Recommendations for Vaccination in Children with Atopic Dermatitis Treated with Dupilumab: A Consensus Meeting, 2020

Dupilumab is the only biologic therapy currently approved in Europe and the United States for severe atopic dermatitis in patients 6 years of age or older. Off-label use is rationalized in younger children with severe atopic dermatitis. Decisions about vaccination for children on dupilumab are complex and depend on both the child’s current treatment and the type of vaccination required. To achieve consensus on recommendations for vaccination of pediatric patients with atopic dermatitis treated with or planning to start dupilumab, a review of the literature and a modified-Delphi process was conducted by a working group of 5 panelists with expertise in dermatology, immunology, infectious diseases and vaccination. Here, we provide seven recommendations for vaccination of pediatric patients with atopic dermatitis treated with or planning to start dupilumab. These recommendations serve to guide physicians’ decisions about vaccination in children with atopic dermatitis treated with dupilumab. Furthermore, we highlight an unmet need for research to determine how significantly dupilumab affects cellular and humoral immune responses to vaccination with live attenuated and inactivated vaccines.

MHC multimer: A Molecular Toolbox for Immunologists

The advent of the major histocompatibility complex (MHC) multimer technology has led to a breakthrough in the quantification and analysis of antigen-specific T cells. In particular, this technology has dramatically advanced the measurement and analysis of CD8 T cells and is being applied more widely. In addition, the scope of application of MHC multimer technology is gradually expanding to other T cells such as CD4 T cells, natural killer T cells, and mucosal-associated invariant T cells. MHC multimer technology acts by complementing the T-cell receptor-MHC/peptide complex affinity, which is relatively low compared to antigen-antibody affinity, through a multivalent interaction. The application of MHC multimer technology has expanded to include various functions such as quantification and analysis of antigen-specific T cells, cell sorting, depletion, stimulation to replace antigen-presenting cells, and single-cell classification through DNA barcodes. This review aims to provide the latest knowledge of MHC multimer technology, which is constantly evolving, broaden understanding of this technology, and promote its widespread use.

Does delayed urticaria induced by drug allergy exist?

With the help of a routine clinical case about delayed urticaria induced by drug, we have analyzed the scientific societies reports published during the last 5 years on this topic. We highlighted the differences between the EAACI consensus and documents on drug allergy, commenting their positions and some of their definitions on delayed urticaria. However, the question of disagreement between definitions of delayed urticaria can generate confusion. It would be beneficial to have more and "official" clearness about this topic because of its important clinical application to our patients.

Benchmarking predictions of MHC class I restricted T cell epitopes in a comprehensively studied model system

T cell epitope candidates are commonly identified using computational prediction tools in order to enable applications such as vaccine design, cancer neoantigen identification, development of diagnostics and removal of unwanted immune responses against protein therapeutics. Most T cell epitope prediction tools are based on machine learning algorithms trained on MHC binding or naturally processed MHC ligand elution data. The ability of currently available tools to predict T cell epitopes has not been comprehensively evaluated. In this study, we used a recently published dataset that systematically defined T cell epitopes recognized in vaccinia virus (VACV) infected C57BL/6 mice (expressing H-2D^b and H-2K^b), considering both peptides predicted to bind MHC or experimentally eluted from infected cells, making this the most comprehensive dataset of T cell epitopes mapped in a complex pathogen. We evaluated the performance of all currently publicly available computational T cell epitope prediction tools to identify these major epitopes from all peptides encoded in the VACV proteome. We found that all methods were able to improve epitope identification above random, with the best performance achieved by neural network-based predictions trained on both MHC binding and MHC ligand elution data (NetMHCPan-4.0 and MHCFlurry). Impressively, these methods were able to capture more than half of the major epitopes in the top N = 277 predictions within the N = 767,788 predictions made for distinct peptides of relevant lengths that can theoretically be encoded in the VACV proteome. These performance metrics provide guidance for immunologists as to which prediction methods to use, and what success rates are possible for epitope predictions when considering a highly controlled system of administered immunizations to inbred mice. In addition, this benchmark was implemented in an open and easy to reproduce format, providing developers with a framework for future comparisons against new tools.

Computational prediction tools are used to screen peptides to identify potential T cell epitope candidates. These tools, developed using machine learning methods, save time and resources in many immunological studies including vaccine discovery and cancer neoantigen identification. In addition to the already existing methods several epitope prediction tools are being developed these days but they lack a comprehensive and uniform evaluation to see which method performs best. In this study we did a comprehensive evaluation of publicly accessible MHC I restricted T cell epitope prediction tools using a recently published dataset of Vaccinia virus epitopes identified in the context of H-2D^b and H-2K^b. We found that methods based on artificial neural network architecture and trained on both MHC binding and ligand elution data showed very high performance (NetMHCPan-4.0 and MHCFlurry). This benchmark analysis will help immunologists to choose the right prediction method for their desired work and will also serve as a framework for tool developers to evaluate new prediction methods.

Considerations for the Child with Nonatopic Asthma

Asthma guidelines provide clinicians with evidence-based management strategies for this chronic condition. The preferred therapy for patient with persistent asthma is inhaled corticosteroids. However, ∼40% of the patients with persistent asthma continue to present with symptoms while treated according to the guidelines. Multiple factors are being explored to explain the variability in response to inhaled corticosteroids including asthma phenotype and genetic predisposition among others. The nonatopic asthma phenotype has been described in the literature. These patients tend to have milder symptoms of asthma and typically outgrow their asthma by adolescence. They present with chronic asthma symptoms in the absence of a positive allergy test, either skin prick test or specific immunoglobulin E blood test. Although patients with nonatopic asthma share many characteristics with patients with atopic asthma, there are several studies that suggest a different inflammatory pathway may be involved in their pathophysiology. Therefore, it is possible that children with nonatopic asthma could respond differently to inhaled corticosteroids compared with those with atopic asthma. Currently there is a variable definition of this phenotype. Furthermore, there is a paucity of therapeutic trial directed toward the patients with nonatopic asthma specifically. Future research should be guided toward identifying the inflammatory pathways in nonatopic asthma and potential phenotype-guided therapies.

Guidelines for the use of flow cytometry and cell sorting in immunological studies (second edition)

These guidelines are a consensus work of a considerable number of members of the immunology and flow cytometry community. They provide the theory and key practical aspects of flow cytometry enabling immunologists to avoid the common errors that often undermine immunological data. Notably, there are comprehensive sections of all major immune cell types with helpful Tables detailing phenotypes in murine and human cells. The latest flow cytometry techniques and applications are also described, featuring examples of the data that can be generated and, importantly, how the data can be analysed. Furthermore, there are sections detailing tips, tricks and pitfalls to avoid, all written and peer-reviewed by leading experts in the field, making this an essential research companion.

Clinical Laboratory Reference Intervals in Ethiopia: Current Status and Future Considerations: Review

<i>Background:</i> Clinical laboratory reference intervals are derived from a sample of selected healthy population and they are used for disease diagnosis, management, and monitoring. International guidelines recommended that laboratories and manufacturers are supposed to establish their own RIs for a certain group of population. Therefore, the aim of this narrative review is to summarize the current status and to show future directions regarding reference intervals of clinical laboratory parameters among Ethiopian population. <i>Methods:</i> PubMed, Google Scholar, and Google databases were searched to access relevant reference interval studies in Ethiopia. Journal articles, guidelines, reports, and related documents published in English language were included without publication period restriction. <i>Results:</i> Fifteen studies were conducted to establish local reference intervals for hematology, immunology, and clinical chemistry parameters in Ethiopia from 1999 - 2018. The majority of those studies determined clinical laboratory reference intervals for adults only. Some other Ethiopian reference interval studies did not include the majority of routine hematology and clinical chemistry parameters. In addition, the studies we reviewed did not consider the cultural, ethnic, demographic, and geographical diversity of Ethiopian population. <i>Conclusions:</i> There is limited data regarding locally established reliable clinical laboratory reference intervals in Ethiopia though attempts are made. Therefore, further local reference interval studies should be undertaken considering the cultural, ethnic, demographical, and geographical diversity of the Ethiopian population.

The Effect of Asthma Clinical Guideline for Adults on Inhaled Corticosteroids PrescriptionTrend: A Quasi-Experimental Study

In order to increase inhaled corticosteroid (ICS) use and to reduce hospitalization, emergency department visits and ultimately the economic burden of asthma, "Korean Asthma Management Guideline for Adults 2007" was developed. To assess the guideline effects on physician's ICS prescription for asthma, we conducted segmented regression and multilevel logistic regression using National Health Insurance claims database of outpatient visits from 2003 to 2010. We set each quarter of a year as a time unit and compared ICS prescription between before and after guideline dissemination. A total of 624,309 quarterly visits for asthma was observed. The ICS prescription rate before and after guideline dissemination was 13.3% and 16.4% respectively (P < 0.001). In the segmented regression, there was no significant guideline effect on overall ICS prescription rate. In multilevel logistic regression analyses, the effect of guideline on overall ICS prescription was not significant (odds ratio, 1.03; 95% CI, 1.00-1.06). In subgroup analysis, ICS prescription increased in secondary care hospitals (odds ratio, 1.15; 95% CI, 1.02-1.30) and in general hospitals (odds ratio, 1.10; 95% CI, 1.04-1.16). However, in primary clinics, which covered 81.7% of asthma cases, there was no significant change (odds ratio, 0.98; 95% CI, 0.94-1.02). From the in-depth interview, we could identify that the reimbursement criteria of the Health Insurance Review and Assessment Service and patient's preference for oral drug were barriers for the ICS prescription. The domestic asthma clinical guideline have no significant effect on ICS prescription, especially in primary clinics.

Consensus document on allergic conjunctivitis (DECA)

Allergic conjunctivitis (AC) is an inflammatory disease of the conjunctiva caused mainly by an IgE-mediated mechanism. It is the most common type of ocular allergy. Despite being the most benign form of conjunctivitis, AC has a considerable effect on patient quality of life, reduces work productivity, and increases health care costs. No consensus has been reached on its classification, diagnosis, or treatment. Consequently, the literature provides little information on its natural history, epidemiological data are scarce, and it is often difficult to ascertain its true morbidity. The main objective of the Consensus Document on Allergic Conjunctivitis (Documento dE Consenso sobre Conjuntivitis Alérgica [DECA]), which was drafted by an expert panel from the Spanish Society of Allergology and Spanish Society of Ophthalmology, was to reach agreement on basic criteria that could prove useful for both specialists and primary care physicians and facilitate the diagnosis, classification, and treatment of AC. This document is the first of its kind to describe and analyze aspects of AC that could make it possible to control symptoms.

Allergic bronchopulmonary aspergillosis

There remains a lack of agreement on diagnostic criteria and approaches to treatment of patients with allergic bronchopulmonary aspergillosis (ABPA). The results of a survey of American Academy of Allergy, Asthma, & Immunology members regarding these 2 issues are presented and compared for concordance with published recommendations. The literature was reviewed for pertinent reports, and an electronic survey was conducted of American Academy of Allergy, Asthma, & Immunology members and fellows regarding diagnostic criteria, numbers of patients evaluated for ABPA, and treatment approaches. From 508 respondents to the survey sent to 5155 US physicians in the American Academy of Allergy, Asthma, & Immunology database of members and fellows, 245 health professionals (48%) had treated at least 1 patient with ABPA in the previous year. For the diagnosis of ABPA, there was a difference in the threshold concentration of total serum IgE because 44.9% used ≥417 kU/L, whereas 42.0% used ≥1000 kU/L. Analysis of these findings suggests that ABPA might be underdiagnosed. With regard to pharmacotherapy, oral steroids were recommended for 97.1% of patients and oral steroids plus inhaled corticosteroids plus antifungal agent were used with 41.2% of patients. The armamentarium for treatment of ABPA includes oral corticosteroids as the initial treatment with inhaled corticosteroids used for management of persistent asthma. Azoles remain adjunctive. Published experience with omalizumab has been limited.

A white paper--consensus and recommendations of a global harmonization team on assessing the impact of immunogenicity on pharmacokinetic measurements

The Global Bioanalysis Consortium (GBC) set up an international team to explore the impact of immunogenicity on pharmacokinetic (PK) assessments. The intent of this paper is to define the field and propose best practices when developing PK assays for biotherapeutics. We focus on the impact of anti-drug antibodies (ADA) on the performance of PK assay leading to the impact on the reported drug concentration and exposure. The manuscript describes strategies to assess whether the observed change in the drug concentration is due to the ADA impact on drug clearance rates or is a consequence of ADA interference in the bioanalytical method applied to measure drug concentration. This paper provides the bioanalytical scientist guidance for developing ADA-tolerant PK methods. It is essential that the data generated in the PK, ADA, pharmacodynamic and efficacy/toxicity evaluations are viewed together. Therefore, the extent for the investigation of the PK sensitivity to the presence of ADA should be driven by the project needs and risk based.

[Diagnosis and therapy of chronic urticaria-what is expected from the revision and update of the international guidelines? A report of the public consensus conference "URTICARIA 2012"]

In November 2012, the 4th International Consensus Meeting on Urticaria ("URTICARIA 2012") took place in Berlin with more than 300 participants. The international and the German guidelines for the definition, classification, diagnosis and management of urticaria are currently being developed based on this meeting. At the time of publication of this article, the guidelines are in the final process of international coordination. The previous international guidelines were updated based on prepared questions as well as a systematic review of the literature by an expert panel. The individual aspects were then discussed with all participants and decided upon, based on the Delphi method with general discussion and open poll. Here, at least a 75 % agreement was required. The new consensus modifies the previous international guidelines on classification and diagnosis and especially on therapy. The treatment algorithm has been changed to a three step approach. The first step is a second generation H1 antihistamine in standard dosage. The second step is increasing the dose up to 4 times the standard dose. In the third step, additional treatment with omalizumab, cyclosporine A or montelukast is recommended as well as possibly systemic corticosteroids for a maximum of 7-10 days. H2 antihistamines and dapsone, which were included in the previous guideline as standard therapies, are no longer recommended for use by the updated and revised guidelines.

The treatment of chronic graft-versus-host disease: consensus recommendations of experts from Germany, Austria, and Switzerland

BACKGROUND

Chronic graft-versus-host disease (cGVHD) is the commonest complication of allogeneic bone marrow and blood stem-cell transplantation, occurring in 50% of all cases and causing late mortality in as many as 25%. There are now about 10 000 patients with cGVHD in Germany, and their number is growing by about 500 each year. cGVHD is a chronic multisystem disease due to impaired tolerance mechanisms. It affects many organs in variable ways, impairing organ function and lowering quality of life.

METHODS

We present consensus recommendations on the treatment of cGVHD that were developed jointly by the German Working Group on Bone Marrow and Blood Stem-Cell Transplantation, the German and Austrian Societies of Hematology and Oncology, the Swiss Blood Stem-Cell Transplantation Group, and the German-Austrian Working Group on Pediatric Stem-Cell Transplantation. All of the recommendations are based on an evaluation of selected publications.

RESULTS

Recommendations are given regarding the diagnostic evaluation of cGVHD, first-line treatment (which has a response rate of 30% to 50%), second-line treatment, and topical immunosuppression. Patients with cGVHD should also receive supportive care including anti-infective prophylaxis, vaccinations, hormone replacement, prevention and treatment of osteoporosis, physiotherapy, rehabilitation, and psychosocial assistance.

CONCLUSION

Patients with cGVHD need multidisciplinary care under the guidance of the transplantation center. The aim of these recommendations is to standardize the treatment of cGVHD and thereby improve patient care.

Allergy prevention

BACKGROUND

Evidence-based primary prevention of allergic conditions is important in view of their increasing prevalence in Western industrialized countries.

METHODS

The Cochrane and Medline databases were searched for relevant scientific publications that appeared from February 2003 to May 2008. Articles in the reference lists of recent reviews were also considered, and experts were directly asked for their opinions. The retrieved publications were screened for relevance by evaluation of the title and abstract, and then by evaluation of the entire text. Each study chosen for inclusion was assigned an evidence grade as well as a grade for study quality relating to its potential for bias (low or high). The revised recommendations were then formally accepted by a consensus of representatives of medical specialist societies and other organizations, including a patient self-help group.

RESULTS

The search initially yielded 4556 results out of which 217 articles (4 Cochrane reviews, 14 meta-analyses, 19 randomized clinical trials, 135 cohort studies, and 45 case-control studies) were chosen for inclusion and critical appraisal. No major changes ensued in the existing recommendations to avoid exposure to tobacco smoke, breast-feed for 4 months (or use hypoallergenic formulas), avoid a mould-promoting indoor climate, avoid exposure to furry pets (particularly cats), and vaccinate according to the current recommendations of the Standing Committee on Vaccination of the Robert Koch Institute (Ständige Impfkommission, STIKO). Neither the delayed introduction of solid food nor the avoidance of potent dietary allergens is recommended as a means of primary prevention. New recommendations were issued regarding fish consumption (by the mother while breastfeeding and nursing, and by the infant as solid food), avoidance of overweight, and reduction of exposure to air pollutants.

CONCLUSIONS

This updated guideline serves as an aid in giving patients current, evidence-based recommendations for allergy prevention.

Suggestions for a uniform terminology in allergology and pneumology

As authors tend to use different terms for the same entity or meaning, it may be the time for a uniformly use terminology in allergology and pneumology. The proposals reflect personal suggestions and are not authorized by any consensus conference, task force or specialized society. Presented are proposals for concepts- it was not intended to give definitions, which would open an even broader field of differing opinions. To avoid misunderstandings and to standardize scientific language, it seems sensible to agree on a single term - even if several alternatives are possible.

[Allergology in Denmark 2006]

Allergic diseases are prominent, possibly life threatening, and a cause of worldwide concern. Evidence-based education of doctors in the specialty of allergology is a prerequisite for correct diagnosis and treatment of patients with allergic diseases. Recently, the specialty of allergology has been abolished in Denmark, without any upgrading of the education of doctors in related specialties. As a consequence, one could fear that allergy expertise will be disappearing. We propose collaboration among experts from related specialties with joint mediation of knowledge through a centre of allergology, common educational programs for doctors in training and physician specialists, and collaboration in regional centres of allergology.

EAACI/GA2LEN position paper: present status of the atopy patch test

A number of scientific reports have been published on patch tests with protein allergens performed on patients with atopic eczema (AE). Evaluation of eczematous skin lesions with an atopy patch test (APT) can be used as a diagnostic tool in characterizing patients with aeroallergen- and food-triggered AE. Indications for testing with APT, choice of allergens (aeroallergens and foods), test materials and technique, including present knowledge on sensitivity and specificity, are reviewed on the basis of available literature. This position paper also points out the need for future research on the clinical use of the APT.

Management of stinging insect hypersensitivity: a 5-year retrospective medical record review

BACKGROUND

The Joint Task Force on Practice Parameters for Allergy and Immunology recommends that patients with a history of a systemic reaction to an insect sting be educated on ways to avoid insect stings, carry injectable epinephrine for emergency self-treatment, undergo specific IgE testing for stinging insect sensitivity, and be considered for immunotherapy.

OBJECTIVE

To review frontline providers' documented care and recommendations for imported fire ant and flying insect hypersensitivity reactions.

METHODS

A retrospective medical record review was performed of emergency department and primary care clinic visits between November 1, 1999, and November 30, 2004. Using International Classification of Diseases, Ninth Revision, codes, medical records were selected for review to identify patients with potential insect hypersensitivity.

RESULTS

A total of 769 medical records from patients who experienced an insect sting were reviewed. Of 120 patients with a systemic reaction, 66 (55.0%) received a prescription for injectable epinephrine, and 14 (11.7%) were given information regarding avoidance of the offending insect. Forty-seven patients with systemic reactions (39.2%) were referred to an allergist. Of 28 patients who kept their appointments and underwent skin testing, 3 had negative results and 25 (89%) had positive results and were advised to start immunotherapy.

CONCLUSION

Adherence to the stinging insect hypersensitivity practice parameter recommendations is poor. Many patients who have experienced a systemic reaction after an insect sting and have sought medical care are not afforded an opportunity for potentially lifesaving therapy.

Proficiency testing in immunopathology: establishing the homogeneity of test material

AIMS

To develop a technique for homogeneity testing of serum aliquot samples suitable for use in the Quality Assurance Program in Clinical Immunology (QAP Pty Ltd).

METHODS

Albumin was selected as the surrogate protein marker for the product to be tested and the coefficient of dispersion (COD) calculated as the measure of homogeneity. To detect changes in the average level of homogeneity, cumulative sum control (cusum) charts were used.

RESULTS

The COD(%) for each triplicate reading of albumin obtained from 34 specimens was normally distributed with a mean of 0.49% and a standard deviation of 0.25%. In industrial quality control schemes the action line is generally set at the upper 99% confidence limits, hence any triplicate sample would be considered to have acceptable homogeneity if the COD was < or = 1.08%. Cusum charts were created to monitor albumin homogeneity over time.

CONCLUSIONS

The use of albumin measurement as the surrogate appears statistically suitable for homogeneity testing in QAP programs for immunodiagnostic testing. CUSUM charts are particularly useful to monitor such homogeneity testing.

United States Pharmacopeia activities in the area of vaccines, virology and immunology

The United States Pharmacopeia (USP) develops public standards for medical products that are enforceable by FDA. USP general information chapters have been providing industrial and academic researchers alike with crucial guidance especially in areas where there is absence of regulatory guidance. In an effort to meet the challenge of rapid advances in vaccine research and manufacturing, the Council of Experts Committee for Vaccines, Virology, and Immunology of the US Pharmacopeia has recently initiated two new general chapters to provide advice for researchers and manufacturers in the vaccine and virology fields and beyond. Chapter 1235 Vaccines and Vaccine Test Methods will focus on manufacturing and analytical requirements for the different types of vaccines currently in manufacture and development. Chapter 1237 Virology Test Methods will discuss modern diagnostic virology techniques and a variety of tests as applicable to vaccine and biologics manufacturing.

Better documentation through standardized forms: what progress have we made since the 1800s?

It has been over a century since allergy skin testing and immunotherapy were first utilized. Both have withstood the test of time and numerous challenges such as cromolyn, antihistamines, and leukotriene modifiers that have threatened to make them obsolete, to continue to play a prominent role in the diagnosis and treatment of the allergic patient. Considerable advances in the understanding of immunotherapy mechanisms and effective allergen dosing as well as improved extract quality have been made in recent years. However, there appears to be a lag in the widespread implementation of these advances into clinical practice, where a broad wide range of practice patterns exists. The wide diversity of allergy practice patterns is likely because of the absence of a uniform curriculum in allergy and immunology training programs. Recently, practice parameters have been developed by the American Academy of Allergy, Asthma and Immunology' Immunotherapy Committee and the Joint Task Force on Practice Parameters, an organization that represents the American Academy of Allergy, Asthma, and Immunology and American College of Allergy, Asthma, and Immunology, aimed at promoting a consistent, objective scientific approach to allergy skin testing and immunotherapy. Standardized allergy skin test and immunotherapy forms were designed to incorporate these guidelines. The following article summarizes the recommendations of the practice parameters and reviews some of the clinical evidence that lends support to these guidelines, which are intended to enhance the safety and efficacy of allergy skin testing and immunotherapy.

A critical appraisal of 'evidence-based medicine' in allergy and asthma

Clinical guidelines are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. They may offer concise instructions on which diagnostic or screening tests to order, stipulate how medical services should be provided, how long patients should stay in hospital, or many other details relevant to clinical practice. This paper argues that guidelines should be simple, adapted to the clinical setting they inform and to treatment availability in their respective geographic context and that they should not be viewed as a yardstick but as support for physicians. The benefits of evidence-based-medicine (EBM), which defines the value of medical interventions in terms of empiric evidence from clinical trials, are growing in many contexts and are well described. Not sufficiently acknowledged, however, are the limits of EBM. A gap still exists between clinical research and clinical practice which should be better recognized and assessed.

Extended histopathology in immunotoxicity testing: interlaboratory validation studies

There has been considerable interest in the use of expanded histopathology as a primary screen for immunotoxicity assessment. To determine the utility of a semiquantitative histopathology approach for examining specific structural and architectural changes in lymphoid tissues, a validation effort was initiated. This study addresses the interlaboratory reproducibility of extended histopathology, using tissues from studies of ten test chemicals and both negative and positive controls from the National Toxicology Program's immunotoxicology testing program. We examined the consistency between experienced toxicologic pathologists, who had varied expertise in immunohistopathology in identifying lesions in immune tissues, and in the sensitivity of the individual and combined histopathological endpoints to detect chemical effects and dose response. Factor analysis was used to estimate the association of each pathologist with a so-called "common factor" and analysis-of-variance methods were used to evaluate biases. Agreement between pathologists was highest in the thymus, in particular, when evaluating cortical cellularity of the thymus; good in spleen follicular cellularity and in spleen and lymph node-germinal center development; and poorest in spleen red-pulp changes. In addition, the ability to identify histopathological change in lymphoid tissues was dependent upon the experience/training that the individual pathologist possessed in examining lymphoid tissue and the apparent severity of the specific lesion.

Raising awareness of the rise in allergy-related conditions

The incidence of allergic disease is increasing, with one in three people now reported as having some kind of allergy. Allergy support groups are working to raise awareness of this increase and also to highlight the inadequacies in NHS allergy management services. This has implications for nursing practice, as nurses are involved in identification and documentation of patients' allergies as well as in the management of allergic reactions including anaphylaxis.

[Diagnosis of allergies]

Various distinct forms of allergic reactions are known (Type I-IV) that demand the appropriate choice of diagnostic procedures. In light of the fact that allergic patients have been offered numerous diagnostic procedures which have proved inappropriate or whose efficacy has not been confirmed, the present review focuses on proven procedures that are in accordance with current guideline recommendations.

[Quality development and quality assurance in allergology]

Since the incidental finding of the anaphylactic reaction allergology has progressed from the empirical medicine emanating from Blackley into a scientifically founded interdisciplinary subject. This development and the resulting improvement of patient care was fundamentally influenced by the research findings and quality efforts of the allergological societies. Quality assurance is solely meant to ensure a certain quality standard. Due to the structural health care reform quality control has been given special emphasis. A deficiency analysis reveals that allergology in the sense of an additional specialisation is limited way too much by the boundaries of the clinical disciplines concerned. Continuing medical education is lacking a standardised subject index. Quality guidelines have been developed under the guidance of the Agency for Quality in Medicine, but have not been passed until the present day. Despite exponentially increasing case numbers allergology further suffers from a lack of quality criteria that would adjust the distribution of remunerations to the actual demand for health care delivery to the general population.