VOLUME NUMBER
85 1, PART 1
The Committee reachedunanimous consensusthat present and future standardization criteria will require biologically equivalent allergenic extracts, the reporting of both in vivo and in vitro tests in quantitative terms, and the need for proficiency testing programs. The chief critique of Dr. Daniel was that we did not extend equivalent recommendationsto skin and in vitro testing. On page 496, we state quite clearly in 3.14 that “With respect to both specificity and sensitivity within a population, more researchis neededto determine the predictive abilities of each test. Moreover, the dose(s) and criteria for positive tests used in such studies should be clearly defined.” The entire section on Recommendations concerning late-phase cutaneous reactions (page 499) stresses the need for cooperative assessmentsof techniques and variables known to affect the interpretation of immediate-type skin test responses.The point I am trying to makeis that a careful reading of the section on skin tests will reveal that we approachedthese tests in the sameobjective manner that we did in vitro tests. The recent survey by the College of American Pathologists that was quoted in the letter by Dr. Daniel (The 1988 CAP Surveys, CAP, copyright 1988 by Henry Homburger, MD) was not avaiIable to our group at the time we prepared the Guidelines (1987-1988). It is indeed gratifying to learn that the results of this survey were as promising as was stated in the letter. In any case, our report could only be interpreted as representing the state of the art in June of 1987 at the time our conference was held. We state quite clearly later in the article that advancesin technology and standardization methodology will require revision of our conclusions from time to time. Certainly the members of our Task Force encourage HIMA to seek ways of improving the standardization of in vitro techniques, as outlined in pages 502-503 of our article. We thank Dr. Daniel very much for his sincereexpression of interest. Commentsfrom his Association will be objectively reviewed in the future. but I am sure he will agree that resolution of differing opinions should only be reached by proper documentationof scientific facts. I. Leonard Bernstein, MD Clinical Professor of Medicine and Environmental Health Sciences Codirector of the Allergy ResearchLaboratory and the Allergy Training Program University of Cincinnati Medical Center, ML 563 231 BethesdaAve. (Rm 7346) Cincinnati. OH 45267-0563
Corresponiience
139
If this food challenge is being done and a patient has a diagnosis of atopic dermatitis, rhinitis, or gastrointestinal symptoms without diagnosis of anaphylaxis, asthma, urticaria, or angioedema,it would not be necessaryto do in a gradedfashion (Klein GL, Miller MF, Ziering RW. A Simplified FoodChallenge for Allergic Rhinitis and Atopic Dermatitis. Immunol Allergy Pratt 1985;7(9):373-5).Doing the challenge in a nongraded fashion would save the patients and doctors money and time. Gerald L. Klein, MD, FAAAi, FXAP Allergy and Immunology Medical Group 2067 W Vista Wq. Suite I40 Visfcv CA 92083
To the Editor We thank Dr. Klein for his kind commentsand support asexpressedin his letter. We would agreewith his comment about avoiding gradedchallenges with the following reservations. Somepatients with gastrointestinalsymptomsneed graded challenges because their history describes fairly markedreactionsto small but not accurately specifiedquantities of food. Starting with an amount approximately half that previously incriminated and then using doubling amountsto arrive at a positive challenge has been found to be cost effective and avoids precipitating marked gastrointestinal reactions. Even in patients without a history of severesymptoms, the emesis can be accompaniedby abdominal cramping and can be rather severe. With respect to patientswith atopic dermatitis, a number of thosepatients qorted by authors of the manual have been found to have concomitant symptoms. Unfortunately, history rarely suggestedany gastrointestinalor respiratory symptomsin these patients. Several patients with asthmadid experience sipnificant bronchospasmduring the early stagesof the graded challenge. Ten to fifteen percent of patients experienced markedvomiting and diarrhea. We would therefore suggest extreme caution in administering nongradedchallenges to patients with severeatopic dermatitis. As pointed out in the manual, there are many histories presentedto the allergist that will most likely be refuted by challenge and can easily be evaluatedby the nongradedchalIengesdescribedby Dr. Klein. S. Allan Bock. MD Hugh A. Sampson,MD National Jewish Centerfor Immunology and Respiratory Medicine 1400 Jackson St. Denver, CO $0206
Dfd3bW4, placebo-controlled food dwdlsnge Dear Editor: The article by Bock et al., “Double-blind, placebocontrolled food challenge(DBPCFC) asan office procedure: A Manual” (J ALLERGYCLIN IMMUNOL1988;82:986-97), is excellent. I believe this procedure should be adoptedby clinical allergists with one modification.
Er in To the Editor: Becauseof a transcription error, several sentenceswere left out of the abstract of our article that appearedin the
85 1, PART 1
The Committee reachedunanimous consensusthat present and future standardization criteria will require biologically equivalent allergenic extracts, the reporting of both in vivo and in vitro tests in quantitative terms, and the need for proficiency testing programs. The chief critique of Dr. Daniel was that we did not extend equivalent recommendationsto skin and in vitro testing. On page 496, we state quite clearly in 3.14 that “With respect to both specificity and sensitivity within a population, more researchis neededto determine the predictive abilities of each test. Moreover, the dose(s) and criteria for positive tests used in such studies should be clearly defined.” The entire section on Recommendations concerning late-phase cutaneous reactions (page 499) stresses the need for cooperative assessmentsof techniques and variables known to affect the interpretation of immediate-type skin test responses.The point I am trying to makeis that a careful reading of the section on skin tests will reveal that we approachedthese tests in the sameobjective manner that we did in vitro tests. The recent survey by the College of American Pathologists that was quoted in the letter by Dr. Daniel (The 1988 CAP Surveys, CAP, copyright 1988 by Henry Homburger, MD) was not avaiIable to our group at the time we prepared the Guidelines (1987-1988). It is indeed gratifying to learn that the results of this survey were as promising as was stated in the letter. In any case, our report could only be interpreted as representing the state of the art in June of 1987 at the time our conference was held. We state quite clearly later in the article that advancesin technology and standardization methodology will require revision of our conclusions from time to time. Certainly the members of our Task Force encourage HIMA to seek ways of improving the standardization of in vitro techniques, as outlined in pages 502-503 of our article. We thank Dr. Daniel very much for his sincereexpression of interest. Commentsfrom his Association will be objectively reviewed in the future. but I am sure he will agree that resolution of differing opinions should only be reached by proper documentationof scientific facts. I. Leonard Bernstein, MD Clinical Professor of Medicine and Environmental Health Sciences Codirector of the Allergy ResearchLaboratory and the Allergy Training Program University of Cincinnati Medical Center, ML 563 231 BethesdaAve. (Rm 7346) Cincinnati. OH 45267-0563
Corresponiience
139
If this food challenge is being done and a patient has a diagnosis of atopic dermatitis, rhinitis, or gastrointestinal symptoms without diagnosis of anaphylaxis, asthma, urticaria, or angioedema,it would not be necessaryto do in a gradedfashion (Klein GL, Miller MF, Ziering RW. A Simplified FoodChallenge for Allergic Rhinitis and Atopic Dermatitis. Immunol Allergy Pratt 1985;7(9):373-5).Doing the challenge in a nongraded fashion would save the patients and doctors money and time. Gerald L. Klein, MD, FAAAi, FXAP Allergy and Immunology Medical Group 2067 W Vista Wq. Suite I40 Visfcv CA 92083
To the Editor We thank Dr. Klein for his kind commentsand support asexpressedin his letter. We would agreewith his comment about avoiding gradedchallenges with the following reservations. Somepatients with gastrointestinalsymptomsneed graded challenges because their history describes fairly markedreactionsto small but not accurately specifiedquantities of food. Starting with an amount approximately half that previously incriminated and then using doubling amountsto arrive at a positive challenge has been found to be cost effective and avoids precipitating marked gastrointestinal reactions. Even in patients without a history of severesymptoms, the emesis can be accompaniedby abdominal cramping and can be rather severe. With respect to patientswith atopic dermatitis, a number of thosepatients qorted by authors of the manual have been found to have concomitant symptoms. Unfortunately, history rarely suggestedany gastrointestinalor respiratory symptomsin these patients. Several patients with asthmadid experience sipnificant bronchospasmduring the early stagesof the graded challenge. Ten to fifteen percent of patients experienced markedvomiting and diarrhea. We would therefore suggest extreme caution in administering nongradedchallenges to patients with severeatopic dermatitis. As pointed out in the manual, there are many histories presentedto the allergist that will most likely be refuted by challenge and can easily be evaluatedby the nongradedchalIengesdescribedby Dr. Klein. S. Allan Bock. MD Hugh A. Sampson,MD National Jewish Centerfor Immunology and Respiratory Medicine 1400 Jackson St. Denver, CO $0206
Dfd3bW4, placebo-controlled food dwdlsnge Dear Editor: The article by Bock et al., “Double-blind, placebocontrolled food challenge(DBPCFC) asan office procedure: A Manual” (J ALLERGYCLIN IMMUNOL1988;82:986-97), is excellent. I believe this procedure should be adoptedby clinical allergists with one modification.
Er in To the Editor: Becauseof a transcription error, several sentenceswere left out of the abstract of our article that appearedin the
