better understanding of the different adjuvant treatments available for patients with totally resected AJCC stage III and IV BRAF^V600-mutant melanoma before considering subsequent treatment strategies.

Patients en unités COVID et usage des antibiotiques : a posteriori, en a-t-on trop fait ?

Introduction

Notre hôpital de soins tertiaires, d’environ 550 lits, est situé dans une zone considérée à forte circulation du Sars-Cov-2. La création de trois unités COVID (39 lits) a permis l’hospitalisation d’environ 300 patients (19 en surveillance continue (USC) et 288 en hospitalisation conventionnelle). Les gaz médicaux et les antibiotiques (ATB) y ont constitué les premiers postes de dépenses en médicaments, avec respectivement 6598 € et 8107 € HT. Notre objectif a été d’analyser a posteriori l’usage des ATB en unités COVID au regard des recommandations du Haut Conseil de Santé Publique (HCSP) du 06/06/2020.

Matériels et méthodes

Les lignes d’ATB prescrites dans le dossier patient informatisé (DPI) entre le 01/02 et le 04/06/20, ont été analysées sur Excel. Les comorbidités et signes de gravité, décrits par le HCSP, ont été recueillis à partir de la synthèse médicale d’entrée et de la pancarte quotidienne du DPI, sans connaissance de la prescription médicale.

Résultats

Cent quatorze patients ont reçu un ATB, soit 37 % des patients en unités conventionnelles et 58 % des patients en USC. L’antibiothérapie empirique initiale était : amoxicilline-acide clavulanique (A-AC) [n = 34] ; C3G + macrolide (M) [n = 28] ; A-AC + M [n = 22] ; C3G [n = 8] ; C3G + doxycycline [n = 4] ; A-AC + doxycycline [n = 4] ; autres [n = 21]. Le recours à la doxycycline est essentiellement retrouvé chez les patients sous hydroxychloroquine en remplacement du macrolide. La durée moyenne d’exposition aux ATB était de 7 jours [± 4 jours]. Parmi ces 114 patients, 32 présentaient des comorbidités et ont été essentiellement traités par A-AC [n = 12], A-AC + M [n = 9], ou par C3G + M [n = 6]. Trente-trois patients présentaient au moins un signe de gravité et ont été traités par C3G + M [n = 11] ; A-AC [n = 6], A-AC + M [n = 5]. Trente et un patients présentaient au moins une comorbidité et un signe de gravité. Ils ont été traités par A-AC [n = 9] ; C3G + M [n = 8] ou A-AC + M [n = 5]. Dix-huit patients sous ATB ne présentaient ni comorbidité ni critères de gravité. Parmi eux, 6 patients présentaient un foyer bactérien (pulmonaire, digestif ou urinaire) objectivé ; 4 présentaient une pneumopathie interstitielle bilatérale, pour laquelle une antibiothérapie était recommandée par notre centre expert régional ; 1 patient de 17 ans était à risque d’immunodépression, traité par adalimumab.

Conclusion

Considérant les comorbidités et signes de gravité décrits dans l’avis du HCSP, ainsi que les étiologies bactériennes objectivées, 90 % des patients ayant reçu un ATB en unité COVID étaient éligibles à l’instauration d’une antibiothérapie selon l’avis du HCSP. Conformément aux recommandations, les prescripteurs ont davantage instauré de l’A-AC chez les patients avec comorbidités, et l’association C3G + M en cas de signe de gravité. Le suivi de ces patients par des infectiologues ou médecins en service d’infectiologie a permis un usage raisonné et un choix pertinent des ATB.

Clinical trial to assess tolerability and subrogate efficacy effects of an abbreviated schedule with house dust mites mixture subcutaneous immunotherapy

Summary

Objective. To evaluate the tolerability and efficacy of Dermatophagoides pteronyssinus/Dermatophagoides farinae mixture subcutaneous immunotherapy (SCIT). Methods. Patients received an abbreviated build-up schedule. The aims were: number, percentage, and severity of adverse reactions. Secondary outcomes included: changes in immunoglobulin titers and changes in dose-response skin prick tests. Results. Out of 289 administrations, 17% elicited any clinically relevant adverse reaction. Most of them were local reactions (LR) (9.4%) and the rest (7.6%) were systemic. Significant increases in sIgG and sIgG4 were detected in serum samples. Cutaneous reactivity decreased significantly. Conclusions. SCIT with house dust mites mixture of ROXALL Medicina España S.A. seems to have an acceptable tolerability profile, induces blocking IgG and decreases skin reactivity.

Relevance and Feasibility of a Personalized Dietary Intervention in Older People with Meals-On-Wheels: A Randomized Controlled Pilot Trial

Objective

The present study aimed at assessing the feasibility and the effectiveness of a personalized dietary intervention in a meals-on-wheels service through a randomized controlled pilot trial.

Design

Sixty recipients of home-delivered meals (75% of women; 70-97 years old) were recruited and randomly assigned to a control and an experimental group and followed over a period of 4 months. In the experimental group, the nutritional status (Mini-Nutritional Assessment - MNA questionnaire), the food intake and the food preferences were measured for each participant. Based on this screening, participants were provided with dietary guidance and follow-up. Those at risk of malnutrition were proposed enriched home-delivered meals. Enrichment was set up considering food preferences of the participants.

Results

Looking at the whole sample at baseline, 80% (n=48/60) were at risk of malnutrition. Furthermore, 55% (n=33/60) ate less than 2/3 of their calorie and/or protein recommended allowances. In the experimental group, the intervention led to an increase of protein intakes and to a lower extent of calorie intake. In the control group, no significant changes were observed.

Conclusion

To conclude, this study suggests that providing dietary guidance and adding nutrient-dense food to meals while considering food preferences is feasible and may help older beneficiaries of meals-on-wheels to increase calorie and protein intake and improve their nutritional status. However, there is a need to develop products or recipes to enrich the meals of the elderly more efficiently to achieve the recommended allowance.

[Leg ulcers occurring under tyrosine kinase inhibitor therapy (sunitinib, nilotinib)]

BACKGROUND

Certain anticancer drugs are known to induce leg ulcers, mainly chemotherapy agents such as hydroxyurea. We report 2 cases of leg ulcers in cancer patients treated with the tyrosine kinase inhibitors, sunitinib and nilotinib, and we discuss the role of these treatments in the pathogenesis of leg ulcers.

PATIENTS AND METHODS

Case 1. A 62-year-old patient on sunitinib for intrahepatic cholangiocarcinoma developed a lesion on her right foot. The vascular evaluation was negative. After progressive worsening, sunitinib was stopped and healing was observed within a few months. Case 2. A 83-year-old patient had been treated for chronic myeloid leukemia since 2005. Nilotinib was introduced in 2009. Peripheral arterial revascularization was required in May 2013. A few months later, worsening was noted with the onset of ulceration and necrosis of the third toe. Further revascularisation surgery was performed, and nilotinib was suspended and antiplatelets introduced. Healing occurred a few months later.

DISCUSSION

Many skin reactions have been described in patients on nilotinib and sunitinib, but few publications report the development of de novo ulcers in patients without risk factors. The pathophysiology of the development of ulcers in patients receiving tyrosine kinase inhibitors is not clear, and probably involves several mechanisms of action. The increasing use of this type of treatment could lead to an upsurge in the incidence of vascular complications.

CONCLUSION

We report two cases of leg ulcers developing in patients on tyrosine kinase inhibitors and raise the question of causal implication of these treatments in the pathogenesis of ulcers.

Reduced work/academic performance and quality of life in patients with allergic rhinitis and impact of allergen immunotherapy

Background

Allergic rhinitis (AR) is characterised by burdensome nasal and/or ocular symptoms. This inflammatory disease can be debilitating and thus result in considerable health-related and economic consequences.

Methods

In a cross-sectional study, adult subjects with AR (N = 683) completed three allergy-specific questionnaires that assessed the impact of AR on the work/academic performance, daily activities, health-related quality of life (HRQOL), and satisfaction with allergen immunotherapy (AIT). Regression analyses were used to examine the associations between several clinical variables and the patient-reported outcomes.

Results

Total loss of productivity was 21.0 and 21.2 % for employed and student patients, respectively, whereas the impairment of daily activities was 22.0 %. The mean overall HRQOL score was 1.94 ± 1.29 (on the scale of 0–6 points). Global score for satisfaction with AIT was 65.5 ± 24.8 (on a 0–100 scale). Simple regression analysis found statistically significant associations between loss of work and academic productivity, impairment of daily activities and the type and severity of AR. AIT was a protective factor. The persistent and more severe types of AR and lack of AIT contributed to the worsening of HRQOL.

Conclusions

AR (the persistent and more severe form of the disease) has an impact on functional characteristics of adult patients in Spain. AIT might reduce the effect of this disease on the work/academic performance and HRQOL.

Trial registration Retrospectively registered

A randomized, 5-arm dose finding study with a mite allergoid SCIT in allergic rhinoconjunctivitis patients

BACKGROUND

The safety and tolerability of a mite allergoid subcutaneous allergen immunotherapy (SCIT) product was previously established. The aim of this study (EudraCT number: 2011-000393-61) was to find the optimally safe and effective allergoid dose by evaluating several dosages in patients with house dust mite (HDM)-induced allergic rhinoconjunctivitis (ARC) using a titrated nasal provocation test (TNPT).

METHODS

In total, 290 adult ARC patients (148 females; 142 males) with established HDM allergy and with a positive TNPT were randomized to receive placebo or mite allergoid SCIT 6667, 20 000, 50 000 or 100 000 AUeq/ml for 12 months. Patients were updosed weekly, followed by monthly maintenance dosing. The primary study endpoint comprised the clinical response to TNPT after 12 months of treatment. Secondary endpoints included response to TNPT after 6 months, PNIF measurements, symptom and medication scores during the last 8 weeks of treatment, serum immunoglobulins and safety assessments.

RESULTS

After 12 months, a dose-response was observed showing statistically significant improvements in the TNPT with SCIT concentrations of ≥20 000 AUeq/ml, while no significantly different outcomes were reached after 6 months. Specific serum IgG and IgG4 levels were dose dependently increased. In the highest dose group, more treatment-emergent adverse events were observed compared with the lower dose groups.

CONCLUSION

In this mite allergoid SCIT dose finding study in HDM-induced ARC, concentrations of ≥20 000 AUeq/ml showed both immunological effects and clinical efficacy in the TNPT compared with placebo. The risk-benefit ratio favours 20 000 AUeq/ml and 50 000 AUeq/ml strengths for further clinical development.

Status of the SPIRAL2 injector commissioning

The SPIRAL2 injector, installed in its tunnel, is currently under commissioning at GANIL, Caen, France. The injector is composed of two low energy beam transport lines: one is dedicated to the light ion beam production, the other to the heavy ions. The first light ion beam, created by a 2.45 GHz electron cyclotron resonance ion source, has been successfully produced in December 2014. The first beam of the PHOENIX V2 18 GHz heavy ion source was analyzed on 10 July 2015. A status of the SPIRAL2 injector commissioning is given. An upgrade of the heavy ion source, named PHOENIX V3 aimed to replace the V2, is presented. The new version features a doubled plasma chamber volume and the high charge state beam intensity is expected to increase by a factor of 1.5 to 2 up to the mass ∼50. A status of its assembly is proposed.

DIRAE study: seasonal allergic rhinitis distribution in Spain

BACKGROUND

National epidemiological study to observe if among patients with pollinic seasonal allergic rhinitis (SAR), there are differences between those visited by primary care physicians (GPs) or allergists (ALs).

METHODS

758 and 739 adults were recruited respectively by GPs and ALs. The physicians filled in a questionnaire: ARIA classification, prescribed treatment, and asthma incidence. The patient completed a visual analogical scale (VAS) to evaluate the severity of the rhinitis. Rhinitis control (controlled, partially controlled, and not controlled) was assessed by physician and patient.

RESULTS

No significant differences were found among patients visited by GPs or ALs concerning the ARIA classification and rhinitis severity. Treatment with oral antihistamines was 92.3% and 89.3% for GPs and ALs, respectively. The use of nasal corticosteroids was 76.7% and 60.4% for GP and AL patients, respectively. 31.9% of the patients visited by the ALs were treated with immunotherapy. The use of alternative medicine was 10.9% and 7.6% in GP and AL patients, respectively. The perception of "controlled" rhinitis was similar among patients (40.0%) and doctors (40.1%), although patients referred differences depending if they were visited by GP (44.8%) or AL (34.9%). Asthma prevalence was higher in those who suffered persistent as compared to intermittent rhinitis (OR=1.81, 95% CI: 1.39-2.36, p<0.001), and moderate/severe vs. mild rhinitis (OR=1.68, 95% CI: 1.05-2.68, p=0.029).

CONCLUSION

The patients with pollinic SAR visited by GPs or ALs show no differences in severity. Less than half of the patients can be considered as "controlled".

A direct comparison of efficacy between desloratadine and rupatadine in seasonal allergic rhinoconjunctivitis: a randomized, double-blind, placebo-controlled study

Background

H1-antihistamines are recommended as the first-line symptomatic treatment of allergic rhinitis. The objective of this study was to evaluate the effects of rupatadine (RUP) versus desloratadine (DES) in subjects with seasonal allergic rhinitis (SAR).

Method

To assess the efficacy and safety of RUP in SAR in comparison with placebo (PL) and DES. A randomized, double-blind, multicenter, international, and PL-controlled study was carried out. The main selection criteria included SAR patients over 12 years old with a positive prick test to a relevant seasonal allergen for the geographic area. Symptomatic patients at screening with a nasal symptom sum score of ≥6 points (nasal discharge, nasal obstruction, sneezing, and nasal pruritus), a non-nasal score of ≥3 points (ocular pruritus, ocular redness, and tearing eyes), and a rhinorrhea score of ≥2 points with laboratory test results and electrocardiography within acceptable limits were included in the study. Change from baseline in the total symptom-score (T7SS) over the 4-week treatment period (reflective evaluation) was considered the primary efficacy variable. Secondary efficacy measures included total nasal symptom score (T4NSS) and conjunctival symptom score (T3NNSS), both of which are reflective and instantaneous evaluations. Furthermore questions related to quality of life (eg, sleep disturbances or impairment of daily activities) have also been evaluated. Safety was assessed according to adverse events reported, as well as laboratory and electrocardiography controls.

Results

A total of 379 patients were randomized, of which 356 were included and allocated to PL (n = 122), RUP (n = 117), or DES (n = 117). Mean change of T7SS over the 4-week treatment period was significantly reduced in the RUP (–46.1%, P = 0.03) and DES (–48.9%, P = 0.01) groups, compared with PL. Similarly, RUP and DES were comparable and significantly superior to PL for all secondary endpoints, including nasal and conjunctival symptoms and patients’ and investigator’s overall clinical opinions. Symptom score evaluation (both reflective and instantaneous evaluations) throughout the treatment period showed a progressive and maintained significant improvement with both treatments at day 7 (P = 0.01), day 14 (P = 0.007), and day 21 (P = 0.01) in comparison with PL. Adverse events were scarce and were similar in both treatment groups. Electrocardiography (QTc) and lab test results did not show any relevant findings

Conclusion

RUP is a very good choice for SAR due to its contribution to the improvement of nasal (including obstruction) and non-nasal symptoms to a similar degree as DES.

Preliminary results of the International Fusion Materials Irradiation Facility deuteron injector

In the framework of the IFMIF-EVEDA project (International Fusion Materials Irradiation Facility-Engineering Validation and Engineering Design Activities), CEA∕IRFU is in charge of the design, construction, and characterization of the 140 mA continuous deuteron injector, including the source and the low energy beam line. The electron cyclotron resonance ion source which operates at 2.45 GHz is associated with a 4-electrode extraction system in order to minimize beam divergence at the source exit. Krypton gas injection is foreseen in the 2-solenoid low energy beam line. Such Kr injection will allow reaching a high level of space charge compensation in order to improve the beam matching at the radio frequency quadrupole (RFQ) entrance. The injector construction is now completed on the Saclay site and the first plasma and beam production has been produced in May 2011. This installation will be tested with proton and deuteron beams either in pulsed or continuous mode at Saclay before shipping to Japan. In this paper, after a brief description of the installation, the preliminary results obtained with hydrogen gas injection into the plasma chamber will be reported.

Upper airway obstruction in patients with endothoracic goiter enlargement: no relationship between flow-volume loops and radiological tests

BACKGROUND

In about 16-85% of subjects with goiter, upper airway obstruction (UAO) is observed. This percentage is higher in patients affected by goiter with endothoracic enlargement. UAO is an indication for surgery. Visual analysis of flow-volume loops (FVL) are the best indicators for UAO, although various studies using clinical and radiological parameters have observed no correlation.

OBJECTIVE

To evaluate the presence of UAO in patients with endothoracic goiter enlargement and the relationship between the FVL with the observed symptoms and the measurements obtained by computed tomography (CT).

SUBJECTS

Subjects with endothoracic goiter enlargement participated in the study.

DESIGN

i) Symptom questionnaire (dysphagia, dyspnea, cough, oppression, dysphonia, and worsened symptoms when prone); ii) analysis: TSH and free thyroxine; iii) cervical ultrasound; iv) cervical-thoracic CT (measurements of area and diameter in the area of maximum stenosis and at 2 cm from the carina); v) chest radiography and vi) forced spirometry: visual analysis of FVL morphology and the maximum forced expiratory volume in 1 s (FEV(1)), forced expiratory flow at 50% vital capacity/forced inspiratory flow at 50% vital capacity and FEV(1)/peak expiratory flow parameters.

RESULTS

Fifty subjects participated in the study: 11 men/39 women, median age 73.8 years (43.76-88.43). UAO was diagnosed in 13 cases (26%, confidence interval: 14.6-40.3%) and 27 subjects (54%) presented symptoms suggesting goiter compression. No clinical or radiological variables showed the presence of UAO.

CONCLUSIONS

The frequency of UAO in subjects affected by goiter with endothoracic enlargement was lower than that described for goiter patients, and there were no clinical or radiological indicators to establish its presence.

[In vivo exploration of cerebral ischemia: use of neuroprotective agents in animal studies]

A "good" in vivo animal model of stroke must reproduce the etiology, anatomical, functional and metabolic consequences of human pathology and must also permit the study of anti-ischemic drugs in conditions pertinent to the clinical therapeutics. As stroke is a very heterogeneous clinical entity, such a model could only mimic a limited part of stroke. Animal data are usually collected in healthy laboratory rodents of the same age, in which a standardized amount of cerebral ischemia is induced by a reproducible intervention. In contrast, aetiology, location and severity of ischaemic stroke in patients is very heterogeneous. Among the various animal models of stroke, two of them are particularly used: a model of global transient ischemia by occlusion of the 4-vessels in the rat (Pulsinelli's model), which induces a delayed neuronal death in the hippocampus and model(s) of permanent or transient focal cerebral ischemia occluding the middle cerebral artery in rodents. A large number of compounds have been shown to be active using these two animal models, but unfortunately, none of them were found to be active in clinical trials. Various factors could be responsible for this major discrepancy and some of them are not related to pre-clinical studies, but to the complexities of the clinical problem of stroke. Failure in the translation of results from animals models to humans implicates potential limitations of the current drug development process. Retrospective analysis of studies suggests possible improvements at several stages during pre-clinical studies. Standardized guidelines for preclinical evaluation of neuroprotective drugs may improve chances of success. For example, preclinical studies should be performed in at least 2 species and 2 strains for a specific specie in order to take into account known strain and species differences. Moreover, while neuroprotection drug development is dominated by volumetric histology as the outcome measure, the demonstration of functional benefits must be performed both after short and long periods of recovery. Attempts should be made to use multiple models such as stroke-prone spontaneously hypertensive rats, outbred rodents and aged animals that more closely simulate clinical conditions. In addition, treatment in animals should not be given immediately after ischaemia, but after a delay, as most patients are not treated within minutes of stroke onset. Animal models should be used to determine dosage and duration of therapy, which will vary with the pharmacokinetic properties of different agents. Moreover, complete dose-response curves should be established as bell-shaped dose-responses curves may predict dose-limiting adverse effects that hinder subsequent efficacy trials. Finally, physiological monitoring (cerebral blood flow, blood pressure and gazes, body temperature, glycemia, ...) should be performed to eliminate confounding variables and to observe adverse systemic effects. The future of neuroprotection for stroke remains bright in spite of previous disappointments.

Ventilatory insufficiency due to asbestos-related diffuse pleural fibrosis successfully treated with noninvasive home mechanical ventilation

A 54-year-old man with diffuse pleural fibrosis due to previous asbestos exposure developed hypercapnic respiratory failure. Noninvasive mechanical ventilation (NIMV) was started at the hospital and maintained at the patient's home, achieving reversal of the respiratory failure. During a 2-year follow-up, NIMV has been well tolerated by the patient and no relapse in ventilatory failure has occurred. Home NIMV can be considered as an alternative to pleural decortication in asbestos-related diffuse pleural fibrosis with ventilatory insufficiency.

Protective effect of the antioxidant 6-ethoxy-2,2-pentamethylen-1,2-dihydroquinoline (S 33113) in models of cerebral neurodegeneration

In a previous study Dorey et al. [Bio. Org. Chem. Lett., 10 (2000) 935] a series of novel dihydroquinoline compounds were developed, based on the potent antioxidant 6-ethoxy-1,2-dihydro-2,2,4-trimethylquinoline (ethoxyquin), and permitted the selection of the analogue 6-ethoxy-2,2-pentamethylen-1,2-dihydroquinoline (S 33113) lacking the hypothermic effects associated with ethoxyquin at equivalent doses. Herein, an extensive investigation of the neuroprotective capacity of S 33113 in different in vitro and in vivo paradigms of oxidative stress-mediated cellular degeneration was undertaken. In vitro S 33113 was a potent inhibitor (IC(50) = 0.29 microM) of Fenton-reaction-induced lipid peroxidation in mouse cortical membranes. Administration of S 33113 either intraperitoneally (< or =150 mg/kg i.p.) or orally (< or =600 mg/kg p.o.) did not significantly modify body temperature in NMRI mice. Furthermore, S 33113 (150 mg/kg i.p. or 600 mg/kg p.o.) markedly reduced the lethality induced by an intracerebroventricular injection of t-butylhydroperoxide in NMRI (naval medical research institute) mice for up to 5 h. Oral administration of S 33113, significantly attenuated alloxan-mediated hyperglycaemia in NMRI mice at 400 and 600 mg/kg (60%; P < 0.001). Administration of S 33113 (150 mg/kg i.p.) 30 min before transient global ischaemia significantly prevented delayed neuronal cell death in the CA1 region of the rat hippocampal formation, 7 days post-ischaemia (33% cell loss vs. 88% in ischaemia controls; P < 0.001). Similarly, a single pre-administration of S 33113 (150 mg/kg i.p.) prevented kainic acid-induced cell death in the CA3 hippocampal region at 7 days post-exposure (17% cell loss vs. 52% in kainate-treated controls; P < 0.01). Furthermore, D-methamphetamine-mediated dopamine depletion in the striatum of C57BL/6 mice (39-46%) was significantly prevented with S 33113 administered at either (2 x 150mg/kg i.p.) (11%; P < 0.01) or (2x150 mg/kg p.o.) (17%; P < 0.001). In conclusion, S 33113 represents a novel dihydroquinoline compound with potential for the treatment of cerebral pathologies implicating chronic neurodegeneration.

[Anaphylaxis caused by royal jelly]

Royal jelly is the food on which are fed and which causes them to develop into queen bees. It is claimed to have rejuvenating virtues for human beings. This report describes a 15-year-old atopic woman who presented, 15 minutes after the intake of royal jelly, local angioedema, generalised urticaria, dysphonia and bronchospasm. She was given antihistaminics and corticoesteroids and responded well. The ingested product contains royal jelly, lactose and potassium sorbate. No anaphylactic reactions to lactose and sorbates have been described previously. Prick test to common food allergens hymenoptera venoms and pollens were negative. RAST to meletin was also negative. Blood eosinophils were 600 and total IgE 465. Non-commercial prepared specific IgE to royal jelly was positive (0.8 KU/l). Prick by prick was positive to 1/10 dilution, being negative in controls (undiluted). No oral provocation test was performed due to the risk of anaphylaxis. No reported cases of royal jelly allergy were founded in a review of the medical literature. Concluding, it is the first described case of IgE anaphylactic reaction due to royal jelly.

[Anaphylaxis caused by human seminal fluid]

Anaphylaxis to human seminal fluid (HSF) is rare. We present an atopic woman with postcoital cutaneous and respiratory symptoms. Prick by prick to HSF was positive. CAP to FSH was also positive (4 KU/l). The clinical findings, differential diagnosis and different treatments are discussed.

The prick test and specific IgE (RAST and MAST-CLA) compared with the oral challenge test with milk, eggs and nuts

In spite of the development of numerous in vivo and in vitro diagnostic techniques for food allergy, the oral challenge test (OCT) is still the "gold standard". Consequently, we have compared it with some of the more recent techniques. We studied 36 patients with a medical history compatible with food allergy (to milk, eggs or nuts) and 11 patients without food allergy (6 nonatopic and 5 with acarid allergy). A prick test, specific IgE (RAST and MAST-CLA) and an OCT with the suspected food were performed in all patients. The following parameters were calculated for all patients overall and for each of the three allergic groups separately: sensitivity, specificity and match with the OCT. We also studied the RAST-MAST-CLA correlation and the variability of the MAST-CLA. The prick test was the most sensitive (95%) and the MAST-CLA (13% divergence in two measurements) the most specific (92%). The RAST and the MAST-CLA (68% match) gave similar results, with an acceptable match (75% and 77%, respectively) with the OCT. The medical history could only suggest the diagnosis (39% false-positives). After comparing the results with those in the literature, it is suggested that greater attention should be paid to the limitations of these techniques compared with the OCT.

The value of specific IgG4 determination in childhood allergy to egg in relation to specific IgE and the provocation test

The value of IgG4 determination in food allergy shows conflicting results in the medical literature. Our pediatric study was carried out in two phases. The first compared the percentage of detection and agreement of specific IgE (RAST) and IgG4 (FAST) for egg white and egg yolk in 104 patients with possible hypersensitivity to egg and positive skin tests. The second, in 22 new patients, compared IgG4 determination with the oral provocation test (OPT; the diagnostic "gold standard"). In the first phase, the percentage of positive cases for both antibodies was almost identical, but little agreement was observed between them. In the second phase, the sensitivity, specificity and agreement with the OPT were higher for IgE than for IgG4. Thus, we conclude that IgG4 levels may be high in food allergy, but their detection seems to have little diagnostic value in allergy to egg proteins in children.

Prevention of exercise-induced asthma in children using low doses of inhaled furosemide

It has been demonstrated that inhaled furosemide inhibits indirect but not direct bronchoconstricting stimuli. The exercise test (ET; indirect) has been shown to be inhibited in adults. Our aim was to determine whether the ET was also inhibited in children by low doses of furosemide. We studied 10 asthmatic patients with a mean age of 11.1 years whose ET results were positive, and in whom the ET was repeated after inhaling 28 mg of furosemide. After 10 min, there were no significant signs of bronchodilatation. The percent decrease in mean FVC, FEV1, MF50 and peak flow (PF) was significantly lower with the premedication. The protection achieved was: FVC, 66.5%; FEV1, 51.4%; MF50, 30.3%; and PF, 63.9%. No clinical response was observed in 5 of 10 cases. It was concluded that 28 mg of inhaled furosemide inhibits the ET in asthmatic children.