Oral challenge vs routine care to assess low-risk penicillin allergy in critically ill hospital patients (ORACLE): a pilot safety and feasibility randomised controlled trial

PURPOSE

Critically ill patients are vulnerable to penicillin allergy labels that may be incorrect. The validity of skin testing in intensive care units (ICUs) is uncertain. Many penicillin allergy labels are low risk, and validated tools exist to identify those amenable to direct oral challenge. This pilot randomised controlled trial explored the feasibility, safety, and validity of direct enteral challenge for low-risk penicillin allergy labels in critical illness.

METHODS

Consenting patients with a low-risk penicillin allergy label (PAL) (PEN-FAST risk assessment score < 3) in four ICUs (Melbourne, Australia) were randomised 1:1 to penicillin (250 mg amoxicillin or implicated penicillin) direct enteral challenge versus routine care (2-h post-randomisation observation for each arm). Repeat challenge was performed post -ICU in the intervention arm. Patients were reviewed at 24 h and 5 days after each challenge/observation.

RESULTS

We screened 533 patients. 130 (24.4%) were eligible and 80/130 (61.5%) enrolled (age median 64.5 years (interquartile range, IQR 53.5, 74), PEN-FAST median 1 (IQR 0,1)), with 40 (50%) randomised to direct enteral challenge. A positive challenge rate of 2.5% was identified. No antibiotic-associated serious adverse events were identified. 32/40 (80%) received a repeat challenge (zero positive). Post-randomisation, 13 (32%) of the intervention arm and 4 (10%) of the control arm received penicillin (odds ratio, OR 4.33 [1.27, 14.78] p = 0.019).

CONCLUSION

These findings support the safety, validity, and feasibility of direct enteral challenge for critically ill patients with PEN-FAST assessed low-risk penicillin allergy. The absence of false negative results was confirmed by subsequent negative repeat challenges. A relatively low recruitment to screened ratio suggests that more inclusive eligibility criteria and integration of allergy assessment into routine ICU processes are needed to optimise allergy delabelling in critical illness.

Beyond a vestigial organ: effects of the appendix on gut microbiome and colorectal cancer

The role of appendectomy in the pathogenesis of colorectal cancer (CRC) is a recent topic of contention. Given that appendectomy remains one of the most commonly performed operations and a first-line management strategy of acute appendicitis, it is inherently crucial to elucidate the association between prior appendectomy and subsequent development of CRC, as there may be long-term health repercussions. In this review, we summarize the data behind the relationship of CRC in post-appendectomy patients, discuss the role of the microbiome in relation to appendectomy and CRC pathogenesis, and provide an appraisal of our current understanding of the function of the appendix. We seek to piece together the current landscape surrounding the microbiome and immunological changes in the colon post-appendectomy and suggest a direction for future research involving molecular, transcriptomic, and immunologic analysis to complement our current understanding of the alterations in gut microbiome.

Iranian Journal of Allergy, Asthma, and Immunology: A Bibliometric and Altmetric Analysis from 2005 to 2022

This study aimed to present a bibliometric and altmetric Analyses of the Iranian Journal of Allergy, Asthma, and Immunology (IJAAI). The citation performance and altmetric data were extracted from Scopus and Altmetric Explorer, respectively. Analyses were done using SPSS 26, Microsoft Excel, VOSviewer, and CiteSpace. The results of the bibliometric analysis revealed that IJAAI had experienced respectable growth. Among the total citations, 4746 citations belong to the first decade (2005-2014) and 3,035 citations belong to the second (2015-2022). The findings demonstrated the significance of IJAAI among Iranian researchers. Pourpak, Z (66; 6.57%) is the top-producing author in IJAAI. The examination of research institutions reveals that the Tehran University of Medical Sciences (TUMS) is ranked first. The most highly cited article in IJAAI over the past 18 years is a review article which has received 138 citations. IJAAI is ranked first at the citing source and journal level, with the most citations (249 citations) to IJAAI. Iran has collaborated with 13 other countries. Overall, the analysis of co-occurred keywords indicates that IJAAI authors have used the following three high-frequency and important keywords: Asthma (162), Inflammation (48), and Multiple sclerosis (40). Co-citation analysis results demonstrated that a total of 6,718 sources were cited in this journal. The results of the altmetric analysis show that IJAAI has a reasonably low presence across various social media platforms, including Twitter, Facebook, Wikipedia, Mendeley, news and blogs. This study aids researchers in exploring and identifying emerging trends in the fields of allergy, asthma, and immunology.

Genetic Polymorphisms of GP1BA, PEAR1, and PAI-1 May Be Associated with Serum sIgE and Blood Eosinophil Levels in Chinese Patients with Allergic Diseases

BACKGROUND

It has been suggested that genetic factors may be substantially linked to allergy disorders.

OBJECTIVE

This study aims to investigate the relationship between the serum specific Immunoglobulin E [sIgE], blood eosinophil, and the polymorphisms of glycoprotein Ib alpha gene [GP1BA] rs6065, platelet endothelial aggregation receptor 1 gene [PEAR1] rs12041331, and plasminogen activator inhibitor 1 gene [PAI-1] rs1799762.

METHODS

From the Peking Union Medical College Hospital, this study enrolled 60 healthy participants and 283 participants with allergic diseases. TaqMan-minor groove binder [MGB] quantitative polymerase chain reaction [qPCR] was used to examine the gene polymorphisms in each group.

RESULTS

The TaqMan-MGB qPCR results were completely consistent with the DNA sequencing results, according to other studies in this medical center [Kappa =1, p <0.001]. The GP1BA rs6065, PEAR1 rs12041331, and PAI-1 rs1799762 polymorphisms did not show different distribution between allergy patients and healthy individuals. Concerning allergy patients, the CT [n=33] genotype of GP1BA rs6065 had higher blood eosinophil level than the CC [n=250] genotype [0.59, IQR 0.32-0.72 vs 0.31, IQR 0.15-0.61, *109/L, p =0.005]. The serum sIgE of AA [n=46] genotype of PEAR1 rs12041331 was lower [median 3.7, interquartile quartiles [IQR] 0.2-16.8, kU/L] than the GA [n=136] and GG [n=101] genotypes [GA median 16.3, IQR 3.1-46.3, kU/L, p = 0.002; GG median 12.9, IQR 3.0-46.9, kU/L, p =0.003]. The GA genotypes of PEAR1 rs12041331were with higher blood eosinophil levels [median 0.42, IQR 0.17-0.74 *109/L] than the AA genotype [median 0.25, IQR 0.15-0.41*109/L, p =0.012]. The sIgE of the 5G5G [n=44] genotype of PAI-1 rs1799762 was lower [median 5.0, IQR 0.1-22.8, kU/L] than the 4G5G [n=144] [median 17.3, IQR 3.7-46.0, kU/L, p = 0.012].

CONCLUSION

The GP1BA rs6065, PEAR1 rs12041331, and PAI-1 rs1799762 polymorphisms may be associated with the genetic susceptibility of serum sIgE or blood eosinophil in Chinese allergic disease patients.

Elevated serum IL-6 levels predict treatment interruption in patients with moderate to severe psoriasis: a 6-year real-world cohort study

BACKGROUND

Real-world, primary data on the treatment of psoriasis are scarce, especially concerning the role of soluble biomarkers as outcome predictors.

OBJECTIVE

The authors evaluated the utility of Th1/Th17 serum cytokines along with clinical characteristics as predictors of drug survival in the treatment of psoriasis.

METHODS

The authors consecutively included participants with moderate to severe psoriasis who were followed up for 6 years. Baseline interferon-α, tumor necrosis factor-α, and interleukin (IL)-2, IL-4, IL-6, IL-10, and IL-17A were measured using a cytometric bead array; clinical data were assessed. The authors calculated hazard ratios (HRs) for drug survival using a Cox proportional hazards model.

RESULTS

The authors included 262 patients, most of whom used systemic immunosuppressants or biologics. In the multivariate model, poor quality of life measured by the Dermatology Life Quality Index (HR = 1.04; 95% CI 1.01‒1.07; p = 0.012) and elevated baseline IL-6 (HR = 1.99; 95% CI 1.29‒3.08; p = 0.002) were associated with treatment interruption.

STUDY LIMITATIONS

The main limitation of any cohort study is the presence of confounders that could not be detected in clinical evaluation.

CONCLUSIONS

Poor quality of life and elevated baseline serum IL-6 level predicted treatment interruption in patients with moderate to severe psoriasis. Although IL-6 is not the most important mediator of the inflammatory pathway in the skin environment, it is an interesting biomarker candidate for predicting psoriasis treatment response.

Age-related differences in IgE between childhood and adulthood allergic asthma: Analysis of NHANES 2005-2006

Background

Asthma exhibits varying clinical features in children and adults. However, previous studies have mainly focused on the clinical significance of immunoglobulin E (IgE) in the diagnosis and treatment of asthma, disregarding the characteristics of IgE and its relevant factors.

Objective

This study aimed to gain a better understanding of the differences in the characteristics of IgE between childhood and adulthood allergic asthma (AA).

Methods

Patients with AA from the 2005 to 2006 National Health and Nutrition Examination Survey (NHANES) were divided into 3 groups based on their current age and onset age of AA: childhood AA (Group 1), childhood-onset adult AA (Group 2), and adulthood-onset AA (Group 3). Intragroup analysis and intergroup comparison were carried out, focusing on the characteristics and relevant factors of IgE, as well as the clinical relevance of total IgE (total IgE, tIgE) and allergen-specific IgE (allergen-specific IgE, sIgE).

Results

A total of 424 patients were analyzed, including 187 with childhood AA, 132 with childhood-onset adult AA, and 105 with adulthood-onset AA. The concentration of tIgE was found to be higher in Group 1 (268.0, 118.0-686.0 kU/L) than in Group 2 (224.0, 78.0-494.0 kU/L) and Group 3 (165.0, 74.4-350.5 kU/L). The sensitization rates did not differ between Group 1 and Group 2 but were higher compared with Group 3, particularly for Alternaria-sIgE (50.3% and 46.2% vs 15.2%) and Aspergillus-sIgE (43.9% and 37.1% vs 16.2%). In Group 1, there was a negative correlation between pollen-sIgEs and indoor allergens, but this correlation was not commonly observed in Group 2 and Group 3. On the other hand, in Group 1, environmental chemicals such as phthalates, polyaromatic hydrocarbons, trihalomethanes, and phenols showed a positive correlation with IgE. However, a greater number of chemicals was observed in Group 2 and Group 3, including cotinine, metals, trihalomethanes, phthalates, phenols, and other volatile organic compounds (VOCs). Furthermore, in Group 1, IgE was positively correlated with asthma-related issues such as emergency visits, absenteeism, limited activities, and medication needs. These correlations were less common in Group 2 and Group 3, particularly in Group 3.

Conclusions

There are notable differences in the characteristics and environmental factors of IgE among childhood AA, childhood-onset adult AA, and adulthood-onset AA. Additionally, IgE plays a more significant role in childhood AA due to its higher concentration, fewer relevant environmental chemicals and greater clinical relevance. This may partially explain the age-related features of asthma.

Connection between maternal suicide attempt and chronic morbidity in children

BACKGROUND

Maternal suicide attempts are associated with adverse psychosocial outcomes in children, but the association with chronic morbidity is poorly understood. We examined the relationship between maternal suicide attempt and risk of hospitalization for potentially preventable conditions in offspring.

METHODS

We analyzed a longitudinal cohort of 1 032 210 children born in Quebec, Canada between 2006 and 2019. The main exposure measure was maternal suicide attempt before or during pregnancy. Outcomes included child hospitalizations for potentially preventable conditions, including infectious diseases, dental caries, atopy, and injury up to 14 years after birth. We used adjusted Cox proportional hazards regression models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of maternal suicide attempt with risk of hospitalization for these outcomes.

RESULTS

Compared with no suicide attempt, children whose mothers attempted suicide had an increased risk of hospitalization for infectious diseases (HR 1.11, 95% CI 1.06-1.16), dental caries (HR 1.31, 95% CI 1.15-1.48), and injury (HR 1.16, 95% CI 1.03-1.31). Risk of hospitalization for any of these outcomes was greater if mothers attempted suicide by hanging (HR 1.46, 95% CI 1.22-1.75), had their first attempt between the age of 25 and 34 years (HR 1.27, 95% CI 1.13-1.42), and had 3 or more attempts (HR 1.56, 95% CI 1.27-1.91). Maternal suicide attempts were more strongly associated with child hospitalization before 10 years of age.

CONCLUSIONS

Children whose mothers have a history of suicide attempt have an elevated risk of hospitalization for potentially preventable conditions.

Dose adjustment of rheumatology and allergy/immunology medications in chronic kidney disease: awareness and knowledge among internal medicine housestaff

Background

Patients with chronic kidney disease (CKD) are at increased risk for adverse drug events due to medication dosing errors. We studied the awareness and knowledge among internal medicine housestaff (IMHS) of proper dose adjustment of commonly used rheumatology and allergy/immunology medications for patients with CKD.

Methods

We surveyed 353 IMHS to evaluate their awareness of the need for medication dose adjustments for patients with CKD and knowledge for medication adjustment by level of glomerular filtration rate for common rheumatology and allergy/immunology medications.

Results

There was lack of awareness and knowledge for both rheumatology and allergy/immunology medications. Incorrect awareness and knowledge were as follows: allopurinol, 21.2%, 73.4%; colchicine, 19.0%, 75.9%; diphenhydramine, 34.0%, 34.0%; loratadine, 82.2%, 93.2%; and montelukast, 34.0%, 34.0%, respectively. Exploratory logistic regression analyses showed that PGY1 residents had higher odds for lack of awareness for allopurinol (odds ratio [OR] 24.57, 95% CI [confidence interval] 4.69, 99.13, P < 0.001), colchicine (OR 3.98, 95% CI 1.50, 10.51, P < 0.01), diphenhydramine (OR 2.24, 95% CI 1.10, 4.54, P < 0.04), and montelukast (OR 2.45, 95% CI 1.20, 5.00, P < 0.05) than PGY3 residents. A nephrology rotation in medical school was associated with lower odds for incorrect knowledge for allopurinol (OR 0.46, 95% CI 0.25, 0.87, P < 0.05) and montelukast (OR 0.50, 95% CI 0.27, 0.92, P < 0.05).

Conclusion

Overall, awareness and knowledge were poor among IMHS for dose adjustments of rheumatology and allergy/immunology medications in patients with CKD. Proper education and exposure to nephrology during training may improve quality and safety of care for patients with CKD.

[Neuroimmunology of allergic rhinitis : Part 1: Cellular and humoral basic principles]

Allergic rhinitis (AR) is a very common disease with a high prevalence worldwide. It is an IgE-mediated type 2 inflammatory disease following exposure to inhalant allergens. A multitude of different neuropeptides including substance P, vasoactive intestinal peptide (VIP), calcitonin gene-related peptide (CGRP), nerve growth factor (NGF), and neuromedin U (NMU) can be released via peripheral axon or central reflexes, interact with immune cells, and thus contribute to neurogenic inflammation which causes the nasal hyperreactivity (NHR) characteristic of AR. Independent production of neuroendocrine hormones and neuropeptides by immune cells has also been demonstrated. Neuro-immune cell units arise when immune and neuronal cells colocalize, for which typical anatomic regions are, e.g., the mast cell-nerve functional unit. The focus of this review is the elucidation of neuroimmune communication mechanisms in AR.

Aspergillus fumigatus-Specific T Cells in Patients with Chronic Rhinosinusitis

INTRODUCTION

Aspergillus fumigatus belongs to the saprophytic fungi, and its spores form a significant part of the daily load of fungal spores inhaled as particles in aerosols. A. fumigatus is a possible T-cell activator. Its contribution to the pathogenesis of chronic rhinosinusitis (CRS) is controversially discussed. The aim of this study was to detect and characterize A. fumigatus-specific CD4+ and CD8+ T cells in patients with CRS with (CRSwNP) and without (CRSsNP) nasal polyps.

METHODS

Tissue and blood samples were collected from patients who underwent paranasal sinus surgery due to CRSwNP or CRSsNP. Afterward, purified CD4+ and CD8+ cells were cultured together with antigen-presenting cells. A peptide mix derived from A. fumigatus antigen was added to the cultures. After 6 days, multicolor flow cytometry was performed, and proliferation was measured using the marker Ki-67. Cytokine secretion was quantified from the supernatant of the cell culture.

RESULTS

Significant differences in the proliferation of nasal CD4+ T cells to A. fumigatus antigen were observed for cells from patients with CRSwNP in comparison to CRSsNP, while no differences were found between nasal and peripheral blood T cells. The activation of tissue-derived CD4+ T cells was associated with significantly higher concentrations of IL-4, IL-5, and IL-17a in the cell culture from patients with CRSwNP in comparison to CRSsNP and/or healthy controls.

CONCLUSION

Our findings indicate that patients with CRSwNP harbor a higher proportion of A. fumigatus-reactive CD4+ T cells in the nasal mucosa than patients with CRSsNP. A. fumigatus-reactive CD4+ T cells of CRSwNP patients secreted TH2 cytokines and IL-17. Our findings suggest a role for A. fumigatus in the pathogenesis of CRSwNP and provide a rationale for targeted therapies.

Artificial Intelligence in Allergy and Immunology: Comparing Risk Prediction Models to Help Screen Inborn Errors of Immunity

BACKGROUND

Inborn errors of immunity (IEI) are underdiagnosed disorders, leading to increased morbimortality and expenses for healthcare system.

OBJECTIVES

The study aimed to develop and compare risk prediction model to measure the individual chance of a confirmed diagnosis of IEI in children at risk for this disorder.

METHOD

Clinical and laboratory data of 128 individuals were used to derive machine learning (ML) and logistic regression risk prediction models, to measure the individual chance of a confirmed diagnosis of IEI in children with suspected disorder, according to previous general pediatrician/clinician judgement. Their performances were compared.

RESULTS

Statistically significant variables were mainly leucopenia, neutropenia, lymphopenia, and low levels of immunoglobulins A/G/M. ML models performed better.

CONCLUSION

The enhanced predictive power provided by ML models could be a resource to track IEI, providing better healthcare outcomes.

Gastrointestinal IgG4 Deposition Is a New Histopathological Feature of Eosinophilic Gastroenteritis

BACKGROUND

The pathogenesis of eosinophilic esophagitis involves immunoglobulin G4 (IgG4) deposition. However, the relationship between IgG4 and eosinophilic gastroenteritis (EGE) is unclear.

AIMS

To investigate gastrointestinal deposition of IgG4 in EGE.

METHODS

Biopsies of the esophagus, stomach, and small intestine were evaluated in patients with and without EGE. Immunohistochemical staining for IgG4 was performed, and the proportions of the stained areas were compared. Sera from patients with EGE were assayed for food-specific IgG4, including egg white, wheat, rice, soy, and cow milk.

RESULTS

Seventeen patients were included in this study (EGE group, n = 10; control group, n = 7). Compared with the control group, the proportion of IgG4-stained area in the EGE group was approximately threefold higher (40.2% [32.3-49.5]) vs. 12.1% [4.0-21.9], p = 0.014) in the esophagus, fivefold higher in the stomach (17.3% [11.1-26.2] vs. 3.7% [1.5-5.2], p = 0.014), and sixfold higher in the small intestine (28.0% [15.0-33.2] vs. 4.5% [2.6-9.8], p = 0.019). There was no significant association between the proportion of IgG4-stained area and the number of infiltrating eosinophils. Serum egg white-specific IgG4 levels were correlated with the proportion of IgG4-stained areas in the small intestine (R = 0.7, p = 0.035).

CONCLUSIONS

IgG4 accumulated within the gastrointestinal mucosa in EGE. The positive correlation between serum egg white-specific IgG4 levels and the proportion of IgG4-stained areas in the small intestine suggests a role for IgG4 in the disease pathophysiology.

The Effects of Combined Therapeutic Protocol on Allergic Rhinitis Symptoms and Molecular Determinants

Current medications to treat allergic rhinitis (AR) include antihistamines, corticosteroids, and anti-leukotrienes. In the present study, we investigated the effects of combination therapy; using these drugs, and evaluates the AR-related markers and parameters in an animal model. After inducing BALB/c mice AR models, the animals were treated with either pranlukast, loratadine, fluticasone, loratadine + fluticasone, loratadine + pranlukast, fluticasone + pranlukast, or loratadine + fluticasone + pranlukast. Clinical symptoms, Immunoglobulin (Ig)G1, ovalbumin (OVA)-specific and total IgE, leukotriene (LT)B4, LTC4, histamine, thymic stromal lymphopoietin (TSLP) serum levels, and interleukin 4 level in the nasal lavage fluid were determined. The expressions of HRH1, CysLT1R, NLR3, Caspase-1, and MUC5a were studied. Allergic symptoms (nasal rubbing and sneezing), serum Igs (IgG1, total and OVA-specific IgE), eicosanoids (LTB4 and LTC4), histamine, TSLP, and IL-4 as well as gene expressions of MUC5a, Caspase-1, NLR3, HRH1, and CysLT1R were reduced in the animals receiving each of the therapeutic regimens; however, more pronounced effects were seen in the group treated with the triple combined protocol (loratadine + fluticasone + pranlukast). The combination of the loratadine, fluticasone, and pranlukast can effectively control the symptoms of AR probably via modulating several related mechanisms at early and late phases of allergic responses.

Study Effect of Azithromycin and Doxycycline in Mucus Producing and Inflammatory Signaling Pathways of Allergic Asthma

Asthma is a respiratory disease; involving millions of people worldwide. The main cause of asthma is allergy and immune response dysregulation. The effects of azithromycin and doxycycline as asthma-controlling drugs were evaluated in this study. Mice asthma model was produced and asthmatic mice were treated with azithromycin (75 mg/kg, orally) and doxycycline (20 mg/kg, orally). Eosinophils and neutrophils count, interleukin (IL)-4, IL-5, IL-12, IL-13, and total immunoglobulin E (IgE) levels were measured. Histological study and evaluating the genes expression of Muc5ac, Muc5b, IL-33, COX2, MYD88, and TRAF6 were performed. Azithromycin and doxycycline did not affect eosinophil and neutrophil percentage, IL-4, IL-5, IL-12, and total IgE levels, peribronchial and perivascular inflammation, goblet cell hyperplasia, and gene expression of MYD88, TRAF6, and COX2. Treatment with azithromycin significantly decreased IL-13 level, mucus secretion, and gene expression of IL-33, Muc5ac, and Muc5b; compared to the non-treated asthma group. Azithromycin administration controls mucus secretion and inflammation. Azithromycin therapy and not doxycycline might be an effective adjuvant option in asthma with reducing mucus in the airway.

Drug-induced hepatitis after Sinopharm COVID-19 vaccination: A case study of a 62-year-old patient

Introduction

COVID-19 virus pandemic has begun since 2020 and became one of the most important causes of mortalities. Accordingly, vaccination has found a vital role in control of COVID-19 virus. Despite many advantages of vaccines in controlling the virus spread and reducing the mortal rate, these benefits came at the expense of side effects which have not been fully explored nor should be ignored. One of the most serious side effects of vaccination, which has been reported recently, is liver injury.

Case presentation

This study presents a case of hepatitis initiated by Sinopharm vaccine for COVID-19. A 62-year-old man presented with jaundice, weight loss and elevated liver enzymes three days after getting the second dose of COVID-19 vaccine. Microscopic sections showed hepatitis pattern of injury with both portal and lobular inflammation and marked eosinophils infiltration.

Discussion

Several cases of hepatitis have been reported after COVID-19 vaccines, but almost all of them were diagnosed as autoimmune hepatitis, triggered by COVID-19 mRNA or viral vector vaccines but the present case is one of the first reported cases of hepatitis after Sinopharm vaccine, an inactivated virus COVID-19 vaccine. Spontaneous decrease in liver enzyme levels, without corticosteroids therapy, is against to the diagnosis of autoimmune hepatitis in other reported cases.

Conclusion

Considering the microscopic findings, along with the negative serologic studies for viral and autoimmune hepatitis, and by ruling out of other causes of hepatitis like COVID-19 or other viral infections, a probable relation between liver injury and Sinopharm vaccine may be interpreted.

•

Increased liver enzymes with negative viral and autoimmune hepatitis markers after getting Sinopharm vaccine

•

COVID-19 vaccines side effects, an important problem nowadays

•

Awareness of life-threatening vaccines side effects, an important issue

•

Sinopharm vaccine, a probable cause of hepatitis

Effect of Loaded Glycyrrhizic Acid on PLGA Nano-particle on Treatment of Allergic Asthma

Asthma is considered a complex disease of the respiratory system that is characterized by bronchoconstriction, airway inflammation, cough, dyspnea, and wheezing. Allergic reactions are the main reason behind asthma which is known as an important health problem with a high rate of morbidity and mortality in patients with respiratory diseases. Liquorice, the root of Glycyrrhiza, is primarily effective for asthma which is widely used in herbal medicine. In the present study, we designed nano-particles that carry Glycyrrhizic acid as the effective component of Liquorice. After Poly (D,L-lactide-co-glycolic acid) PLGA nanoparticle preparation and Glycyrrhizic acid loading, the morphology of the nanoparticle, the electric charge distribution, and drug-releasing ability were studied. Then the effect of Glycyrrhizic acid-PLGA on the animal model of allergic asthma was investigated. Glycyrrhizic acid-nanoparticle had a mean±SD size of 350±50 nm. about 67% of the effective component was released after 10 h. The interleukin (IL)-4, IL-5, IL-13, and IL-25 levels and the Muc5ac mRNA expression were decreased in the Glycyrrhizic acid-PLGA treated group. In addition, a significant decline was observed in goblet cell hyperplasia, mucus hyper-secretion, and eosinophilic inflammation around bronchi and vessels of the nano-drug treated group, compared with the asthmatic group. We found that Glycyrrhizic acid-PLGA nanoparticle had an anti-asthma effect which may be used as a new drug to cure asthma. It can prevent bronchial obstruction, breathlessness, and asthma attacks.

Chronic pain and infection: mechanisms, causes, conditions, treatments, and controversies

Throughout human history, infection has been the leading cause of morbidity and mortality, with pain being one of the cardinal warning signs. However, in a substantial percentage of cases, pain can persist after resolution of acute illness, manifesting as neuropathic, nociplastic (eg, fibromyalgia, irritable bowel syndrome), or nociceptive pain. Mechanisms by which acute infectious pain becomes chronic are variable and can include immunological phenomena (eg, bystander activation, molecular mimicry), direct microbe invasion, central sensitization from physical or psychological triggers, and complications from treatment. Microbes resulting in a high incidence of chronic pain include bacteria such as the Borrelia species and Mycobacterium leprae, as well as viruses such as HIV, SARS-CoV-2 and herpeses. Emerging evidence also supports an infectious cause in a subset of patients with discogenic low back pain and inflammatory bowel disease. Although antimicrobial treatment might have a role in treating chronic pain states that involve active infectious inflammatory processes, their use in chronic pain conditions resulting from autoimmune mechanisms, central sensitization and irrevocable tissue (eg, arthropathy, vasculitis) or nerve injury, are likely to cause more harm than benefit. This review focuses on the relation between infection and chronic pain, with an emphasis on common viral and bacterial causes.

Studying the Effects of Vitamin A on the Severity of Allergic Rhinitis and Asthma

Allergic asthma is a complex lung disease characterized by breathlessness, airway inflammation, and obstruction. Allergy and allergic rhinitis (AR) are the main triggers of asthma. Vitamin A is an important supplementary factor for the physiological activation of the immune system. In the present study, we investigated the effects of vitamin A on the exacerbation of allergic asthma symptoms. BALB/c mice were allocated to four groups. Asthma was created in two groups, and in the other two groups, rhinitis was induced. One of the asthma groups and one of the rhinitis groups orally received vitamin A (20 IU/g for 15 days). The levels of Immunoglobulin (Ig) E, histamine, leukotriene B4 (LTB4), Cysteinyl leukotriene receptor (Cys-LT), interleukin (IL)-4, IL-5, IL-13, and IL-35 as well as eosinophil peroxidase activity, were measured. Also, the histopathology of mice lungs was evaluated. The levels of total IgE, LTB4, Cys-LT, IL-4, IL-5, IL-17, and IL-33, eosinophil peroxidase activity, perivascular and peribronchial inflammation significantly decreased in vitamin A-treated asthma and rhinitis groups compared to non-treated groups. Also, IL-13 and histamine levels, hyperplasia of the goblet cell, and hyper-secretion of the mucus insignificantly decreased in vitamin A-treated asthma and rhinitis groups. Asthma and AR are common diseases that are generally developed due to the dysregulation of the immune system. Vitamin A plays an important role in controlling the immunopathologic mechanisms of allergic diseases. Vitamin A could be a useful supplement in managing AR and asthma by decreasing the severity of inflammatory responses. Therefore, control of vitamin A deficiency is recommended in Allergy.

Detection of Salivary Tryptase Levels in Children following Oral Food Challenges

BACKGROUND

Oral food challenge (OFC) is commonly used to diagnose food allergy. This test is time and resource intensive, and conclusions are not always unequivocal as this relies on the interpretation of symptoms. Therefore, an objective marker would improve the accuracy of the diagnostic workup of food allergy.

OBJECTIVES

The aim of this study was to investigate whether tryptase can be detected in saliva of children following OFC.

METHOD

Children from 3 to 18 years of age were eligible for inclusion if an OFC for peanut or tree nut had been recommended. Saliva samples were collected prior to the first dose and 5, 10, and 15 min following the last administered dose during OFC. Assay precision, spike-and-recovery, and assessment of lower limit of detection of the tryptase immunoassay were examined before analysis of tryptase in saliva was performed.

RESULTS

A total of 30 children were included (median age 8 years, 63.3% male, 53.3% positive OFC outcome). Tryptase was detected in saliva samples. The mean of the change in baseline tryptase value to each saliva collecting time point was significantly different in patients with a positive OFC outcome compared to a negative outcome (p < 0.01).

CONCLUSIONS

This study showed that tryptase can be detected in saliva of children following OFC. Increased levels of tryptase compared to baseline were found if the OFC outcome was positive, suggesting that measuring tryptase in saliva may be useful in the diagnosis of food allergy. Further research is needed to evaluate the potential association between tryptase levels and symptoms.

Study Effect of Vitamin D on the Immunopathology Responses of the Bronchi in Murine Model of Asthma

Allergic asthma is a complicated respiratory problem characterized by airway inflammation, airway hyperresponsiveness (AHR), breathlessness, mucus hyper-secretion, and goblet cell hyperplasia. Asthma is controlled by genetic and environmental factors. Allergy is the main trigger of asthma and is mediated by Th2 cytokines along with IgE production. Vitamin D (Vit D) is the main supplementary factor for the immune system. In the present study, we investigated the effect of Vit D on the exacerbation of allergic asthma. A murine model of allergic asthma was induced by ovalbumin (OVA) in four of five groups of studied female BALB/c mice (each group, n=20). One group was considered as control. Of OVA-induced mice, two groups received Vit D via oral (10,000 IU/kg diet) or intranasal (inhalation) forms (30 min on days 25, 27, and 29), and the third group received budesonide. At least, AHR, the levels of IL-4, IL-5, IL-13, and INF-g in bronchoalveolar lavage fluid (BALF), serum IgE and histamine, IL-25 and IL-33 gene expression, as well as histopathology study of the lung were done. The Penh values, type2 Cytokines in BALF (in both protein and molecular levels), total IgE and histamine, perivascular and peribronchial inflammation, goblet cell hyperplasia, and mucus hypersecretion decreased significantly in both oral and intranasal Vit D-treated asthmatic mice groups, especially on day 38 of orally treated mice. Here, we found Vit D as a promising agent in control of allergic asthma with a remarkable ability to decrease the severity of inflammation. Therefore, Vit D sufficiency is highly recommended in asthmatic patients.

[Selective IgA deficiency]

Selective IgA deficiency (SIgAD) is defined by the European Society for Immunodeficiencies (ESID) as a serum IgA of less than 0.07g/L in patients greater than 4 years old with normal levels of IgG and IgM, normal vaccine responses, and with the exclusion of secondary causes of hypogammaglobulinemia. When serum IgA level is higher than 0.07g/L but two standard deviations below normal for age, the condition may be referred to as partial IgA deficiency, which is quite common. SIgAD is the most common primary immunodeficiency in Europe (1/600 in France) and most patients with SIgAD are asymptomatic (75-90%). The clinical complications associated with SIgAD include recurrent respiratory infections (in particular involving Haemophilus influenza and Streptococcus pneumoniae) and gastrointestinal (mainly due to Giardialamblia), autoimmune and allergic manifestations (anaphylaxis if blood products with IgA are administrated), inflammatory gastrointestinal disease. There is no specific treatment for SIgAD and each patient must be managed individually. While asymptomatic subjects do not need any treatment, it is still necessary for them to be up-to-date with vaccinations. If the patient experiences recurrent infections, prophylactic antibiotics may be beneficial. Immunoglobulin replacement therapy should be considered in patients with SIgAD and concomitant IgG subclass deficiency. Treatment for autoimmune and allergic manifestations is based on current standards of care for specific disease entities. To improve quality of life and reduce morbidity, an interdisciplinary team approach is essential.

Non-association between low vitamin d levels and aeroallergen-positivity evaluated using multiple allergen simultaneous test in Korean adults

Background

Studies on the association between vitamin D levels and allergen sensitization have reported conflicting results. We aimed to evaluate the association between low vitamin D levels and sensitization to 59 aeroallergens in Korean adults.

Methods

We retrospectively reviewed serum 25-hydroxyvitamin D (25[OH]D) measurements of participants (n = 57,467) in a healthcare center between May 2003 and June 2020. Serum 25(OH)D levels were categorized as follows: severe deficiency (< 10 ng/mL), deficiency (10 to < 20 ng/mL), insufficiency (20 to < 30 ng/mL), and sufficiency (≥ 30 ng/mL). Among all subjects, 1277 simultaneously underwent the multiple allergen simultaneous test. Multiple linear and logistic regression analyses were used to estimate coefficients and odds ratios (ORs) with 95% confidence interval (CI) for the association between serum vitamin D deficiency and aeroallergen sensitization after adjustment for potential confounders. Subgroup analyses were conducted for the types of aeroallergen (house dust mites, pollens, animal dander, foods, cockroach, and fungus).

Results

Vitamin D deficiency, defined as serum 25(OH)D level < 20 ng/mL, was noted in 56.4% of participants. There were significant differences in serum 25(OH)D levels according to sex, age, season, and bone mineral density (all P < 0.001). In multiple linear regression analyses, serum 25(OH)D levels were significantly lower in young subjects (adjusted coefficient [95% CI], 0.188 [0.101, 0.275]) and during winter (− 4.114 [− 6.528, − 1.699]). However, no significant association was observed between serum 25(OH)D levels and allergen sensitization (adjusted coefficients [95% CI], − 0.211 [− 1.989, 1.567], P = 0.816). In multivariate logistic regression analyses, male sex, young age, and winter season were significant risk factors for vitamin D deficiency. However, allergen sensitization showed no significant association with 25(OD)D levels after adjusting for confounders (adjusted OR [95% CI], 1.037 [0.642, 1.674] in insufficiency; 0.910 [0.573, 1.445] in deficiency; 0.869 [0.298, 2.539] in severe deficiency groups, P for trend = 0.334). There were consistent findings across subgroups regarding type of aeroallergen sensitized.

Conclusion

Vitamin D deficiency was prevalent but was not significantly associated with aeroallergen sensitization in Korean adults. To the best of our knowledge, this is the first large-scale study to evaluate the association between vitamin D deficiency and sensitization to 59 different aeroallergens.

Home environment allergen exposure scale in older adult cohort with asthma

OBJECTIVES

Home environmental exposures are a primary source of asthma exacerbation. There is a gap in decision support models that efficiently aggregate the home exposure assessment scores for focused and tailored interventions. Three development methods of a home environment allergen exposure scale for persons with asthma (weighted by dimension reduction, unweighted, precision biomarker-based) were compared, and racial disparity tested.

METHODS

Baseline measures from a longitudinal cohort of 187 older adults with asthma were analyzed using humidity and particulate matter sensors, allergy testing, and a home environment checklist. Weights for the dimension reduction scale were obtained from factor analysis, applied for loadings > 0.35. Scales were tested in linear regression models with asthma control and asthma quality of life outcomes. Racial disparities were tested using t tests. Scale performance was tested using unadjusted regression analyses with asthma control and asthma quality of life outcomes, separately.

RESULTS

The 7-item empirically weighted scale demonstrated best performance with asthma control associations (F = 4.65, p = 0.03, R2 = .02) and quality of life (F = 6.45, p = 0.01, R2 = .03) as follows: evidence of roach/mice, dust, mold, tobacco smoke exposure, properly venting bathroom fan, self-report of roach/mice/rats, and access to a HEPA filter vacuum. Pets indoors loaded on a separate scale. Racial differences were observed (t = - 3.09, p = 0.004).

CONCLUSION

The Home Environment Allergen Exposure Scale scores were associated with racial disparities. Replicating these methods in populations residing in high-risk/low-income housing may generate a clinically meaningful, tailored assessment of asthma triggers. Further consideration for variables that address allergic reactivity and biomarker results is indicated to enhance the potential for a precision prevention score.

Allergy/Immunology Trainee Experiences During the COVID-19 Pandemic: AAAAI Work Group Report of the Fellows-in-Training Committee

As a result of the coronavirus disease 2019 (COVID-19) global pandemic, medical trainees have faced unique challenges and uncertainties. To capture the experiences of allergy and immunology fellows throughout the United States and Canada during this time, a 17-item electronic questionnaire was distributed to 380 fellow-in-training (FIT) members of the American Academy of Allergy, Asthma, and Immunology enrolled in US and Canadian allergy/immunology fellowship programs. Voluntary and anonymous responses were collected from April 15 to May 15, 2020. In addition to summary statistics, categorical data were compared using χ² tests (Fisher's exact). Responses were obtained from FITs across all years of training and primary specialties (Internal Medicine, Pediatrics, and Medicine-Pediatrics) with a response rate of 32.6% (124 of 380). Reassignment to COVID-19 clinical responsibilities was reported by 12% (15 of 124) of FITs, with the largest proportion in the US northeast region. A majority of FITs used telehealth (95%) and virtual learning (82%) during the pandemic. Overall, 21% (25 of 120) of FITs expressed concern about potentially lacking clinical experience for independently practicing allergy and immunology. However, FITs using telehealth reported lower concern compared with those who did not (18.4% [21 of 114] vs 66.7% [4 of 6]; P = .01). The survey shows that allergy and immunology trainee experiences have varied considerably since the COVID-19 outbreak. Notably, the adoption of telehealth and virtual learning was commonly reported, and optimization of these virtual experiences will be helpful. Even outside of pandemics, training on the use of telemedicine may be a sound strategy in preparation for future health care delivery and unexpected events.

[Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]

This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Change in Allergy Practice during the COVID-19 Pandemic

Background

International guidelines in asthma and allergy has been updated for COVID-19 pandemic and pandemic has caused dramatic changes in allergy and immunology services. However, it is not known whether specialty-specific recommendations for COVID-19 are followed by allergists.

Objectives

By conducting this study, we aimed to determine the attitudes and experiences of adult/pediatric allergists on allergy management during COVID-19.

Method

We used a 20-question survey to elicit data from allergists (residents and pediatric and adult allergists registered to the Turkish National Society of Allergy and Clinical Immunology) across Turkey via e-mail. We analyzed the data statistically for frequency distributions and descriptive analysis.

Results

A total of 183 allergists participated in the survey. Telemedicine was used for management of asthma (73%), allergic rhinitis (53%), atopic dermatitis (51%), chronic urticaria/angioedema (59%), drug hypersensitivity (45%), food allergy (48%), venom allergy (30%), anaphylaxis (22%), and hereditary angioedema (28%). Thirty-one percent of the respondents discontinued subcutaneous immunotherapy (SCIT) during the COVID-19 pandemic. Thirty-four percent of the physicians reported interruption of systemic steroid use in asthma patients, and 25% of the respondents discontinued biological therapy.

Conclusions

Allergists in Turkey have been using telemedicine at a high rate during the COVID-19 pandemic for asthma and rhinitis. The continuation rate of SCIT was low while the discontinuation rate of biologicals and systemic steroid use in asthma was high in Turkey. Our study results and learning from the experiences of other countries and specialties may help to optimize allergy practice and compatibility with international guidelines.

[Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment]

Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.

Atopic Patients Who Fulfilled Rome III Criteria for Irritable Bowel Syndrome Had Higher Animal Danders Sensitization

Background/Aims

The relationship between animal exposure and irritable bowel syndrome (IBS) is debated. Epidemiological studies have shown that atopy is more prevalent in IBS patients and vice versa. We set out to examine the association between animal danders sensitization and IBS-like symptoms in atopic patients.

Methods

We recruited 69 consecutive atopic patients from the allergy clinic of a tertiary hospital. Subjects completed validated bowel questionnaires, underwent skin prick test, blood was collected for serum total immunoglobulin E, and ImmunoCAP immune solid-phase allergen chip (ISAC) IgE multiplex assay.

Results

Twenty-eight (41.0%) atopic patients fulfilled the Rome III IBS criteria (atopy-IBS). There were no differences in gender, age, pet ownership, total serum IgE, or food allergen sensitization between atopy-IBS group and atopy-non-IBS group. We found that atopy-IBS group had significantly higher number of positive skin prick test for cat dander (64.3% vs 24.4%, P < 0.001), dog dander (64.3% vs 41.5%, P = 0.015) and weed pollens (32.1% vs 14.6%, P = 0.050) compared to atopy-non-IBS group. Out of 112 components from 51 allergen sources (both aeroallergen and food allergens), only Fel d1 (a major cat dander antigen) IgE is significantly higher in atopy-IBS group than atopy-non-IBS group (21.4% vs 2.4%, P = 0.029). Majority of atopy-IBS patients had mixed-type IBS.

Conclusions

We demonstrated an association between animal danders sensitization, in particular cat dander sensitization, and IBS-like symptoms in atopic patients. Future studies are needed to explore the relationship between aeroallergen and functional gastrointestinal disorders. Sensitization may be related to the pathophysiology of IBS or it could be that we are missing aeroallergen-induced gut allergy.

[Experience in food protein-induced enterocolitis syndrome in a paediatric allergy clinic]

INTRODUCTION

Food Protein-Induced Enterocolitis Syndrome (FPIES) is a gastrointestinal syndrome due to a non-IgE mediated food hypersensitivity.. The most common triggers are cow's milk and soy. Fish is one of the most frequently reported causes in Spain. The objective of this study is to describe the clinical characteristics of patients diagnosed with (FPIES) in a Paediatric Allergy Clinic.

MATERIAL AND METHODS

A retrospective descriptive study was carried out by reviewing medical records of patients diagnosed with FPIES in the Paediatric Allergy Unit of the Miguel Servet Children's Hospital from the years 2007 to 2017.

RESULTS

A total of 135 patients were diagnosed during the study period, of whom 45% were male and 55% were female. The mean age at diagnosis was 11±1.5 months and the mean age of improvement was 2 years and 6 months±2.5 years (n=83). A personal history of atopy was observed in 31.9%. The main trigger foods were: white fish (41.4%), cow's milk (25.1%), and egg (15.5%). A conversion to IgE-mediated allergy was seen in 4.4% of patients. There was vomiting in 81.5% of the cases, with a mean of 1.75±1.1hours of latency, as well as diarrhoea in 41.5%, with a mean of 7.86±15.16hours of latency, and decline in 30.4% with a mean latency of 3.81±11.57hours.

DISCUSSION

In our series, the most frequent trigger of the FPIES was fish. It was manifested mainly by late vomiting and a tolerance was reached mostly at 2 years 6 months.

AAAAI Work Group Report: Physician Wellness in Allergy and Immunology

BACKGROUND

Physician health and wellness can be negatively impacted by burnout, which, in turn, can lead to medical errors and early retirement. Burnout issues can start in medical school and progress during residency, fellowship, and throughout a physician's career. Previous studies have reported burnout rates between 45% and 54% for US physicians in general. However, there is currently little data regarding health and wellness specifically in the field of allergy and immunology.

OBJECTIVE

This workgroup report was developed to assess health and wellness in our specialty.

METHODS

The American Academy of Allergy, Asthma, and Immunology (AAAAI) electronically distributed an anonymous questionnaire using the validated mini-Z survey to a random sample of 1035 fellows and members. In addition to the mini-Z items, the survey queried personal and professional demographic characteristics, and included open-ended wellness questions.

RESULTS

A total of 138 fellows and members of the AAAAI completed the survey, yielding a 13% response rate. The burnout rate was 35%, which is lower than the national average among US physicians, and is overall encouraging. However, there is room for improvement. Limitations of the study include a small sample size as well as evolving definitions of burnout.

CONCLUSIONS

Our results identify specialty specific concerns and can be used to inform the development of tailored interventions to improve wellness and minimize burnout. However, future surveys with a larger sample size are needed to obtain a more robust data set on allergy and immunology specific wellness challenges.

Exposure to air pollution during the first 1000 days of life and subsequent health service and medication usage in children

BACKGROUND

Evidence of health effects following early life exposure to short-to-medium duration of high pollution levels is extremely limited.

OBJECTIVES

We aimed to evaluate the associations between: 1. intrauterine exposure to fine particulate matter (PM_2.5) from coal mine fire emissions and the frequencies of general practitioner attendances and dispensations of prescribed asthma inhalers, steroid skin creams, and antibiotics during the first year of life; 2. infant exposure and those outcomes during the year following the fire.

METHODS

All participants were recruited from the Latrobe Valley of Victoria, Australia. Participants' 24-h average and hourly peak mine fire-specific PM_2.5 exposures from 09/02/2014 to 31/03/2014 were estimated using chemical transport modelling. Outcome data were obtained from the Australian Medicare Benefits Schedule and Pharmaceutical Benefits Scheme from each child's birth to 31/12/2016. We used negative binomial and logistic regression models to independently assess risks of the outcomes associated with every 10 and 100 μg m^-3 increase in average or peak PM_2.5 exposure, respectively, while adjusting for potential confounders.

RESULTS

We included 286 of 311 children whose parents consented to be linked, comprising 77 with no exposure, 88 with intrauterine exposure and 121 with exposure in infancy. 10- and 100- μg m^-3 increases in average and peak PM_2.5 exposure during infancy were associated with greater incidence of antibiotics being dispensed during the year following the fire: the adjusted incidence rate ratios were 1.24 (95% CI 1.02, 1.50, p = 0.036) and 1.14 (1.00, 1.31, p = 0.048) respectively. No other significant associations were observed.

CONCLUSION

Exposure to coal mine fire emissions during infancy was associated with increased dispensing of antibiotics. This could reflect increased childhood infections or increased prescriptions of antibiotics in the year following the fire.

Therapeutic Effect of Glucosamine on an Atopic Dermatitis Animal Model

Background

Recent studies have reported that glucosamine (GlcN) showed therapeutic effects in allergic diseases such as asthma and rhinitis, and its mechanisms include the suppression of T helper type 2 immune responses and the nuclear factor-κB pathway.

Objective

We aimed to investigate the effect of GlcN on atopic dermatitis (AD) in an animal model.

Methods

Twenty-five BALB/c mice were divided into five groups (groups A~E). Group A was the phosphate-buffered saline (PBS)-treated group without AD induction. Group B was the PBS control group with AD induction. Groups C to E were the AD induction groups, which were treated with three different doses of GlcN (10 mg, 20 mg, and 40 mg, respectively). Histopathological examination was performed after GlcN administration. Interleukin (IL)-4, IL-13, and IL-17 cytokine levels were measured by enzyme-linked immunosorbent assay using skin biopsy specimens. Serum total immunoglobulin E (IgE) concentrations were measured before and after administration with GlcN or PBS.

Results

Clinical dermatitis scores decreased with increasing GlcN dose (p<0.001). Concentrations of tissue IL-13 and IL-17 decreased after GlcN administration (each group: p=0.002 and p<0.001, respectively), but the concentrations of tissue IL-4 did not show differences across groups. Serum IgE levels tended to be lower after GlcN administration (p=0.004). Histopathological scores were not significantly different among groups B~E (p=0.394).

Conclusion

GlcN improved AD symptoms and decreased tissue IL-13, IL-17, and serum total IgE levels in an animal model.

COLA (Conferences On-Line Allergy) at 10 Years - Evolution of an Online Fellowship Curriculum

Online learning has been present since the early days of the Internet. As with any new technology, users look to make their life easier and to save time. Experts in medical education are no different than other users. They want to adapt new technologies to their fullest. Medical educators have been challenged with keeping education interesting and up to date, while maximizing their resources. The challenges with any online educational program include being able to reach large numbers of learners, having content that is relevant and timely, and having it available thorough many different formats to suit the user. There are many examples of online learning programs in all fields of medicine and many specific to Allergy/Immunology. In this review, we describe a form of real-time videoconferencing referred to as Conferences On-Line Allergy (COLA), which was developed at Children's Mercy Hospital and Clinics. This program, which started as a once a month webinar, has transformed into a well-known curriculum used by many Allergy/Immunology training programs across the United States. It provides not only live interactive conferences but also a library of recorded lectures and workshops that can be used at the learner's convenience. Taking advantage of the generosity of many volunteer presenters, it allows sharing of resources and provides benefits to the Allergy/Immunology community.

Atypical Cutaneous Presentations of Sarcoidosis: Two Case Reports and Review of the Literature

PURPOSE OF REVIEW

The goal of this review is to provide the reader with an updated summary of the cutaneous manifestations of systemic sarcoidosis, with a particular emphasis on the predilection of sarcoidosis for scars, tattoos, and other areas of traumatized skin.

RECENT FINDINGS

While the mechanism underlying the propensity for traumatized skin to develop sarcoidosis lesions remains unclear, several theories have been proposed including the idea that cutaneous sarcoidosis represents an exuberant, antigen-driven foreign-body response, as well as the theory that traumatized skin represents an immunocompromised district with altered local immune trafficking and neural signaling. In this review, we present two cases in which the development of cutaneous lesions in scars and tattoos was integral to the diagnosis of systemic sarcoidosis. We then review the various cutaneous manifestations of systemic sarcoidosis, the clinical characteristics and differential diagnosis of scar and tattoo sarcoidosis, the proposed mechanism by which traumatized skin is prone to developing sarcoidosis lesions, and current treatments for cutaneous sarcoidosis.

Idiopathic systemic capillary leak syndrome presenting as septic shock: A case report

BACKGROUND

Idiopathic capillary leak syndrome (Clarkson's Disease) is a rare angiopathy with a heterogenous phenotype that may present as distributive shock refractory to resuscitative management.

OBJECTIVE

We report a case of idiopathic systemic capillary leak syndrome presenting as septic shock.

METHODS

Structured case report and review of the literature.

RESULTS

A 27-year old man admitted to our institution with coryzal symptoms rapidly deteriorated with presumed sepsis, leading to intensive care unit admission. Following further deterioration, Idiopathic systemic capillary leak syndrome was considered and intravenous immunoglobulin administered, resulting in rapid improvement in the patient's clinical status.

CONCLUSIONS

Idiopathic systemic capillary leak syndrome is a rare and potentially life-threatening angiopathy that may present as, and should be considered in, refractory distributive shock. Administration of intravenous immunglobulin resulted in rapid recovery in this patient, and has been associated with positive outcomes in previous cases.

Knowledge of allergies and performance in epinephrine auto-injector use: a controlled intervention in preschool teachers

Epinephrine auto-injectors are used for first aid in anaphylactic emergencies by non-healthcare professionals, e.g., (pre-)school teachers. We developed an education session for preschool teachers addressing allergies, anaphylactic emergencies, and administering auto-injectors. We assessed their attitudes and knowledge in allergies and anaphylactic emergency by a questionnaire and monitored their practical performance in administering auto-injectors before the education session, directly after, and 4-12 weeks after the session. From 75 teachers giving their consent to participate, 81% had children with allergies under their supervision and 3% had already administered medication from an available rescue kit. The knowledge of triggers of allergies increased from 9 to 55% directly and to 33% 4-12 weeks after the session (both p < 0.001, compared to baseline). Directly after the session, the number of teachers who felt well-prepared for an anaphylactic emergency rose from 11 to 88%, which decreased to 79% 4-12 weeks thereafter (each p < 0.001). The number of auto-injector administrations without any drug-related problems increased from 3 to 35% directly after the session and shrunk to 16% 4-12 weeks afterwards (both p < 0.025).

CONCLUSION

A single education session substantially improved preschool teachers' attitudes and knowledge in allergies and anaphylactic emergencies. Additionally, their practical performance in auto-injector administration increased. What is Known: • Food allergies are increasing among children. • The knowledge about allergies and anaphylactic emergencies is poor. What is New: • The proportion of teachers who felt well-prepared for an anaphylactic emergency increased after a single education session. • The proportion of auto-injector administrations without any drug-related problems additionally increased due to an education session.

Interpretation of the hygiene and microflora hypothesis for allergic diseases through epigenetic epidemiology

The hygiene hypothesis (HH) proposed by Strachan in 1989 was expanded to explain the inverse association between the occurrence of allergy disorders and the risk of infectious diseases and parasite infestation. The microflora hypothesis (MH) suggests that gut microbial dysbiosis in early life might trigger hypersensitivity disorders. The sharing concept of both HH and MH is gene-environment interaction, which is also a key concept in epigenetics. The amalgamation of epidemiology and epigenetics has created a scientific discipline termed epigenetic epidemiology. To accomplish an era of gene-environment-wide interaction studies, it is necessary to launch a national human epigenome project.

Evaluation of the associations between immunoglobulin E levels and the number of natural teeth

BACKGROUND/PURPOSE

The purpose of the study was to evaluate the association between the number of natural teeth and the total serum immunoglobulin E (IgE), allergen-specific IgE against Dermatophagoides farina, allergen-specific IgE against cockroaches, or allergen-specific IgE against dogs with nationally representative data using the Korean National Health and Nutrition Examination Survey (KNHANES).

METHODS

This study involved a cross-sectional analysis using KNHANES data from 2010. A total of 1916 participants were eligible for this study. Multiple regression analyses were used to evaluate the risk of tooth loss in relation to IgE levels. The model was adjusted for age, sex, body mass index, smoking habits, drinking habits, exercise habits, vitamin D levels, metabolic syndrome, allergic rhinitis, asthma, atopic dermatitis, and tooth-brushing frequency.

RESULTS

The number of natural teeth of the first quartile to the fourth quartile of total serum IgE were 25.9 ± 0.2, 25.9 ± 0.2, 25.1 ± 0.2, and 25.4 ± 0.2, respectively, showing an inverse association (P < 0.05). The number of natural teeth of the first quartile to the fourth quartile of allergen-specific IgE against Dermatophagoides farina and allergen-specific IgE against dogs farina both showed an inverse association with statistical significance (P < 0.05).

CONCLUSION

This study clearly showed the inverse association between total serum IgE and number of natural teeth after adjustments, especially regarding participants without systemic diseases, including diabetes mellitus, hypertension, metabolic diseases, and obesity.

Provider Health and Wellness

Provider health and wellness is a significant issue and can impact patient care, including patient satisfaction, quality of care, medical errors, malpractice risk, as well as provider and office staff turnover and early retirement. Health and wellness encompasses various areas including burnout, depression, divorce, and suicide and affects providers of all specialties and at all levels of training. Providers deal with many everyday stresses, including electronic health records, office politics, insurance and billing issues, dissatisfied patients, and their own personal and family issues. Approximately half of all physicians suffer from burnout, and the rate of burnout among physicians of all specialties is increasing. An important first step in dealing with burnout is recognition and then seeking assistance. Strategies to prevent and treat burnout include increasing provider resiliency as well as implementing practical changes in the everyday practice of medicine. There is currently very little data regarding health and wellness specifically in the field of allergy and immunology, and studies are necessary to determine the prevalence of burnout and related issues in this field. Many medical specialties as well as state and national medical associations have health and wellness committees and other resources, which are essential for providers. Health and wellness programs should be introduced early in a provider's training and continued throughout a provider's career.

Porphyromonas gingivalis Capsule-Mediated Coaggregation as a Virulence Factor in Mixed Infection With Fusobacterium nucleatum

BACKGROUND

Porphyromonas gingivalis (Pg) capsule enables evasion from phagocytosis, invasion of keratinocytes, and bacterial survival. In mixed infection, the capsule also participates in coaggregation, which may lead to characteristic virulence not present in the monoinfection. The aim of this study is to evaluate the role of Pg capsule as a virulence factor in coaggregated mixed infection with Fusobacterium nucleatum (Fn).

METHODS

Mixed infections containing Fn and non-capsulated or capsulated strains of Pg were compared with the same infection with lactose as coaggregation inhibitor. Murine experimental periodontitis was used to assess disease severity. Primary polymorphonuclear leukocytes and keratinocytes were used to examine phagocytosis and bacterial invasion, respectively.

RESULTS

Mixed infection with capsulated Pg augmented alveolar bone loss compared with that of mixed infection with non-capsulated Pg. Addition of lactose led to attenuation of bone loss in the capsulated mixed infection and to intensification of bone loss in the non-capsulated mixed infection. In the latter mixed infection, Fn evaded phagocytosis, whereas in the capsulated mixed infection Pg displayed a greater capacity for invasion of keratinocytes.

CONCLUSIONS

Pg capsule was found to serve as a unique virulence factor in mixed infection with Fn. Capsule-dependent coaggregation led to augmented invasion of Pg and may be responsible for the severity of disease after mixed infection with Fn.

Nickel allergy: blood and periodontal evaluation after orthodontic treatment

The aim of this study was to assess periodontal status and blood parameters in orthodontic patients with nickel allergy one month after removal of brackets. Ninety-six randomly selected patients were initially evaluated. Allergy to nickel was diagnosed using a patch test. After determining the prevalence of subjects allergic to nickel, two groups were formed: 16 allergic (experimental) and 16 non-allergic (control) patients. Their periodontal status was determined regularly by a single, blinded, duly calibrated examiner using the Löe Index (GI) and their blood was tested (complete blood test, including nickel and IgE levels) after nine months of orthodontic treatment and again one month after removing the orthodontic appliances. Statistical analyses included paired and non-paired t-tests, Mann-Whitney, Wilcoxon, McNemar and linear trend chi-square tests (p≤0.05). Comparison of the values recorded during orthodontic treatment and one month after removing the appliances showed that in the allergic group there was significant increase in eosinophils (p=0.046), basophils (p=0.001) and monocytes (p=0.002), and decrease in number of bands (p=0.000), while in the control group, there was increase in lymphocytes (p=0.039) and decrease in segmented neutrophils (p=0.030) and IgE levels (p=0.001). In both groups, plasma nickel levels increased (p=0.010; p=0.039) and GI scores decreased. One month after removing the brackets, blood and periodontal parameters from patients with and without nickel allergy were similar.

Inducible urticaria: Case series and literature review

Inducible urticaria is a heterogeneous group of skin disorders characterized by the appearance of wheals, pruritus and/or angioedema, sometimes accompanied by systemic symptoms caused by innocuous stimuli (cold, heat, pressure, etc.). This group of disorders compromises people's quality of life and most of the literature in this regard comes from case reports and case series since its epidemiology has been poorly studied and some cases are very rare. The aim of this review is to show an up-to-date overview of the available literature for various types of inducible urticarias, always beginning with an illustrative case and then describing their pathophysiological mechanisms, clinical manifestations, and treatment.

The necessity of an observational study on the interactions between allergic history and citrus fruit intake for the prevention of pancreatic cancer

While the main product of Jeju Island is citrus fruit and the prevalence of atopic dermatitis among the students who live there is relatively high, the incidence of pancreatic cancer is lowest in Korea. Systematic reviews reporting allergic history and intake of citrus fruit as protective factors against pancreatic cancer (PCC) were published in 2005 and 2008, respectively. Although there were discrepancies in the results of the subgroup analyses between case-control and cohort studies, it is necessary to evaluate an interaction effect between allergic history and intake of citrus fruits on PCC risk.

[Adverse reaction to not iodinated contrast]

Adverse reactions to drugs are relatively frequent in clinical practice, and some of them can be life threatening. Reactions to contrast material (CM) represent an important percentage of these adverse reactions. It has been found that 70% of reactions to contrast material happen within the first five minutes of their administration. Despite the fact that hypersensitivity reactions are traditionally classified as non-allergic, in recent years investigators have reported positive skin prick tests in patients with immediate and late reactions to contrast material. This paper reports the case of a female patient with non-Hodgkin lymphoma that has presented on two distinct occasions adverse reactions to contrast material. We discuss on the type of reaction, severity, suggested prophylaxis, prognosis and recommendations, keeping in mind the underlying disease and the need to have further image studies performed.

Systemic mastocytosis - a diagnostic challenge

Mastocytosis refers to a group of disorders characterized by the infiltration of clonally derived mast cells to the skin or extracutaneous tissues resulting in a heterogeneous clinical picture. It is a rare hematologic disorder in all its forms. The exact incidence is unknown; it affects patients of any age and males and females equally. Its molecular pathogenesis is incompletely understood. The clinical features of mastocytosis result from both chronic and episodic mast cell mediator release, signs and symptoms arising from diffuse or focal tissue infiltration, and, occasionally, the presence of an associated non-mast cell clonal hematologic disease. The histopathologic analysis is essential for definitive diagnosis but there is no curative treatment. The authors report a clinical case of a 72-year-old woman with no history of allergies, with bicytopenia, weight loss, and diffuse axial osteolytic lesions. This is a rare clinical case of aggressive systemic mastocytosis for which palliative treatment can improve survival and quality of life. A brief review of the literature about this pathology is also included.

Middle East Consensus Statement on the Prevention, Diagnosis, and Management of Cow's Milk Protein Allergy

Presented are guidelines for the prevention, diagnosis, and treatment of cow's milk protein allergy (CMPA) which is the most common food allergy in infants. It manifests through a variety of symptoms that place a burden on both the infant and their caregivers. The guidelines were formulated by evaluation of existing evidence-based guidelines, literature evidence and expert clinical experience. The guidelines set out practical recommendations and include algorithms for the prevention and treatment of CMPA. For infants at risk of allergy, appropriate prevention diets are suggested. Breastfeeding is the best method for prevention; however, a partially hydrolyzed formula should be used in infants unable to be breastfed. In infants with suspected CMPA, guidelines are presented for the appropriate diagnostic workup and subsequent appropriate elimination diet for treatment. Exclusive breastfeeding and maternal dietary allergen avoidance are the best treatment. In infants not exclusively breastfed, an extensively hydrolyzed formula should be used with amino acid formula recommended if the symptoms are life-threatening or do not resolve after extensively hydrolyzed formula. Adherence to these guidelines should assist healthcare practitioners in optimizing their approach to the management of CMPA and decrease the burden on infants and their caregivers.

Relation of Nickel Allergy with in-Stent Restenosis in Patients Treated with Cobalt Chromium Stents

Background

In-stent restenosis (ISR) is the major limitation of percutaneous coronary stenting procedure. The elements like nickel, chromate and molybdenum are known to cause contact allergy. Hypersensitivity reaction, against these metal ions, may be one of the reasons of ISR. Cobalt chromium coronary stents, which are increasingly being used in percutaneous coronary interventions, have more nickel amount than the stainless steel stents.

Objective

We aimed to investigate the association between nickel hypersensitivity reaction and ISR in patients treated with cobalt chromium coronary stents.

Methods

Epicutaneous patch tests for nickel were applied to 31 patients who had undergone elective cobalt chromium coronary stent implantation and had ISR in control angiogram. Thirty patients, without ISR, were included as the control group. Patch test results and other clinical variables were compared.

Results

There was no statistically significant difference of the mean age, sex, body mass index, rate of hypercholesterolemia, diabetes, hypertension and smoking between the patients with and without ISR. All other lesion characteristics were similar in the 2 groups. According to the patch test results, 7 patients had nickel contact allergy. All of these patients were in the ISR group, which was statistically significant (p<0.006).

Conclusion

Patients treated with cobalt chromium coronary stents and had ISR were found to have significantly more nickel allergy than the control group. Nickel allergy may play role in restenosis pathophysiology.