We report two schoolchildren who developed dyspnea after eating school lunches that contained Candida utilis (torula yeast) used as a flavoring. Case 1: A seven-year-old boy. The patient had suffered only three asthma attacks up to the time of elementary school entrance, but thereafter visited my clinic because of frequently repeated asthma attacks. His mother reported that he had suffered 11 of 12 asthma attacks on days when soup had been served for school lunch. A subsequent prick test using a sample of the soup elicited a positive result. Case 2: An eight-year-old boy. The patient had suffered from wheezing since the age of two years, but this had improved up to the age of seven years. At eight years of age, however, he had begun to suffer repeated symptoms that included an itchy throat, cough and dyspnea after taking school lunch. These episodes had developed eleven out of twelve times the boy had eaten school lunch containing Candida utilis. He suspected that the soup served may have been the cause of his symptoms, and a subsequent prick test using a sample of the soup elicited a positive result. Both of these patients were positive for specific IgE against Candida utilis, and the percentages of specific IgE inhibition by Candida utilis were 100% and 98.8%, respectively. Both were confirmed to have IgE specific to Candida utilis, and a prick test using a meal sample was useful for diagnosis.

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In 2011, the American Thoracic Society (ATS) has announced the guidelines of Interpretation of Exhaled Nitric Oxide (eNO) for clinical applications, in which eNO values were classified into three zones of low eNO, intermediate eNO and high eNo. However, its practical usefulness has not been clear yet. In this study, we classified asymptomatic asthmatic children over the age of 12, being treated with inhaled corticosteroids, according to ATS zone interpretation added with pulmonary function of %V50 zone classification, and investigated the characteristics of cases belong to low, intermediate and high eNO zones. The results were as follows, 1: significant correlation between IgE and eNO, and between small airways indicators such as %V50 and eNO were re-confirmed, 2: low eNO zone consisted of many mild atopic asthma and a small number of non-eosinophilic asthma. 3: intermediate eNO zone included many atopic cases, so it was necessary for them to check adherence to drug therapy and inhalation technique. 4: high eNO zone consisted of many severe atopic cases with small airway obstruction, so it was necessary for them not only to check the inhalation procedure and the drug adherence, but also to re-assess their asthma control. 5: ATS zone interpretation of eNO added with %V50 zone classification is one of useful clinical tool for management of asthmatic patients.

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Background: The number of patients who use an adrenaline auto-injector (AAI, Epipen^®) is relatively small in Japan, with a usage rate of approximately 1% of the prescribed AAIs. Obtaining practical information on patients who have used these devices would be helpful to predict various scenarios that might occur during any emergency. Method: We retrospectively evaluated the detailed medical records of the patients who used an AAI. Results: There were 25 cases who used an AAI from August 2005 to December 2013. The situations of the causative intake were eating at a restaurant or purchased products (n=10), school lunch (n=8) and oral immunotherapy (n=7). At the time of discovery, about 70% of the cases were presenting with Grade 1-2 on the anaphylaxis grading classification, and only 28% of the cases were discovered with Grade 4 symptoms. The median time between discovery and AAI usage was 20 minutes (0-300 minutes), and was generally less than one hour. Discussion: The cases with absolute indications for AAI use at the onset were limited, and, in many cases, the symptoms progressed to the indication level after discovery. At the time of prescription, it is important for physicians to instruct patients on a systematic approach to treatment, including frequent evaluation of the symptoms, in order to ensure the appropriate timing of injection.

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Objective: As prevalence of food allergy (FA) is increasing, many FA children are taken care in childcare facilities. The aim of this study is to evaluate 10-year changes in food elimination policies in childcare facilities. Methods: An anonymous questionnaire was sent to all childcare facilities (n=401) in Toyama prefecture in March 2012. The results were compared with the data from the previously performed surveys. Results: Out of 282 facilities with complete data, 222 facilities provided elimination diets. Comparing data of the previous surveys, percentages of children receiving elimination diet were significantly increased (2001, 1.2%; 2006, 2.0%; 2012, 3.6%; p<0.001). Approximately half the facilities answered that they knew Allergy Guideline for Nursery, which was issued in March 2011. Percentage of the facilities answered that they knew how to use adrenaline auto-injector was significantly higher in the facilities where they understood the guideline compared to the facilities where they did not (31.0 vs 4.7%, p<0.05). However, 42.2% of the facilities insisted that any medical procedures could not be done by themselves. Conclusions: The number of FA children who were provided elimination diet in childcare facilities is increasing. The guideline should be implemented in more facilities.

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Purpose: The aim of this study was to examine financial effects and change of utilization of hospital beds for managing by introducing the oral food challenge (OFC) test performed on a regular basis in hospital on bed management and hospitalization charges. Method: We compared the monthly number of hospitalized patients and length of hospital stays, as well as bed occupancy rates and hospitalization charges across three time periods: 3 years before the OFC was regularly performed (Period A), 2 years when the OFC was regularly performed (Period B), and 1 year after the OFC was stopped (Period C). Results: The monthly number of hospitalized patients, bed occupancy rate, and hospitalization charges were significantly higher in Period B than in Periods A and C. The length of hospital stays during Period B was also significantly shorter compared to that in the latter two periods. Conclusion: Introduction of the OFC enabled more efficient utilization of hospital beds and led to a significant increase in hospitalization charges. However, charges decreased after the OFC was stopped. These results suggest that performing the OFC regularly in hospital contributes to efficient hospital bed management and an increase in hospitalization charges.

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Purpose: To measure the prevalence of dietary protein enterocolitis among congenital heart disease patients undergoing cardiac surgical procedures, and to identify risk factors in those patients. Patients and Methods: A retrospective chart review was conducted for 451 patients with congenital heart disease undergoing cardiac surgical procedures in the infant period at Chiba Children's Hospital. Results: Among the 451 patients, 14 received a diagnosis of dietary protein enterocolitis. Nine patients were excluded due to congenital malformations of the alimentary tract or acute epidemic gastroenteritis, as other risk factors for development of dietary protein enterocolitis. In the remaining five patients with dietary protein enterocolitis, we assessed associations between congenital heart disease or operation and dietary protein enterocolitis. The prevalence of dietary protein enterocolitis was 5/451 (1.1%). These five patients had high pulmonary flow or underwent systemic-to-pulmonary artery shunting associated with congenital heart diseases. High pulmonary flow or systemic-to-pulmonary artery shunting lead to low intestinal blood flow. The clinical course of these five patients suggests that neonates and infants with these conditions were more likely to develop dietary protein enterocolitis. Conclusion: Patients such as these with low intestinal blood flow should be monitored closely, and appropriate nutritional support is needed to prevent the development of dietary protein enterocolitis.

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Corticosteroids cause growth disorder not only by impairing the GH/IGF-1 axis but also by interfering with cartilage growth plates directly. Even modest doses of corticosteroids as low as 3 mg/m² per day of prednisolone can suppress linear growth. Regarding inhaled corticosteroids (ICS), recent randomized cohort study revealed that the mean adult height was 1.2 cm reduced in patients treated with budesonide. However, as ICS is established as the first-line therapy for children with persistent asthma, the accompanying slight growth suppression may be justified so long as its efficacy surpasses it. Regarding oral corticosteroids, severe adverse events resulting from prolonged use of Celestamine^®, a fixed-dose combination of betamethasone and d-chlor-pheniramine malate, are reported from various institutions. Growth disorder is observed in more than 70% of the reported cases. To prevent growth suppression resulting from the administration of corticosteroids, it is essential to examine the efficacy, toxicity, necessity, and replaceability of the drug and to minimize the total amount and duration of the medication.

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Importance of oral food challenge (OFC) test has been recognized for management of food allergy, and Japan has become one of countries in which doctors perform the test in practice most frequently in the world. However, a variety of information and know-how is required to be accumulated for its actual performance. In the previous issue of this journal, we have written the review paper entitled "Theory and practice of oral food challenge test". In this issue, we are going to touch on specific methods and measures for the evaluation of OFC-induced symptoms, treatments to those symptoms, a system development etc. from the technical point of view, to disseminate OFC test more in the future.

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Non-IgE mediated gastrointestinal food allergy in neonates and infants increases rapidly since around 2000. Because food-specific IgE antibodies are not the center of pathogenic mechanism, diagnosis is not easy. Food challenge test is the only one test that provides a definitive diagnosis. Unlike IgE-mediated food allergy, the reaction starts several hours or days after the challenge. There are cases that require everyday challenge of the allergen for 3 weeks before the start of the response. To rescue hypotensive reaction, glucocorticoids are more effective than epinephrine. Allergen-specific lymphocyte proliferation test is the only test which provide in-vitro allergen-specifying method in the present condition. Since neither sensitivity nor specificity is high, it is necessary to identify responsible T cell subsets and to improve to more effective diagnostic test.

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Immediate-reading skin tests such as prick puncture tests, scratch tests and intradermal tests detect sensitization to a specific allergen and often utilized as a diagnostic tool of IgE-mediated diseases. Since the value of skin tests are dependent on technically correct methodology, practical tips for the correct application of the tests in the diagnosis are described in this review. Patch tests for the diagnosis of contact dermatitis, or delayed hypersensitivity reactions, are also briefly mentioned.

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The histamine release test is in vivo inspection using the basophil. Unlike a food challenge test, there is not the risk of the anaphylactic shock. This test is inspection to evaluate the release of the chemical mediator by the degranulation through IgE-dependent immediate allergic reaction. This histamine release test is effective in the case of food allergy of an egg white, milk and wheat. In addition, there is less pseudo-positive reaction than RAST, and usefulness is high as inspection to cancellation of elimination diet. In Japan, An insurance application is accepted and can carry it out by an examination of outside orders such as SRL. However, evidence of the histamine release test is not enough, and future results of research are expected.

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Serum test for the detection of allergen-specific IgE antibodies is essential test for clinical allergy. However, the demonstration of sensitization is not sufficient to diagnose an allergy, because a sensitized individual may be entirely asymptomatic upon exposure to the allergen in question. Thus, allergy tests must be interpreted in the context of the patient's specific clinical history, food challenge or provocation test, and the diagnosis of an allergic disorder cannot be based solely on a laboratory result. Patients with food-specific IgE antibody levels greater than the 95% predictive value for some foods which have reliable probability curve are extremely likely to experience an allergic reaction if they ingest the food. Therefore, those patients do not need to be challenged to establish a diagnosis of food allergy. Because the test for the detection of allergen-specific IgE antibodies for some foods have poor sensitivity or specificity, clinicians need to pay attention if make a judgment.

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