Effects of Er:YAG and Er,Cr:YSGG lasers on dentine hypersensitivity. Short-term clinical evaluation

Dentine hypersensitivity (DH) is a painful condition and is a clinical challenge due to the different treatment strategies available. High-intensity lasers have been studied as a possible option. The aim of this randomized, controlled, double-blind clinical study was to evaluate the effects of Er:YAG and Er,Cr:YSGG lasers on DH. The study group comprised 28 subjects who met the inclusion criteria. A visual analogue scale was used to quantify sensitivity before treatment as baseline, immediately before and immediately after treatment, and 1 week and 1 month after treatment. Teeth were assigned to four groups: group 1 control (no treatment), group 2 Er:YAG laser treatment (2 Hz/32.4 mJ/5.9 J/cm(2)), group 3 Er,Cr:YSGG laser treatment (0.25 W/4.4 J/cm(2)), and group 4 Er,Cr:YSGG laser treatment (0.50 W/ 8.9 J/cm(2)). Data were collected and submitted to statistical analysis for both evaporative (air) and mechanical (probe) stimulation. For both the air and probe stimulation no differences were observed between the pretreatment sensitivities. With the evaporative stimulus, the pain level immediately after treatment was reduced; however, after this the values remained stable. Irradiation with the Er:YAG laser was associated with the lowest level of pain. With the mechanical stimulus, group 4 showed the most pronounced decrease in pain immediately after treatment; however, by the end of the study, pain levels had increased. Groups 1, 2 and 3 showed a reduction in pain that was significantly different from that in group 4 after the 4 weeks of clinical follow up. Based on the results and within the limits of this study, it can be concluded that none of the laser treatments studied was capable of completely eliminating pain, but the Er:YAG and Er,Cr:YSGG lasers are suitable for the treatment of DH.

A cross-sectional study on canine Leishmania (L.) infantum chagasi infection in Amazonian Brazil ratifies a higher prevalence of specific IgG-antibody response than delayed-type hypersensitivity in symptomatic and asymptomatic dogs

This was a cross-sectional study which analyzed the prevalence and the clinical and immunological spectrum of canine Leishmania (L.) infantum chagasi infection in a cohort of 320 mongrel dogs living in an endemic area of American visceral leishmaniasis in the Amazonian Brazil by using, mainly, the indirect fluorescence antibody test (IFAT-IgG) and the delayed-type hypersensitivity (DTH), and the parasite research by the popliteal lymph node aspiration. The IFAT and DTH reactivity recognized three different immune response profiles: (1) IFAT((+))/DTH(-) (107 dogs), (2) IFAT((-))/DTH(+) (18 dogs), and (3) IFAT((+))/DTH(+) (13 dogs), providing an overall prevalence of infection of 43 % (138/320). Thus, the specific prevalence of IFAT ((+)) /DTH ((-)) 33.4 % (107/320) was higher than those of IFAT ((-)) /DTH ((+)) 5.6 % (18/320) and IFAT ((+)) /DTH ((+)) 4.0 % (13/320). Moreover, the frequency of these profiles among 138 infected dogs showed that the IFAT ((+)) /DTH ((-)) rate of 77.5 % (107/138) was also higher than those of 13.0 % (18/138) of IFAT ((-)) /DTH ((+)) and 9.5 % (13/138) of IFAT ((+)) /DTH ((+)) rates. The frequency of asymptomatic dogs (76 %-105) was higher than those of symptomatic (16.6 %-23) and oligosymptomatic ones (7.4 %-10). A total of 16 (11.6 %) L. (L.) i. chagasi isolates were obtained from infected dogs, all from the IFAT ((+)) /DTH ((-)) profile: 41 % (9/22) from symptomatic, 33.3 % (3/9) from oligosymptomatic, and 5.2 % (4/76) from asymptomatic dogs. These findings strongly suggested that despite the higher frequency of asymptomatic dogs (76 %-105), the majority (72.4 %-76) was characterized by the IFAT ((+)) /DTH ((-)) profile with a doubtful immunogenetic resistance against infection.

Perioperative latex hypersensitivity reactions: an integrative literature review

This article characterizes hypersensitivity reactions during anesthetic-surgical procedures. This integrative literature review was conducted in the LILACS, CINAHL, COCHRANE and MEDLINE databases including papers published from 1966 to September 2011. A total of 17 case reports, two prevalence studies and one cohort study were identified. Latex reactions were mainly type III and the primary source of intraoperative reaction was latex gloves. The average time for clinical manifestation was 59.8 minutes after anesthetic induction; 44.4% of patients reported a reaction to latex at the pre-anesthetic evaluation. It was determined that the history of allergic reactions to latex obtained in the pre-anesthetic evaluation does not ensure the safety of patients if the staff is inattentive to the severity of the issue. There is also a tendency to initially attribute the anaphylactic event to the anesthetic drugs.

Drug reaction with Eosinophilia and Systemic Symptoms (DRESS) / Drug-induced Hypersensitivity Syndrome (DIHS): a review of current concepts

The Drug Reaction with Eosinophilia and Systemic Symptoms syndrome, also known as Drug Induced Hypersensitivity Syndrome presents clinically as an extensive mucocutaneous rash, accompanied by fever, lymphadenopathy, hepatitis, hematologic abnormalities with eosinophilia and atypical lymphocytes, and may involve other organs with eosinophilic infiltration, causing damage to several systems, especially to the kidneys, heart, lungs, and pancreas. Recognition of this syndrome is of paramount importance, since the mortality rate is about 10% to 20%, and a specific therapy may be necessary. The pathogenesis is related to specific drugs, especially the aromatic anticonvulsants, altered immune response, sequential reactivation of herpes virus and association with HLA alleles. Early recognition of the syndrome and withdrawal of the offending drug are the most important and essential steps in the treatment of affected patients. Corticosteroids are the basis of the treatment of the syndrome, which may be associated with intravenous immunoglobulin and, in selected cases, Ganciclovir. The article reviews the current concepts involving this important manifestation of adverse drug reaction.

Hypersensitivity reactions to non beta-lactam antimicrobial agents, a statement of the WAO special committee on drug allergy

Antibiotics are used extensively in the treatment of various infections. Consequently, they can be considered among the most important agents involved in adverse reactions to drugs, including both allergic and non-allergic drug hypersensitivity [J Allergy Clin Immunol 113:832–836, 2004]. Most studies published to date deal mainly with reactions to the beta-lactam group, and information on hypersensitivity to each of the other antimicrobial agents is scarce. The present document has been produced by the Special Committee on Drug Allergy of the World Allergy Organization to present the most relevant information on the incidence, clinical manifestations, diagnosis, possible mechanisms, and management of hypersensitivity reactions to non beta-lactam antimicrobials for use by practitioners worldwide.

Tactile perception - Perception of tactile distance changes with body site: a neural network modelling study.

La distorsione della percezione della distanza tra due stimoli puntuali applicati sulla superfice della pelle di diverse regioni corporee è conosciuta come Illusione di Weber. Questa illusione è stata osservata, e verificata, in molti esperimenti in cui ai soggetti era chiesto di giudicare la distanza tra due stimoli applicati sulla superficie della pelle di differenti parti corporee. Da tali esperimenti si è dedotto che una stessa distanza tra gli stimoli è giudicata differentemente per diverse regioni corporee. Il concetto secondo cui la distanza sulla pelle è spesso percepita in maniera alterata è ampiamente condiviso, ma i meccanismi neurali che manovrano questa illusione sono, allo stesso tempo, ancora ampiamente sconosciuti. In particolare, non è ancora chiaro come sia interpretata la distanza tra due stimoli puntuali simultanei, e quali aree celebrali siano coinvolte in questa elaborazione. L’illusione di Weber può essere spiegata, in parte, considerando la differenza in termini di densità meccano-recettoriale delle differenti regioni corporee, e l’immagine distorta del nostro corpo che risiede nella Corteccia Primaria Somato-Sensoriale (homunculus). Tuttavia, questi meccanismi sembrano non sufficienti a spiegare il fenomeno osservato: infatti, secondo i risultati derivanti da 100 anni di sperimentazioni, le distorsioni effettive nel giudizio delle distanze sono molto più piccole rispetto alle distorsioni che la Corteccia Primaria suggerisce. In altre parole, l’illusione osservata negli esperimenti tattili è molto più piccola rispetto all’effetto prodotto dalla differente densità recettoriale che affligge le diverse parti del corpo, o dall’estensione corticale. Ciò, ha portato a ipotizzare che la percezione della distanza tattile richieda la presenza di un’ulteriore area celebrale, e di ulteriori meccanismi che operino allo scopo di ridimensionare – almeno parzialmente – le informazioni derivanti dalla corteccia primaria, in modo da mantenere una certa costanza nella percezione della distanza tattile lungo la superfice corporea. E’ stata così proposta la presenza di una sorta di “processo di ridimensionamento”, chiamato “Rescaling Process” che opera per ridurre questa illusione verso una percezione più verosimile. Il verificarsi di questo processo è sostenuto da molti ricercatori in ambito neuro scientifico; in particolare, dal Dr. Matthew Longo, neuro scienziato del Department of Psychological Sciences (Birkbeck University of London), le cui ricerche sulla percezione della distanza tattile e sulla rappresentazione corporea sembrano confermare questa ipotesi. Tuttavia, i meccanismi neurali, e i circuiti che stanno alla base di questo potenziale “Rescaling Process” sono ancora ampiamente sconosciuti. Lo scopo di questa tesi è stato quello di chiarire la possibile organizzazione della rete, e i meccanismi neurali che scatenano l’illusione di Weber e il “Rescaling Process”, usando un modello di rete neurale. La maggior parte del lavoro è stata svolta nel Dipartimento di Scienze Psicologiche della Birkbeck University of London, sotto la supervisione del Dott. M. Longo, il quale ha contribuito principalmente all’interpretazione dei risultati del modello, dando suggerimenti sull’elaborazione dei risultati in modo da ottenere un’informazione più chiara; inoltre egli ha fornito utili direttive per la validazione dei risultati durante l’implementazione di test statistici. Per replicare l’illusione di Weber ed il “Rescaling Proess”, la rete neurale è stata organizzata con due strati principali di neuroni corrispondenti a due differenti aree funzionali corticali: • Primo strato di neuroni (il quale dà il via ad una prima elaborazione degli stimoli esterni): questo strato può essere pensato come parte della Corteccia Primaria Somato-Sensoriale affetta da Magnificazione Corticale (homunculus). • Secondo strato di neuroni (successiva elaborazione delle informazioni provenienti dal primo strato): questo strato può rappresentare un’Area Corticale più elevata coinvolta nell’implementazione del “Rescaling Process”. Le reti neurali sono state costruite includendo connessioni sinaptiche all’interno di ogni strato (Sinapsi Laterali), e connessioni sinaptiche tra i due strati neurali (Sinapsi Feed-Forward), assumendo inoltre che l’attività di ogni neurone dipenda dal suo input attraverso una relazione sigmoidale statica, cosi come da una dinamica del primo ordine. In particolare, usando la struttura appena descritta, sono state implementate due differenti reti neurali, per due differenti regioni corporee (per esempio, Mano e Braccio), caratterizzate da differente risoluzione tattile e differente Magnificazione Corticale, in modo da replicare l’Illusione di Weber ed il “Rescaling Process”. Questi modelli possono aiutare a comprendere il meccanismo dell’illusione di Weber e dare così una possibile spiegazione al “Rescaling Process”. Inoltre, le reti neurali implementate forniscono un valido contributo per la comprensione della strategia adottata dal cervello nell’interpretazione della distanza sulla superficie della pelle. Oltre allo scopo di comprensione, tali modelli potrebbero essere impiegati altresì per formulare predizioni che potranno poi essere verificate in seguito, in vivo, su soggetti reali attraverso esperimenti di percezione tattile. E’ importante sottolineare che i modelli implementati sono da considerarsi prettamente come modelli funzionali e non intendono replicare dettagli fisiologici ed anatomici. I principali risultati ottenuti tramite questi modelli sono la riproduzione del fenomeno della “Weber’s Illusion” per due differenti regioni corporee, Mano e Braccio, come riportato nei tanti articoli riguardanti le illusioni tattili (per esempio “The perception of distance and location for dual tactile pressures” di Barry G. Green). L’illusione di Weber è stata registrata attraverso l’output delle reti neurali, e poi rappresentata graficamente, cercando di spiegare le ragioni di tali risultati.

Tactile Perception - Perception of tactile distance on a single skin surface changes with stimulus orientation: a neuronal network modelling study

L’interazione che abbiamo con l’ambiente che ci circonda dipende sia da diverse tipologie di stimoli esterni che percepiamo (tattili, visivi, acustici, ecc.) sia dalla loro elaborazione per opera del nostro sistema nervoso. A volte però, l’integrazione e l’elaborazione di tali input possono causare effetti d’illusione. Ciò si presenta, ad esempio, nella percezione tattile. Infatti, la percezione di distanze tattili varia al variare della regione corporea considerata. Il concetto che distanze sulla cute siano frequentemente erroneamente percepite, è stato scoperto circa un secolo fa da Weber. In particolare, una determinata distanza fisica, è percepita maggiore su parti del corpo che presentano una più alta densità di meccanocettori rispetto a distanze applicate su parti del corpo con inferiore densità. Oltre a questa illusione, un importante fenomeno osservato in vivo è rappresentato dal fatto che la percezione della distanza tattile dipende dall’orientazione degli stimoli applicati sulla cute. In sostanza, la distanza percepita su una regione cutanea varia al variare dell’orientazione degli stimoli applicati. Recentemente, Longo e Haggard (Longo & Haggard, J.Exp.Psychol. Hum Percept Perform 37: 720-726, 2011), allo scopo di investigare come sia rappresentato il nostro corpo all’interno del nostro cervello, hanno messo a confronto distanze tattili a diverse orientazioni sulla mano deducendo che la distanza fra due stimoli puntuali è percepita maggiore se applicata trasversalmente sulla mano anziché longitudinalmente. Tale illusione è nota con il nome di Illusione Tattile Orientazione-Dipendente e diversi risultati riportati in letteratura dimostrano che tale illusione dipende dalla distanza che intercorre fra i due stimoli puntuali sulla cute. Infatti, Green riporta in un suo articolo (Green, Percpept Pshycophys 31, 315-323, 1982) il fatto che maggiore sia la distanza applicata e maggiore risulterà l’effetto illusivo che si presenta. L’illusione di Weber e l’illusione tattile orientazione-dipendente sono spiegate in letteratura considerando differenze riguardanti la densità di recettori, gli effetti di magnificazione corticale a livello della corteccia primaria somatosensoriale (regioni della corteccia somatosensoriale, di dimensioni differenti, sono adibite a diverse regioni corporee) e differenze nella dimensione e forma dei campi recettivi. Tuttavia tali effetti di illusione risultano molto meno rilevanti rispetto a quelli che ci si aspetta semplicemente considerando i meccanismi fisiologici, elencati in precedenza, che li causano. Ciò suggerisce che l’informazione tattile elaborata a livello della corteccia primaria somatosensoriale, riceva successivi step di elaborazione in aree corticali di più alto livello. Esse agiscono allo scopo di ridurre il divario fra distanza percepita trasversalmente e distanza percepita longitudinalmente, rendendole più simili tra loro. Tale processo assume il nome di “Rescaling Process”. I meccanismi neurali che operano nel cervello allo scopo di garantire Rescaling Process restano ancora largamente sconosciuti. Perciò, lo scopo del mio progetto di tesi è stato quello di realizzare un modello di rete neurale che simulasse gli aspetti riguardanti la percezione tattile, l’illusione orientazione-dipendente e il processo di rescaling avanzando possibili ipotesi circa i meccanismi neurali che concorrono alla loro realizzazione. Il modello computazionale si compone di due diversi layers neurali che processano l’informazione tattile. Uno di questi rappresenta un’area corticale di più basso livello (chiamata Area1) nella quale una prima e distorta rappresentazione tattile è realizzata. Per questo, tale layer potrebbe rappresentare un’area della corteccia primaria somatosensoriale, dove la rappresentazione della distanza tattile è significativamente distorta a causa dell’anisotropia dei campi recettivi e della magnificazione corticale. Il secondo layer (chiamato Area2) rappresenta un’area di più alto livello che riceve le informazioni tattili dal primo e ne riduce la loro distorsione mediante Rescaling Process. Questo layer potrebbe rappresentare aree corticali superiori (ad esempio la corteccia parietale o quella temporale) adibite anch’esse alla percezione di distanze tattili ed implicate nel Rescaling Process. Nel modello, i neuroni in Area1 ricevono informazioni dagli stimoli esterni (applicati sulla cute) inviando quindi informazioni ai neuroni in Area2 mediante sinapsi Feed-forward eccitatorie. Di fatto, neuroni appartenenti ad uno stesso layer comunicano fra loro attraverso sinapsi laterali aventi una forma a cappello Messicano. E’ importante affermare che la rete neurale implementata è principalmente un modello concettuale che non si preme di fornire un’accurata riproduzione delle strutture fisiologiche ed anatomiche. Per questo occorre considerare un livello astratto di implementazione senza specificare un’esatta corrispondenza tra layers nel modello e regioni anatomiche presenti nel cervello. Tuttavia, i meccanismi inclusi nel modello sono biologicamente plausibili. Dunque la rete neurale può essere utile per una migliore comprensione dei molteplici meccanismi agenti nel nostro cervello, allo scopo di elaborare diversi input tattili. Infatti, il modello è in grado di riprodurre diversi risultati riportati negli articoli di Green e Longo & Haggard.

Type IV delayed-type hypersensitivity of the respiratory tract due to budesonide use: report of two cases and a literature review

Respiratory type-IV hypersensitivity reactions due to corticosteroids is a rare phenomenon. We describe two such cases. The first is a 37- year-old atopic woman who developed labial angioedema and nasal itching after the use of budesonide nasal spray. A month later, after the first puffs of a formoterol/budesonide spray prescribed for asthma, she noticed symptoms of tongue and oropharyngeal itching and redness with subsequent dysphagia, labial and tongue angioedema, and facial oedema. The second is a 15-year-old non-atopic woman who reported pruritic eruptions around the nostrils after using a budesonide nasal spray. A year later she presented with nasal pruritus with intense congestion and labial and facial oedema after using the same spray. Both patients were evaluated with patch-tests using the commercial T.R.U.E. test, a budesonide solution, and corticosteroid creams. Test evaluation was performed at 48 and 96 hours. In both patients, patch tests were positive to budesonide (++) on the second day. The first patient also had a positive (+) reaction to tixocortol-21-pivalate. All the other patch tests were negative. Clinicians should be aware that hypersensitivity reactions may occur during the use of nasal or inhaled corticosteroids.

Drug hypersensitivity reactions involving skin

Immune reactions to drugs can cause a variety of diseases involving the skin, liver, kidney, lungs, and other organs. Beside immediate, IgE-mediated reactions of varying degrees (urticaria to anaphylactic shock), many drug hypersensitivity reactions appear delayed, namely hours to days after starting drug treatment, showing a variety of clinical manifestations from solely skin involvement to fulminant systemic diseases which may be fatal. Immunohistochemical and functional studies of drug-specific T cells in patients with delayed reactions confirmed a predominant role for T cells in the onset and maintenance of immune-mediated delayed drug hypersensitivity reactions (type IV reactions). In these reactions, drug-specific CD4+ and CD8+ T cells are stimulated by drugs through their T cell receptors (TCR). Drugs can stimulate T cells in two ways: they can act as haptens and bind covalently to larger protein structures (hapten-carrier model), inducing a specific immune response. In addition, they may accidentally bind in a labile, noncovalent way to a particular TCR of the whole TCR repertoire and possibly also major histocompatibility complex (MHC)-molecules - similar to their pharmacologic action. This seems to be sufficient to reactivate certain, probably in vivo preactivated T cells, if an additional interaction of the drug-stimulated TCR with MHC molecules occurs. The mechanism was named pharmacological interaction of a drug with (immune) receptor and thus termed the p-i concept. This new concept may explain the frequent skin symptoms in drug hypersensitivity to oral or parenteral drugs. Furthermore, the various clinical manifestations of T cell-mediated drug hypersensitivity may be explained by distinct T cell functions leading to different clinical phenotypes. These data allowed a subclassification of the delayed hypersensitivity reactions (type IV) into T cell reactions which, by releasing certain cytokines and chemokines, preferentially activate and recruit monocytes (type IVa), eosinophils (type IVb), or neutrophils (type IVd).

Investigating interocclusal perception in tactile teeth sensibility using symmetric and asymmetric analysis

The purpose of this clinical trial was to determine the active tactile sensibility of natural teeth and to obtain a statistical analysis method fitting a psychometric function through the observed data points. On 68 complete dentulous test persons (34 males, 34 females, mean age 45.9 ± 16.1 years), one pair of healthy natural teeth each was tested: n = 24 anterior teeth and n = 44 posterior teeth. The computer-assisted, randomized measurement was done by having the subjects bite on thin copper foils of different thickness (5-200 µm) inserted between the teeth. The threshold of active tactile sensibility was defined by the 50% value of correct answers. Additionally, the gradient of the sensibility curve and the support area (90-10% value) as a description of the shape of the sensibility curve were calculated. For modeling the sensibility curve, symmetric and asymmetric functions were used. The mean sensibility threshold was 14.2 ± 12.1 µm. The older the subject, the higher the tactile threshold (r = 0.42, p = 0.0006). The support area was 41.8 ± 43.3 µm. The higher the 50% threshold, the smaller the gradient of the curve and the larger the support area. The curves showing the active tactile sensibility of natural teeth demonstrate a tendency towards asymmetry, so that the active tactile sensibility of natural teeth can mathematically best be described by using the asymmetric Weibull function.

The role of central hypersensitivity in the determination of intradiscal mechanical hyperalgesia in discogenic pain

OBJECTIVE: The primary aim of the present study was to investigate whether there is a relationship between central hypersensitivity (assessed by pressure pain thresholds of uninjured tissues) and intradiscal pain threshold during discography. The secondary aim was to test the hypothesis that peripheral noxious stimulation dynamically modulates central hypersensitivity. PATIENTS: Twenty-four patients with positive provocation discography were tested for central hypersensitivity by pressure algometry before and after the intervention with assessments of pressure pain detection and tolerance thresholds. Intradiscal pain threshold was assessed by measuring intradiscal pressure at the moment of pain provocation during discography. Correlation analyses between intradiscal pain threshold and pressure algometry were made. For the secondary aim, pressure algometry data before and after discography were compared. RESULTS: Significant correlation with intradiscal pain threshold was found for pressure pain detection threshold at the toe (regression coefficient: 0.03, P = 0.05) and pressure pain tolerance thresholds at the nonpainful point at the back (0.02, P = 0.024). Tolerance threshold at the toe was a significant predictor for intradiscal pain threshold only in multiple linear regression (0.036, P = 0.027). Detection as well as tolerance thresholds significantly decreased after discography at the painful and the nonpainful point at the back, but not at the toe. CONCLUSIONS: Central hypersensitivity may influence intradiscal pain threshold, but with a modest quantitative impact. The diagnostic value of provocation discography is therefore not substantially impaired. Regional, but not generalized central hypersensitivity is dynamically modulated by ongoing peripheral nociceptive input.

Osseoperception: active tactile sensibility of osseointegrated dental implants

The phenomenon of developing a certain tactile sensibility through osseointegrated dental implants is called osseoperception. Active tactile sensibility can be tested by having the subject bite on test bodies. The aim of the study was to describe the active tactile sensibility of single-tooth implants based on the 50% value and the slope of the sensibility curve at the 50% value.

Hypersensitivity and oral tolerance in the absence of a secretory immune system

Mucosal immunity protects the epithelial barrier by immune exclusion of foreign antigens and by anti-inflammatory tolerance mechanisms, but there is a continuing debate about the role of secretory immunoglobulins (SIgs), particularly SIgA, in the protection against allergy and other inflammatory diseases. Lack of secretory antibodies may cause immune dysfunction and affect mucosally induced (oral) tolerance against food antigens.

Vaccine hypersensitivity--update and overview

Concerns about possible reactions to vaccines or vaccinations are frequently raised. However, the rate of reported vaccine-induced adverse events is low and ranges between 4.8-83.0 per 100,000 doses of the most frequently used vaccines. The number of true allergic reactions to routine vaccines is not known; estimations range from 1 per 500,000 to 1 per 1,000,000 doses for most vaccines. When allergens such as gelatine or egg proteins are components of the formulation, the rate for serious allergic reactions may be higher. Nevertheless, anaphylactic, potentially life-threatening reactions to vaccines are still a rare event (approximately 1 per 1,500,000 doses). The variety of reported vaccine-related adverse events is broad. Most frequently, reactions to vaccines are limited to the injection site and result from a non specific activation of the inflammatory system by, for example, aluminium salts or the active microbial components. If allergy is suspected, an accurate examination followed by algorithms is the key for correct diagnosis, treatment and the decision regarding revaccination in patients with immediate-type reactions to vaccines.