Immediate Hypersensitivity to Contrast Agents: The French 5-year CIRTACI Study

BACKGROUND

Iodinated and gadolinium-based contrast media (ICM; GBCM) induce immediate hypersensitivity (IH) reactions. Differentiating allergic from non-allergic IH is crucial; allergy contraindicates the culprit agent for life. We studied frequency of allergic IH among ICM or GBCM reactors.

METHODS

Patients were recruited in 31 hospitals between 2005 and 2009. Clinical symptoms, plasma histamine and tryptase concentrations and skin tests were recorded. Allergic IH was diagnosed by intradermal tests (IDT) with the culprit CM diluted 1:10, "potentially allergic" IH by positive IDT with pure CM, and non-allergic IH by negative IDT.

FINDINGS

Among 245 skin-tested patients (ICM = 209; GBCM = 36), allergic IH to ICM was identified in 41 (19.6%) and to GBCM in 10 (27.8%). Skin cross-reactivity was observed in 11 patients with ICM (26.8%) and 5 with GBCM (50%). Allergy frequency increased with clinical severity and histamine and tryptase concentrations (p < 0.0001). Cardiovascular signs were strongly associated with allergy. Non-allergic IH was observed in 152 patients (62%) (ICM:134; GBCM:18). Severity grade was lower (p < 0.0001) and reaction delay longer (11.6 vs 5.6 min; p < 0.001). Potentially allergic IH was diagnosed in 42 patients (17.1%) (ICM:34; GBCM:8). The delay, severity grade, and mediator release were intermediate between the two other groups.

INTERPRETATION

Allergic IH accounted for < 10% of cutaneous reactions, and > 50% of life-threatening ones. GBCM and ICM triggered comparable IH reactions in frequency and severity. Cross-reactivity was frequent, especially for GBCM. We propose considering skin testing with pure contrast agent, as it is more sensitive than the usual 1:10 dilution criteria.

Injector design for liner-on-target gas-puff experiments

We present the design of a gas-puff injector for liner-on-target experiments. The injector is composed of an annular high atomic number (e.g., Ar and Kr) gas and an on-axis plasma gun that delivers an ionized deuterium target. The annular supersonic nozzle injector has been studied using Computational Fluid Dynamics (CFD) simulations to produce a highly collimated (M > 5), ∼1 cm radius gas profile that satisfies the theoretical requirement for best performance on ∼1-MA current generators. The CFD simulations allowed us to study output density profiles as a function of the nozzle shape, gas pressure, and gas composition. We have performed line-integrated density measurements using a continuous wave (CW) He-Ne laser to characterize the liner gas density. The measurements agree well with the CFD values. We have used a simple snowplow model to study the plasma sheath acceleration in a coaxial plasma gun to help us properly design the target injector.

Evaluation of patients' expectations and benefits in the treatment of allergic rhinitis with a new tool: the patient benefit index - the benefica study

Background

Symptoms of allergic rhinitis (AR) have a detrimental effect on quality of life. The AR-Patient Benefit Index (AR-PBI), a specific self-assessment tool has been developed to assess treatment-related benefit in two separate sections: the Patient Needs Questionnaire (PNQ) which explores the patient’s expectations before treatment and the Patient Benefit Questionnaire (PBQ) which evaluates treatment benefit. For the PNQ, three dimensions summarize patients’ expectations: symptoms, social life and emotional state, thus covering a larger field than symptomatic relief. The aim of the study was to validate the French language version of the AR-PBI and to assess the treatment-related expectations and benefits provided in patients with allergic rhinitis treated with H1-antihistamines in a real-life study.

Methods

BENEFICA was a prospective, observational study involving patients with allergic rhinitis who were starting treatment with H1-antihistamines. The Patient Needs Questionnaire (PNQ) was administered before treatment (D0) and the Patient Benefit Questionnaire (PBQ) was collected after a 14-day course of H1-antihistamines (D15). Discomfort (visual analog scale), and quality of life (miniRQLQ) were measured on D0 and D15.

Results

Three thousands and eighty-nine patients were enrolled in the study: mean age 39 ± 14 years, women 52%, 81% of patients with moderate to severe persistent rhinitis (Allergic Rhinitis and its Impact on Asthma, ARIA); 19% had (a) concomitant condition(s), 18% were asthmatic, and 12% had atopic dermatitis. Discomfort and quality of life improved between D0 and D15. AR-PBI was 2.7 ± 0.8, superior to 1 (threshold for clinically relevant benefit) for 97% of patients and greater in patients willing to continue the treatment. PBI was moderately correlated to change in miniRQLQ (r = −0.45, p < 0.0001) and change in discomfort (r = −0.38, p < 0.0001), suggesting a richer conceptual content than symptoms relief.

Conclusions

The French version of the Allergic Rhinitis-Patient Benefit Index (AR-PBI) has been validated. It complements the discomfort and quality of life tools and assesses the needs and benefits in patients suffering from allergic rhinitis. This new tool may help physicians to better understand patients’ expectations and to discuss treatment issues with their patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13223-015-0073-1) contains supplementary material, which is available to authorized users.

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.

Tomographic imaging system for measuring impurity line emission in a field-reversed configuration

A 16 chord optical tomography system has been developed and implemented in the flux coil generated-field reversed configuration (FRC). The chords are arranged in two fans of eight, which cover ~35% of the vessel area at the midplane. Each illuminate separate photomultiplier tubes (PMTs) which are fitted with narrow band-pass filters. In this case, filters are centered at 434.8 nm to measure emission from singly ionized argon. PMT crosstalk is negligible. Background noise due to electron radiation and H(γ) line radiation is <10% of argon emission. The spatial resolution of the reconstruction is 1.5 cm. Argon is introduced using a puff valve and tube designed to impart the gas into the system as the FRC is forming. Reconstruction of experimental data results in time-dependent, 2D emissivity profiles of the impurity ions. Analysis of these data show radial, cross-field diffusion to be in the range of 10-10(3) m(2)∕s during FRC equilibrium.

A statement on cefazolin immediate hypersensitivity: data from a large database, and focus on the cross-reactivities

BACKGROUND

More perioperative cefazolin use has resulted in an increased risk of cefazolin-associated reactions.

OBJECTIVE

The aim of this article is to study immediate reactions to cefazolin and attempt to determine possible allergic cross-reactivity with other ß-lactams using data from the Drug Allergy and Hypersensitivity Database (DAHD).

METHODS

All 25 cefazolin-associated reactions in the DAHD were reviewed. The cases identified were then investigated according to the European Network for Drug Allergy (ENDA) recommendations by skin testing and challenges.

RESULTS

A total of 10 individuals with proven IgE-mediated cefazolin hypersensitivity were identified between January 1999 and July 2009. All the index reactions were compatible with an acute IgE-mediated process, six with anaphylaxis, two with systemic allergic reactions without hypotension, and two with urticaria/angioedema. Cefazolin skin tests were positive in seven individuals and cefazolin challenges were positive in three more individuals. In the eight cefazolin allergic patients who had challenges with other ß-lactams, there was no positive reaction noted.

CONCLUSION AND CLINICAL RELEVANCE

In this cohort of patients with IgE-mediated reactions to cefazolin, a majority tolerated amoxicillin and several patients tolerated other cephalosporins. This implies that the R1 side-chain may play an essential role in IgE-mediated reactions to cefazolin. No clear rule to predict cross-reactivity with other ß-lactams could be determined. More research on IgE-mediated hypersensitivity to cefazolin and other cephalosporins is needed.

Spectroscopic measurement of ion temperature and ion velocity distributions in the flux-coil generated FRC

One aim of the flux-coil generated field reversed configuration at Tri Alpha Energy (TAE) is to establish the plasma where the ion rotational energy is greater than the ion thermal energy. To verify this, an optical diagnostic was developed to simultaneously measure the Doppler velocity-shift and line-broadening using a 0.75 m, 1800 groves/mm, spectrometer. The output spectrum is magnified and imaged onto a 16-channel photomultiplier tube (PMT) array. The individual PMT outputs are coupled to high-gain, high-frequency, transimpedance amplifiers, providing fast-time response. The Doppler spectroscopy measurements, along with a survey spectrometer and photodiode-light detector, form a suite of diagnostics that provide insights into the time evolution of the plasma-ion distribution and current when accelerated by an azimuthal-electric field.

Two-chord interferometry using 3.39 μm He-Ne laser on a flux-coil-generated FRC

A two-chord λ(IR)∼3.39 μm He-Ne laser interferometer system was developed for a flux-coil-generated field-reversed configuration to estimate the electron density and the total temperature of the field-reversed configuration (FRC) plasma. This two-chord heterodyne interferometer system consists of a single ∼2 mW infrared He-Ne laser, a visible (λ(vis)∼632.8 nm) He-Ne laser for the alignment, a 40 MHz acousto-optic modulator, photodetectors, and quadrature phase detectors. Initial measurement was performed and the measured average electron densities were 2-10×10(19) m(-3) at two different radial positions in the midplane. A time shift in density was observed as the FRC expands radially. The time evolution of the line-averaged density agrees with the density estimated from the in situ internal magnetic probes, based on a rigid-rotor profile model.

Systematic follow-up increases incidence of anaphylaxis during adverse reactions in anesthetized patients

BACKGROUND

The incidence of hypersensitivity reactions during anesthesia is underestimated because clinical symptoms may vary and diagnosis is not obvious. Our aim was to investigate the consequences of a systematic follow-up of patients on the estimated incidence of allergic reactions during anesthesia.

METHODS

We conducted a prospective study over a 2-year period (70,000 anesthesias). When patients were suspected with hypersensitivity reactions or with unexplained adverse reactions during anesthesia, blood was sampled to measure histamine and tryptase, and then skin tests were performed 4-6 weeks later.

RESULTS

During the studied period, 39 patients were enrolled in the database. Eight were excluded because of lack of skin tests. Twenty-two patients had clinical features compatible with immediate hypersensitivity reaction, and nine had reactions rated as 'unexplained' by the attending physician. Following systematic investigation, we found 22 hypersensitivity reactions (15 patients with obvious and seven with unexplained reactions) during anesthesia. This increases the estimated incidence of hypersensitivity reactions from 1 : 4667 to 1 : 3180 anesthesias. Tryptase concentrations were increased in only 50% of these patients. In our series, positive and negative predictive values of tryptase at T(0) for the diagnosis of anaphylaxis were 100% and 60%, respectively. Latex was the major causative agent, followed by neuromuscular blocking agents and antibiotics.

CONCLUSIONS

Systematic follow-up of patients with unexplained reactions during anesthesia increases the estimated incidence of IgE-mediated hypersensitivity reactions during anesthesia by 50%.

Sublingual-swallow immunotherapy (SLIT) with a standardized five-grass-pollen extract (drops and sublingual tablets) versus placebo in seasonal rhinitis

BACKGROUND

Recent studies have demonstrated the efficacy of sublingual-swallow immunotherapy (SLIT) in seasonal and perennial rhinitis. Sublingual administration of solutions is not convenient for all patients. The aim of the study was to evaluate the efficacy and safety of immunotherapy administered sublingually, initially as drops, and then as tablets during maintenance therapy.

METHODS

A total of 126 patients with grass-pollen seasonal rhinitis were included in this double-blind, randomized, placebo-controlled trial. During the progression of doses phase, the five-grass extract was given as sublingual drops from 1 to 100 IR/ml. Once the 100 IR dose was reached, the drops were replaced by a single 100-IR sublingual tablet per day.

RESULTS

Throughout the grass-pollen season, patients in the active treatment group had significantly lower (P < 0.05) total conjunctivitis and ocular redness scores. Rhinitis symptoms were not significantly different between the two groups. Patients given the active treatment were significantly (P < O.02) less likely to have asthma symptoms. The global medication score showed no significant difference between the two groups. A highly significant difference in favor of the active treatment group was seen in inhaled salbutamol use (P < 0.01).

CONCLUSIONS

Clinical benefits achieved during the present study included significant improvements in conjunctivitis symptoms and prevention of asthma symptoms. The overall safety profile of the active treatment (drops or tablets) was good.

Sublingual-swallow immunotherapy (SLIT) with a standardized five-grass-pollen extract (drops and sublingual tablets) versus placebo in seasonal rhinitis

BACKGROUND

Recent studies have demonstrated the efficacy of sublingual-swallow immunotherapy (SLIT) in seasonal and perennial rhinitis. Sublingual administration of solutions is not convenient for all patients. The aim of the study was to evaluate the efficacy and safety of immunotherapy administered sublingually, initially as drops, and then as tablets during maintenance therapy.

METHODS

A total of 126 patients with grass-pollen seasonal rhinitis were included in this double-blind, randomized, placebo-controlled trial. During the progression of doses phase, the five-grass extract was given as sublingual drops from 1 to 100 IR/ml. Once the 100 IR dose was reached, the drops were replaced by a single 100-IR sublingual tablet per day.

RESULTS

Throughout the grass-pollen season, patients in the active treatment group had significantly lower (P < 0.05) total conjunctivitis and ocular redness scores. Rhinitis symptoms were not significantly different between the two groups. Patients given the active treatment were significantly (P < O.02) less likely to have asthma symptoms. The global medication score showed no significant difference between the two groups. A highly significant difference in favor of the active treatment group was seen in inhaled salbutamol use (P < 0.01).

CONCLUSIONS

Clinical benefits achieved during the present study included significant improvements in conjunctivitis symptoms and prevention of asthma symptoms. The overall safety profile of the active treatment (drops or tablets) was good.

[Peri-anesthesia allergies to antibiotics]

The author reports his personal experience of allergy to antibiotics following anaesthesia. Over a period of four years, corresponding to 5,500 patients who had consulted for reasons of allergy, 32 patients presented per-operative anaphylactic accident of which 5 were attributed to antibiotics (about 15%). Three of these accidents were attributed to cephalosporin, 1 to vancomycin and 1 to erythromicin.

[Portable emergency kits prescribed for patients allergic to hymenoptera venoms]

Allergy to hymenoptera venoms may produce anaphylactic reactions that are severe in 0.8 - 5% of the adult population, according to different epidemiological studies. The risk of a severe reaction in allergic patients who have not been desensitized is 50%. This risk falls to 5 - 10% for allergy to wasp and to 10 - 20% for allergy to bee (1, 2, 3, 4). Because of this serious and vital risk, there is a consensus to prescribe an emergency kit that contains auto-injectable adrenaline (5). An enquiry was made of the allergists of ANAFORCAL and their patients to find the actual practice in comparison with this consensus... 80 physicians and 181 patients replied. It seems that adrenalin is almost always prescribed, together with other products (antihistamines and corticosteroids the most frequent). On the other hand, the following of prescriptions by the patient is not always perfect. It is important therefore to check that the kit is regularly carried, that it is still valid and to be sure that the patient always knows how to manage the product.

[Conjunctivitis, keratitis, keratoconjunctivitis: role of allergy]

The author has counted 0.85% of conjunctivitis in an unselected allergic population of 2,865. All the causes are explored, microbial, viral, metabolic , ophthalmological, drugs, mechanical, allergic... He describes different forms of conjunctivitis amongst which are those of spring time. The roles of the ophthalmologist and allergist are emphasized for establishment of diagnosis and treatment.

[Introduction: can one still desensitize in 1994?]

The immunological component of allergic disease is the subject of constant fundamental research work, but the clinical results of specific immunotherapy are still controversial. Only well constructed clinical studies can prove efficacy and tolerance of the therapy. Therefore it seems to us there should be search for a consensus and a reference system for the therapy, on the basis of rigorous therapeutical tests. It is only thus that the practice of allergology will be recognised and respected in the medical world, for the benefit and health of the patients.

A comparative study of the efficacy and safety of loratadine syrup and terfenadine suspension in the treatment of 3- to 6-year-old children with seasonal allergic rhinitis

The efficacy and safety of loratadine and terfenadine in the treatment of 3- to 6-year-old children with seasonal allergic rhinitis were compared in a third-party-blind, randomized, parallel-group study. A total of 96 children were included in the efficacy analysis: 49 children received 5 or 10 mg of loratadine once daily, and 47 received 15 mg of terfenadine twice daily, for 14 days. The mean total score for both nasal and non-nasal symptoms was decreased significantly from baseline at days 3, 7, and 14 in both treatment groups. At endpoint, these scores had improved 73% in each group. There were no statistically significant differences between the two groups in the total symptom scores at any point during the study. Both treatments were effective in relieving individual nasal and nonnasal symptoms. Therapeutic response to treatment was good or excellent in 82% of loratadine-treated children and in 60% of terfenadine-treated children. Few adverse events were reported during the study; all were mild or moderate and were not significantly different between the two treatment groups. There were no reports of sedation or dry mouth in either group. Once-daily treatment with 5 or 10 mg of loratadine was as effective as twice-daily treatment with 15 mg of terfenadine in improving the symptoms of seasonal allergic rhinitis in children 3 to 6 years old. Both treatments were well tolerated.