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Original Article
Clinical and anatomopathological features of eosinophilic oesophagitis in children and adults
A. Agulló-Garcíaa,b,
Corresponding author
aagullog@gmail.com

Corresponding author.
, J.L. Cuberoa,b, A. Lezauna,b, J. Bonéc, I. Guallarc, C. Colása,b
a Allergy Department, University Hospital Lozano Blesa, Zaragoza, Spain
b Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
c Pediatric Allergy Department, University Hospital Miguel Servet, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Eosinophilic oesophagitis &#40;EoE&#41; is a chronic clinical-pathological disorder with an immunological basis in which diagnosis is based on the presence of symptoms related to oesophageal dysfunction and a predominant infiltration of eosinophils on the wall of the oesophagus&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Nowadays it is considered the most common cause of solid-food dysphagia and spontaneous perforation of the oesophagus&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">EoE is more frequent in males &#40;3&#58;1&#41;&#44; with an average age at diagnosis of between 30 and 50 years&#44; although it can occur at any age&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The majority present a personal and&#47;or family history of atopy&#46; Seasonal variations are also observed&#44; with it being more frequent in the pollen season than in winter&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">EoE is predominantly but not exclusively an allergic disease triggered by food allergens&#46; Its pathogenesis seems to depend to a great extent on cell-mediated hypersensitivity&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> These characteristics make EoE a unique and distinct form of food allergy in which the current tests for diagnosing food allergies &#40;skin prick test and specific IgE&#41; are suboptimal for predicting the foods that cause EoE&#44; especially in adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is believed that EoE is caused by an immune response mediated by Th2 cells &#40;involving IL-4&#44; IL-5 and IL-13&#41; to food and&#47;or environmental allergens&#46; IL-5 promotes selective expansion of eosinophils in bone marrow and their release into the circulating blood&#44; whilst IL-13 stimulates the oesophageal epithelium to produce eotaxin-3 &#40;a powerful chemokine that recruits eosinophils in the oesophagus&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> The activated eosinophils release multiple factors that promote local inflammation and tissue damage&#46; In addition to the eosinophils&#44; other inflammatory cells&#44; such as T-cells&#44; mast cells&#44; basophils and NK cells&#44; are also involved&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There are differences in the pathogenesis and clinical presentation between EoE cases in children and adults&#44; which has raised the question of whether they represent different entities of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Infants and small children frequently present feeding difficulties &#40;rejection of food&#44; weight loss&#44; growth retardation&#44; etc&#46;&#41;&#44; while school-age children have a higher probability of presenting vomiting or abdominal pain&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Dysphagia is the predominant symptom in adolescents&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The symptoms in adults with EoE are somewhat stereotyped and include dysphagia&#44; thoracic pain&#44; upper abdominal pain and food impaction &#40;requiring endoscopic extraction of the bolus in 33&#8211;54&#37; of cases<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#41;&#46; Solid-food dysphagia continues to be the most common presenting symptom&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The most frequent complications are nutritional deficiencies in children and oesophageal stenosis and perforation in adults&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Any patient with symptoms suggestive of EoE should have a detailed medical history taken&#44; with particular attention to eating and swallowing habits&#46; The additional tests to be performed for correct diagnosis are the following&#58; &#40;1&#41; upper endoscopy&#58; typical endoscopic alterations with EoE include fixed oesophageal rings &#40;trachealisation&#41; or transient oesophageal rings &#40;felinisation&#41;&#44; whitish exudates&#44; reduction of oesophageal calibre&#44; focal oesophageal strictures&#44; linear furrows&#44; reduced vascularisation and &#8220;crepe paper&#8221; mucosa &#40;a sign of severe mucosal fragility&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> although none of them can be considered pathognomonic for EoE<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#59; &#40;2&#41; biopsy&#58; endoscopy with oesophageal biopsy is the only reliable diagnostic test for EoE&#46; However&#44; the finding of isolated EoE without associating compatible symptoms and ruling out other causes of EoE is insufficient for making the diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> One study identified a diagnostic sensitivity of 84&#37;&#44; 97&#37; and 100&#37; with two&#44; three and six biological samples&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#59; &#40;3&#41; allergy testing&#58; it is important to perform directed anamnesis to assess the possible involvement of foods in the disease&#46; Skin prick tests with aeroallergens and foods&#44; total and specific serum IgE determination and epicutaneous tests with foods &#40;NPV 90&#37;&#41; should be performed&#44; although the latter are not standardised&#46; It is important to interpret the results accurately to avoid unnecessary avoidance diets&#59; &#40;4&#41; biological markers&#58; to date&#44; there is no biological marker available that has demonstrated its utility in monitoring EoE activity&#46; The markers studied include peripheral eosinophilia&#44; total serum IgE and eosinophil mediators&#44; but none of them has demonstrated sufficient specificity and sensitivity and&#44; therefore&#44; are not recommended as a tool for monitoring disease activity&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnostic criteria for EoE are as follows&#58; &#40;a&#41; presence of symptoms related to oesophageal dysfunction&#59; &#40;b&#41; inflammation with predominance of eosinophils in the oesophageal biopsy &#40;&#62;15 intraepithelial eosinophils&#47;high-power field&#41;&#59; &#40;c&#41; limited effect on the oesophagus&#59; &#40;d&#41; exclusion of other causes of EoE&#59; &#40;e&#41; response to treatment with elimination diets and&#47;or corticosteroids &#40;not essential&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the diverse options for treatment of EoE&#44; we find pharmacological therapy&#44; food avoidance diets and oesophageal dilation&#46; Within pharmacological treatment&#44; we find proton pump inhibitors &#40;PPIs&#41; and corticosteroids &#40;CS&#41;&#46; PPIs are important for the differential diagnosis between gastro-oesophageal reflux disease &#40;GORD&#41; and PPI-responsive oesophageal eosinophilia &#40;PPI-ROE&#41;&#46; Whenever there is any suspicion of EoE&#44; treatment should be started with PPIs at high doses and endoscopy repeated after 6-8 weeks to observe the response&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Corticosteroids are powerful anti-inflammatory drugs that help to reduce EoE symptoms&#44; and they can be administered topically &#40;swallowed&#41; or systemically&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are currently three main modalities of dietary therapy for EoE&#58; the elemental diet &#40;consisting of feeding with an elemental formula in which all proteins have been eliminated and nitrogen is supplied exclusively by individual amino acids&#44; making it devoid of antigenic capacity&#41;&#59;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;16</span></a> the elimination diet&#44; guided by food allergy testing &#40;eliminating from the diet foods with positive results in cutaneous and epicutaneous testing&#41;&#59;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;17</span></a> and empirical elimination diets &#40;consisting of eliminating from the diet the six &#91;cow&#39;s milk&#44; wheat&#44; egg&#44; soy&#44; peanut&#47;tree nuts&#44; fish&#44; and seafood&#93;&#44; four &#91;milk&#44; gluten-containing cereals&#44; egg&#44; legumes&#93; or two &#91;milk and gluten-containing cereals&#93; most common trigger foods in EoE and re-evaluating after the re-introduction of each group after objectifying the histological remission&#41;&#46; Elemental diet and empiric six-food elimination diet have consistently shown the best cure rates but their high level of restriction and need for multiple endoscopies have been an obstacle for both patients and physicians&#46; Less restrictive empiric schemes &#40;like four-food or two-food elimination diets&#41; have lately shown encouraging results&#46; Therefore&#44; a novel step-up strategy &#40;2-4-6&#41; can improve patient uptake and promptly identify most responders to few food triggers&#44; besides saving unnecessary dietary restrictions and endoscopic procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;18&#8211;22</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">All dietary treatment strategies are aimed at inducing remission of EoE as a starting point for subsequent identification of possible food triggers&#46; The ultimate objective is to exclude from the diet only the foods responsible for triggering and maintaining the disease in each patient&#46; Therefore&#44; once the biopsy shows remission of eosinophilia&#44; the foods should be reintroduced one by one over a minimum of six weeks&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> with an endoscopy following the reintroduction of each food&#46; Once all the food groups have been reintroduced individually&#44; the triggers identified should be eliminated from the diet indefinitely&#44; whilst the foods that are well tolerated can be eaten regularly&#46; The disassociation between clinical symptoms and histology in EoE has been documented repeatedly in children and adults&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> which implies that the absence of symptoms following the reintroduction of the foods does not necessarily signify remission of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;23</span></a> Due to the lack of non-invasive biomarkers that can adequately predict the presence or absence of eosinophils in the oesophagus&#44; multiple endoscopies with systematic biopsies are currently required to precisely identify the trigger foods&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Our objective is to describe the differences in the epidemiological characteristics&#44; sensitisation profiles&#44; clinical manifestations&#44; endoscopic findings and therapeutic management between a group of paediatric patients and a group of adult patients diagnosed with EoE&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Patients</span><p id="par0070" class="elsevierStylePara elsevierViewall">The inclusion criteria were patients &#40;adults and children&#41; diagnosed with EoE from January 2009 to December 2016&#44; meeting the criteria proposed in the 2011 consensus document by Liacouras et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> EoE diagnosis was understood to mean patients who presented symptoms of oesophageal dysfunction and had &#62;15 eosinophils&#47;high-power field in the oesophageal biopsy&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The existence of other allergic and&#47;or digestive pathologies was not a reason for exclusion&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">This is a descriptive&#44; retrospective&#44; cross-sectional study&#46; A total of 80 patients were selected randomly&#58; 40 paediatric patients from Hospital Universitario Miguel Servet &#40;Zaragoza&#41; and 40 adult patients from Hospital Cl&#237;nico Universitario Lozano Blesa &#40;Zaragoza&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A database of the patients diagnosed with EoE at both hospitals from 2009 to 2016&#44; both inclusive&#44; was available&#46; Using the randomisation function of the software application Excel 2003 &#40;Microsoft&#44; Redmond&#44; WA&#44; USA&#41;&#44; 40 patients from each group were selected&#46; After selecting the 80 patients for the study&#44; work began on a database with the included variables &#40;see <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Once the data from the clinical histories were obtained&#44; the variables were included in an Excel 2003 database&#44; without any data that would identify the patients&#44; for subsequent analysis using the statistics program SPSS 15&#46;0 &#40;Chicago&#44; IL&#44; USA&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">A preliminary descriptive analysis was conducted in which the qualitative data were measured using percentages to express the proportions and frequencies observed&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Next&#44; a comparative analysis between the two patient groups &#40;children vs&#46; adults&#41; was conducted&#46; A univariate analysis was conducted using the specific tests for each variable &#40;Student&#39;s <span class="elsevierStyleItalic">t</span>-test for quantitative variables&#44; chi-squared test for qualitative variables&#41;&#44; considering a significance level with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Epidemiology</span><p id="par0100" class="elsevierStylePara elsevierViewall">A higher proportion of males was observed in both groups&#44; with a ratio of 3&#58;1&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The average age at diagnosis was 10 years in the paediatric group &#91;3&#8211;16&#93; and 34 years in the adults &#91;7&#8211;62&#93;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">There was a predominance of urban population with respect to rural population in both groups&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Noteworthy family histories included three children with a family history of EoE &#40;two brothers and one father&#41;&#46; As regards personal histories&#44; 90&#37; of the children and 77&#46;5&#37; of the adults were atopic&#46; Two children had been treated with milk immunotherapy and five adults with subcutaneous immunotherapy with aeroallergens &#40;pollen&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The characteristics of both groups are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Profile of sensitivities</span><p id="par0125" class="elsevierStylePara elsevierViewall">72&#46;5&#37; of the children and 82&#46;5&#37; of the adults were sensitised to one or more aeroallergens&#44; with a predominance of pollens in both groups&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">70&#37; of the children were sensitised to foods&#44; with the most frequent being nuts&#44; fruits and LTP &#40;lipid transfer protein&#41;&#46; In a lower proportion were legumes and eggs&#44; fish and shellfish&#44; and milk&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Considering positivity to be specific IgE &#62;0&#46;35 KU&#47;L&#44; fruits and nuts predominated&#44; followed by milk&#44; grains&#44; eggs and fish&#47;shellfish&#44; with sensitisation percentages that were slightly higher than for the skin prick tests&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">82&#46;5&#37; of the adults were sensitised to foods&#44; with the most frequent ones being fruits&#44; grains&#44; nuts and LTP&#46; In a lower proportion were legumes&#44; fish&#47;shellfish&#44; eggs&#44; milk and meats&#46; The high percentage of adults sensitised to grains should be noted&#44; 57&#46;5&#37; of these being to corn&#44; 53&#37; to wheat and barley&#44; 26&#37; to rice&#44; and 21&#37; to oats and rye&#46; Statistically significant differences were found in the sensitisation to fruits &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41; and to grains &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Considering positivity to be specific IgE &#62;0&#46;35<span class="elsevierStyleHsp" style=""></span>kU&#47;L&#44; grains&#44; nuts&#44; fruits&#44; LTP&#44; fish&#47;shellfish and milk and egg predominated&#44; with sensitisation percentages that were slightly lower than for the skin prick tests&#44; contrary to the case of children&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Food sensitisation differences between the two groups are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Symptoms</span><p id="par0155" class="elsevierStylePara elsevierViewall">Dysphagia was the most frequent symptom in children&#44; whilst in adults it was impaction&#46; We observed statistically significant differences between the two groups in the presentation of impaction &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; dysphagia &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and abdominal pain &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;034&#41;&#46; Other symptoms&#44; such as gastro-oesophageal reflux &#40;GOR&#41; and thoracic pain&#44; were less frequent&#46; In the paediatric group&#44; there was a small group &#40;7&#37;&#41; that had started with symptoms that were more unspecific&#44; such as constipation&#44; yellow faeces or blood in faeces&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows clinical differences between the two groups</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Diagnosis</span><p id="par0160" class="elsevierStylePara elsevierViewall">In the endoscopies of the paediatric population&#44; the most frequent finding was exudates&#44; whilst in the adult population it was trachealisation&#46; We observed statistically significant differences between the two groups in the endoscopic findings of exudates &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; trachealisation &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; stenosis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;025&#41;&#44; and absence of endoscopic alterations &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The oesophageal biopsies of all the patients in the two groups showed &#62;15 eosinophils&#47;high-power field at diagnosis&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment</span><p id="par0170" class="elsevierStylePara elsevierViewall">Statistically significant differences were observed in treatment with swallowed CS &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; but not in treatment with PPIs&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Both drugs had been administered at different points in time or&#44; in some cases&#44; simultaneously&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">77&#46;5&#37; of the children had followed food elimination diets with one&#44; two&#44; three and four or more foods&#44; and the percentage was observed to increase in proportion to the number of foods eliminated from the diet&#46; The most frequently withdrawn foods were milk&#44; eggs&#44; wheat&#44; nuts and fish&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">75&#37; of the adults followed food elimination diets with one&#44; two&#44; three and four or more foods&#46; The most frequently withdrawn foods were nuts&#44; followed by fruits and grains&#44; mustard and milk&#44; and eggs&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evolution</span><p id="par0190" class="elsevierStylePara elsevierViewall">Of the 25 children treated with PPIs&#44; 28&#37; showed good clinical-pathological response&#59; of the 12 treated with CS&#44; 33&#46;3&#37; responded&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">39&#37; of the children who followed a diet free of one or more foods responded to it&#46; Of the nine children not following a diet free of certain foods&#44; three improved following treatment with PPIs&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Of the 31 adults treated with PPIs&#44; 32&#37; showed good response&#44; 19&#37; did not respond&#44; and in 49&#37; the response was unknown because the protocol of periodic endoscopies could not be followed exactly&#46; Of the patients treated with swallowed CS&#44; the same results were obtained&#44; as many of them were in treatment with both drugs when the biopsy was performed or the response to the other drug had not been ascertained prior to adding or replacing it with the current one&#44; making interpretation of these results invalid&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">36&#46;6&#37; of the adults who followed a diet free of one or more foods responded&#44; with the result being unknown in 33&#37; of the cases &#40;the endoscopy was not performed at the indicated time&#41;&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0210" class="elsevierStylePara elsevierViewall">EoE is a disease of growing interest in which the real prevalence is unknown&#44; but advances in its current recognition have resulted in greater detection of it in patients with high clinical suspicion&#46; It predominantly affects children and young adults of the male sex&#46; In our series&#44; a high predominance of males was observed &#40;3&#58;1&#41; in both groups&#44; which coincides with the findings described in earlier studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;17</span></a> As regards age&#44; EoE can occur at any age&#44; but it is diagnosed predominantly in the paediatric age group and in adults under the age of 45 years&#46; In our sample&#44; the average age at diagnosis was 10 years in the paediatric group and 34 years in the adults&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In the pathogenesis of EoE&#44; an aberrant response to allergens seems to exist&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> which explains why 90&#37; of the children and 77&#46;5&#37; of the adults in our series present a history of atopy&#46; 72&#46;5&#37; of the children and 82&#46;5&#37; of the adults in our sample were sensitised to one or more aeroallergens&#46; 70&#37; of the children and 82&#46;5&#37; of the adults were sensitised to some food&#46; These data are similar to other Spanish series&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;27&#8211;29</span></a> This shows the benefits of allergy testing in these patients&#44; as indicated by other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;26</span></a> Skin prick tests for foods like milk&#44; eggs&#44; soy&#44; wheat&#44; meat or nuts were disproportionately represented in our series compared to others&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Nuts and fruits predominated in the children&#44; whilst in the adults fruits and grains predominated&#44; unlike other studies that indicate milk&#44; eggs and wheat as the most frequently implicated foods&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;26</span></a> In our sample&#44; we found a lower proportion of patients sensitised to milk &#40;17&#37; children and 10&#37; adults&#41;&#44; eggs &#40;27&#37; children 15&#37; adults&#41;&#44; and wheat &#40;5&#37; children and 47&#37; adults&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">The symptoms varied by age&#44; from difficult feeding in infants&#44; vomiting and abdominal pain in school-age children&#44; to dysphagia in adolescents and adults&#46; Significant differences were also observed between the two groups in the forms of clinical presentation&#46; Coinciding with earlier studies&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> dysphagia is the main symptom of EoE&#44; but our series showed different proportions in children &#40;42&#37;&#41; and adults &#40;78&#37;&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Diagnosis requires a high degree of suspicion by the doctor&#44; who needs to be attentive to both the gastrointestinal symptoms of EoE and the accompanying symptoms &#40;growth retardation&#44; allergic rhinitis&#44; asthma&#44; etc&#46;&#41;&#46; An upper digestive endoscopy should be requested&#44; indicating the diagnostic suspicion for adequate visualisation and biopsy and referral to a specialist for an assessment and proper management of the disease&#46; The endoscopic findings of EoE can vary greatly&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> ranging from normal-looking mucosa to significant changes such as whitish exudates&#44; oesophageal rings or oesophageal stenosis&#46; In our sample&#44; we observed different endoscopic findings in the two groups&#44; with exudates being more frequent in children &#40;92&#46;5&#37; vs&#46; 35&#37;&#41; and trachealisation more frequent in adults &#40;50&#37; vs&#46; 5&#37;&#41;&#44; as observed in other series but with a smaller magnitude of the differences &#40;36&#37; vs&#46; 19&#37; and 57&#37; vs&#46; 11&#37; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> We also found stenosis to be more frequent in adults &#40;17&#46;5&#37; vs&#46; 2&#46;5&#37;&#41;&#44; a fact that was not observed in other series &#40;9&#37; vs&#46; 11&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> 2&#37; of the paediatric endoscopies and 25&#37; of the endoscopies of adults in our series were macroscopically normal&#44; which contrasts with other series &#40;21&#37; vs&#46; 15&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> but also justifies the use of oesophageal biopsy in all cases of diagnostic suspicion&#44; even in healthy mucosa&#46; The use of biopsies in patients with suspected EoE has been the subject of extensive studies&#59; as regards the location and number of these&#44; it seems reasonable to say that at least four biopsies&#44; in all the oesophageal segments &#40;proximal and distal&#41;&#44; establish the diagnosis with a high degree of sensitivity and specificity whenever the morphological-histological study demonstrates the presence of intraepithelial eosinophils&#44; thickening of the basal layer and a count of &#62;15 eosinophils per 40x field&#46; In our sample&#44; the presence of these histological findings was demonstrated in all cases&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">One of the advantages of this study is the inclusion of children and adults in our analysis&#44; whilst the majority of studies have focused on a single age group&#46; Hence the main characteristics of the two groups can be compared to observe whether there are differences between them&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The main limitations of our study include its retrospective nature&#44; the small sample size and the variation in the tests of sensitisation to food and environmental allergens among our patients &#40;the same skin prick test and specific IgE determinations were not performed for all of them&#44; as they came from two different hospitals and no established protocol previously existed for allergological assessment of this disease&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">EoE is a complex disease that behaves differently according to the age of onset&#44; calls for a multidisciplinary team for correct assessment and requires new non-invasive techniques to facilitate its management&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In conclusion&#44; in accordance with the literature&#44; our findings show a high prevalence of atopic diseases and sensitisation to food and environmental allergens in both children and adults&#44; as well as differences in the food sensitisation profiles&#44; clinical manifestations&#44; endoscopic findings and treatments received&#46; Knowledge of these differential data can help us to establish a suspected diagnosis of EoE based on the symptoms presented by the patient initially&#59; this would avoid a delay in diagnosis&#44; which is associated with oesophageal remodelling and the development of stenosis&#46; Current data suggest that EoE is the same disease in children and adults taken from the same population&#44; probably representing a different phenotype or spectrum&#44; but more longitudinal studies are needed to show the evolution of the disease in paediatric patients and adults&#46; It is important to clarify this point and try to elucidate whether there are differences in the characteristics&#44; evolution or prognosis of the disease depending on the age at which the disease&#39;s debut occurs&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Disclaimer</span><p id="par0250" class="elsevierStylePara elsevierViewall">Data of this study have not been presented in abstract or poster form at conferences&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding sources</span><p id="par0255" class="elsevierStylePara elsevierViewall">Nil&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Author conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Eosinophilic oesophagitis &#40;EoE&#41; is a chronic clinical-pathological disorder with an immunological basis characterised by symptoms of oesophageal dysfunction and&#44; histologically&#44; eosinophilic inflammation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate the clinical characteristics and differences in children and adults diagnosed with EoE in a tertiary level hospital&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Descriptive&#44; retrospective and cross-sectional study&#46; We randomly selected 40 children and 40 adults diagnosed with EoE between 2009 and 2016&#46; The patient characteristics were analysed by means of epidemiological&#44; clinical&#44; diagnostic and therapeutic variables&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The average age at diagnosis was 10 years &#40;children&#41; and 34 years &#40;adults&#41;&#44; with a higher frequency in males&#46; The majority were sensitised to aeroallergens &#40;77&#46;5&#37; children vs&#46; 82&#46;5&#37; adults&#41; and foods &#40;75&#37; children vs&#46; 82&#46;5&#37; adults&#41;&#46; Statistically significant differences were detected in sensitisation to fruits &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41; and grains &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Differences were observed in impaction &#40;22&#46;5&#37; children vs&#46; 82&#46;5&#37; adults&#41;&#44; dysphagia &#40;42&#46;5&#37; children vs&#46; 77&#46;5&#37; adults&#41; and abdominal pain &#40;25&#37; children vs&#46; 7&#46;5&#37; adults&#41;&#46; Endoscopy showed that children had a higher frequency of exudates &#40;92&#46;5&#37;&#41; and adults&#44; trachealisation &#40;50&#37; vs&#46; 5&#37;&#41; and stenosis &#40;17&#46;5&#37; vs&#46; 2&#46;5&#37;&#41;&#46; Statistically significant differences were found in treatment with topical corticosteroids &#40;30&#37; children vs&#46; 77&#46;5&#37; adults&#41;&#44; with a variable positive response&#46; 77&#46;5&#37; of the patients received elimination diets&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Statistically significant differences were observed between the paediatric and adult populations in the food sensitisation profiles&#44; clinical manifestations&#44; endoscopic findings and treatments received&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This is a complex pathology that calls for a multidisciplinary team and would require new non-invasive techniques to facilitate its management&#46;</p></span>"
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        "etiqueta" => "Figure 2"
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Personal history of atopy</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rhinitis&#47;asthma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Food allergy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Atopic dermatitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Symptoms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dysphagia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">42&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">31&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Impaction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">22&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">82&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abdominal pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">25&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;034&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Thoracic pain&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">12&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>GOR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">17&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Aeroallergen prick test</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pollens&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">62&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Moulds&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Erosions&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 03010546
Original language: English
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2023 September 71 4 75
2023 August 64 15 79
2023 July 63 25 88
2023 June 30 9 39
2023 May 60 14 74
2023 April 65 3 68
2023 March 53 10 63
2023 February 40 13 53
2023 January 58 2 60
2022 December 67 8 75
2022 November 76 15 91
2022 October 43 17 60
2022 September 55 8 63
2022 August 56 19 75
2022 July 40 14 54
2022 June 51 13 64
2022 May 42 19 61
2022 April 45 13 58
2022 March 43 18 61
2022 February 40 13 53
2022 January 33 9 42
2021 December 32 10 42
2021 November 30 23 53
2021 October 42 28 70
2021 September 30 28 58
2021 August 18 13 31
2021 July 27 13 40
2021 June 27 8 35
2021 May 28 16 44
2021 April 89 17 106
2021 March 23 14 37
2021 February 24 21 45
2021 January 24 7 31
2020 December 1 0 1
2020 August 0 3 3
2020 June 0 2 2
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos