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1.  Montelukast for the high impact of asthma exacerbations in Venezuela: a practical and valid approach for Latin America? 
Background
Asthma affects mainly Venezuela’s urban and poor majority. Exacerbations bring about a high demand in health services, thus becoming a significant public health problem. In general, asthma control programs (GINA) with use of inhaled steroid medications have proven effective, although their implementation in real life remains cumbersome. Montelukast could be a useful and practical tool for these deprived socioeconomic sectors.
Methods
This real-life pilot study was conducted in a prospective, double blinded, placebo-controlled manner with randomized and parallel groups. Asthmatics that had never used leukotriene modifiers were recruited and followed-up every three months. The main outcome was the number of exacerbations meriting use of nebulized bronchodilators administered by the health care system.
Results
Eighty-eight asthmatic patients were enrolled, between children and adults. Groups were comparable in: demographic data, previous use of other medications, ACT scores, pulmonary functions (Wright Peak Flow meter), allergy status (Skin Prick Test) as well as adherence to the prescribed Montelukast treatment. By an intention to treat (ITT), a total of 64 patients were included for analysis. For the three and six months time points the difference between placebo and Montelukast was found to be significant (p < 0.03 and p < 0.04, respectively). Such trends continued for the rest of the year, but without statistical significance, due to patient attrition.
Conclusions
This real-life pilot study shows that a simplified strategy with oral Montelukast was practical and effective in controlling exacerbations in an asthmatic population of a vulnerable community from Caracas. Such an approach reinforces the role of primary care in asthma treatment.
doi:10.1186/1939-4551-7-20
PMCID: PMC4155393  PMID: 25232371
Asthma; Asthma exacerbations; Asthma control; Montelukast; Practical approach; Deprived urban majorities; Venezuela; Latin America
2.  519 Occupational Flaxseed Allergy (Conjunctivitis): A Case Report 
Background
K.F. a19 y/o male, with history of atopy (food/drug allergy, atopic dermatitis, asthma and or rhinitis) developed conjunctivitis (without cough or rhinitis) on the third month of exposure to an enviroment of dust from sieving of grounded flaxseeds (imported brown organic Canadian Flaxseeds). Exposure to this dust caused severe itching and tearing with prominent development of "red eyes" quickly after begining of exposure with complaints abating during weekends. Due to eye scratching he also developed significant palpebral edema and purulent discharge.
Methods
Prick skin Testing (H-S Lancetter, results read at 15 minutes, with positive and negative controls) with a panel of 20 inhalant and food allergens (Diater Labs,Argentina) was performed.
Results
Commercial Allergens were found negative at 10 minutes reading (0 mm papule/0 mm erythema) for inhalants such as: mites, blomia t epithelia, grass pollen, shellfish, fish mix and coconut; only positive finding was to mold mix (5 mm papule/10 mm erythema). Prick to Prick skin (PtP) testing to a solution of flaxseed: 1 gram of flaxseed brought by patient from work place/1 mL of phenol saline, was positive at 20 minutes (papule 12 mm/erythema 25 mm). This same solution was applied to 5 controls (with no symtomps after ingestion of esposure to flaxseed) and found negative.
Conclusions
Patient improved with use of goggles and removal from sieving area, remaining free of symtomps, as of today. Patient refused mucosal/oral challenge with a solution of flaxseed or other allergy diagnostic procedures. Though PtP skin testing may suggest a possible IgE mediated reaction.
Unable to be confirmed by other means (challenge, IgE intears for flaxseed, etc); this is-to our knowledge- the first case of isolated conjunctivitis from exposure to flaxseed sieved dust. Flaxseed Allergy, in spite of its wide spread used and human consumption (mainly as dietary fiber) has been infrequently reported, with occasional cases of anaphylaxis.
We report a case of isolated conjunctivitis on exposure to dust from sievings of ground flaxseed.
doi:10.1097/01.WOX.0000411634.17044.09
PMCID: PMC3512648
3.  Mite-induced inflammation: More than allergy 
Allergy & Rhinology  2012;3(1):e25-e29.
Clinical observations have suggested that there is an association of atopic conditions with hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). This relationship has been especially present in patients allergic to mites. This study was designed to review clinical and experimental evidence linking atopy, mite allergy, and hypersensitivity to aspirin and NSAIDs and discuss the possible mechanisms explaining this association. A review of the medical literature concerning the association of atopic diseases, mite hypersensitivity, and intolerance to NSAIDs using PubMed and other relevant articles is presented. NSAID-sensitive patients are frequently atopic and allergic to mites, and patients who develop oral mite anaphylaxis (OMA) show an increased prevalence of NSAID hypersensitivity. The study of atopic, mite-sensitive patients, who experience urticaria and angioedema when exposed to NSAIDs and patients with OMA suggests an interesting interaction between atopic allergy and disorders of leukotriene synthesis or metabolism. Various mechanisms that could be involved in this interaction are presented, including genetic factors, inhibition of cyclooxygenase-1, and other effects (not related to IgE sensitization) of mite constituents on the immune system. The association of mite hypersensitivity with aspirin/NSAIDs intolerance has been confirmed and provides additional clues to various nonallergic pathways that may contribute to the acute and chronic inflammatory process observed in atopic, mite-allergic, individuals. The clinical relevance of these observations is presently under investigation.
doi:10.2500/ar.2012.3.0025
PMCID: PMC3404474  PMID: 22852126
Aspirin; acetylsalicylic acid; angioedema; cysteinyl-leukotrienes; Dermatophagoides; immunoglobulin E; mites; leukotriene C4 synthase; nonsteroidal anti-inflammatory drugs; NSAIDs
4.  Asthma Care in Resource-Poor Settings 
Asthma prevalence in low-to middle-income countries is at least the same or higher than in rich countries, but with increased severity. Lack of control in these settings is due to various factors such as low accessibility to effective medications, multiple and uncoordinated weak infrastructures of medical services for the management of chronic diseases such as asthma, poor compliance with prescribed therapy, lack of asthma education, and social and cultural factors. There is an urgent requirement for the implementation of better ways to treat asthma in underserved populations, enhancing the access to preventive medications and educational approaches with modern technological methods.
doi:10.1097/WOX.0b013e318213598d
PMCID: PMC3651059  PMID: 23282401
asthma; asthma therapy; inhaled corticosteroids; leukotriene receptor antagonists; socioeconomic aspects
5.  Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs: An Update 
Pharmaceuticals  2010;3(1):10-18.
After beta lactam antibiotics, hypersensitivity reactions to nonsteroidal anti-inflammatory drugs are the second cause of hypersensitivity to drugs. Acute manifestations affect the respiratory tract (aspirin exacerbated respiratory disease), the skin (urticaria and angioedema), or are generalized (anaphylaxis). Correct diagnosis and treatment in order to prevent unnecessary morbidity and the potential risk of death from these severe reactions, and to provide proper medical advice on future drug use frequently requires the participation of allergology specialists familiar with these clinical conditions.
doi:10.3390/ph3010010
PMCID: PMC3991018
asthma; anaphylaxis; drug reactions; non steroidal anti-inflammatory drugs (NSAIDs); urticaria and angioedema
6.  Pancake Syndrome (Oral Mite Anaphylaxis) 
Oral mite anaphylaxis is a new syndrome characterized by severe allergic manifestations occurring in atopic patients shortly after the intake of foods made with mite-contaminated wheat flour. This clinical entity, observed more frequently in tropical/subtropical environments, is more often triggered by pancakes and for that reason it has been designated "pancake syndrome". Because cooked foods are able to induce the symptoms, it has been proposed that thermoresistant allergens are involved in its production. A novel variety of this syndrome occurs during physical exercise and therefore has been named dust mite ingestion-associated exercise-induced anaphylaxis. To prevent mite proliferation and the production of anaphylaxis, it has been recommended that wheat flour be stored at low temperatures in the refrigerator.
doi:10.1186/1939-4551-2-5-91
PMCID: PMC3651046  PMID: 23283016
anaphylaxis; exercise-induced anaphylaxis; food allergy; immunoglobulin E; mites
7.  A Novel Phenotype of Nonsteroidal Anti-Inflammatory Drug Hypersensitivity The High-Risk Patient 
Background
Some nonsteroidal anti-inflammatory drug (NSAID)-hypersensitive patients develop adverse reactions when challenged with weak cyclooxygenase 1 (COX-1) inhibitors.
Objectives
To investigate the prevalence and clinical features of this high-risk population.
Materials and methods
Patients from 2 outpatient allergy clinics consulting between October 2005 and October 2007 because of adverse reactions to classic NSAIDs were submitted to confirmatory double-blind oral challenges with the suspected NSAID and with acetaminophen, preferential and/or specific COX-2 inhibitors. Patients were then classified as low-risk and high-risk groups according to the results of provocation tests.
Results
Three hundred three patients were studied: 179 (59.0%) were tolerant to acetaminophen and the selective COX-2 inhibitors (low-risk group), whereas 124 (40.9%) developed reactions to at least one of the ''low COX-1 inhibitors'' (high-risk group). No distinctive demographic or clinical characteristics were present when both groups of patients were compared.
Conclusions
A large proportion of patients sensitive to classic NSAIDs cannot tolerate the weak COX-1 inhibitors. Oral challenges should be performed by trained specialists to advise these patients about the use of NSAIDs.
doi:10.1097/WOX.0b013e3181971b89
PMCID: PMC3650990  PMID: 23282933
aspirin; angioedema; cyclooxygenases; NSAIDs; urticaria

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