<p>Asthma is a common chronic respiratory illness worldwide, consisting of longstanding airway inflammation with acute exacerbations. Traditionally, asthma has been managed in a step-wise fashion, with older guidance recommending short-acting beta-agonists (SABAs) as required for mild cases, and the addition of regular inhaled corticosteroids (ICS) for more persistent symptoms [<span>1</span>]. Since 2019, GINA has highlighted the risks of SABA-only treatment, and advised for a combination ICS and long-acting beta agonist (LABA), to be used as required with mild symptoms, and regularly for more persistent symptoms [<span>2</span>]. Long-acting muscarinic agonists (LAMAs) are considered a later add-on therapy if initial stages of therapy are not sufficient to control symptoms.</p><p>This Cochrane review addresses the approach to a patient with residual asthma symptoms despite the use of a first-line preventer therapy (MD-ICS), a common consultation in both the primary and secondary care setting.</p><p>We included 38,276 participants from 35 studies (median duration 24 weeks [range 12–78]; mean age 44.1; 38% male; 69% white; mean forced expiratory volume in one second 2.1 L and 68% of predicted).</p><p>MD- and HD-ICS/LABA likely reduce and MD-ICS/LAMA possibly reduces moderate to severe asthma exacerbations compared to MD-ICS (hazard ratio [HR] 0.70, 95% credible interval [CrI] 0.59–0.82; moderate certainty; HR 0.59, 95% CrI 0.46–0.76; moderate certainty; and HR 0.56, 95% CrI 0.38–0.82; low certainty, respectively), whereas HD-ICS probably does not (HR 0.94, 95% CrI 0.70–1.24; moderate certainty). There is no clear evidence to suggest that any combination therapy or HD-ICS reduces severe asthma exacerbations compared to MD-ICS (low to moderate certainty).</p><p>This study suggests no clinically meaningful differences in the symptom or quality of life score between dual combinations and monotherapy (low to high certainty).</p><p>MD- and HD-ICS/LABA increase or likely increase the odds of Asthma Control Questionnaire (ACQ) responders at 6 and 12 months compared to MD-ICS (odds ratio [OR] 1.47, 95% CrI 1.23–1.76; high certainty; and OR 1.59, 95% CrI 1.31–1.94; high certainty at 6 months; and OR 1.61, 95% CrI 1.22–2.13; moderate certainty and OR 1.55, 95% CrI 1.20–2.00; high certainty at 12 months, respectively).</p><p>MD-ICS/LAMA probably increases the odds of ACQ responders at 6 months (OR 1.32, 95% CrI 1.11–1.57; moderate certainty). No data were available at 12 months. There is no clear evidence to suggest that HD-ICS increases the odds of ACQ responders or improves the symptom or quality of life score compared to MD-ICS (very low to high certainty).</p><p>There is no evidence to suggest that ICS/LABA or ICS/LAMA reduces asthma-related or all-cause serious adverse events (SAEs) compared to MD-ICS (very low to high certainty). HD-ICS results in or likely results in little or no difference in the included safety outcomes compared to MD-ICS as well as
BTS/SIGN[1]和美国国立卫生研究院（NIH）[4]的指南建议，如果患者症状未得到控制，可在低剂量 ICS 的基础上加用 LABA，而 GINA[2] 则建议从一开始就使用低剂量 ICS/LABA。与单独使用 HD-ICS 相比，两种组合都能减少中度-重度病情恶化。尽管如此，所有指南都将 LABA 作为 ICS 的首选附加疗法。有研究表明，在 ICS/LABA 组合中添加 LAMA 有益[5]，但指南将其保留为专科治疗[1, 2]。只有在添加 LABA 无益，或 LABA 不能耐受或无法获得的情况下，指南才会推荐使用 ICS/LAMA（不含 LABA）[2]。LAMA 的证据不足，以及指南后期增加 LAMA（依赖于这些证据）的原因可能是，与许多可用于 ICS/LABA 的联合吸入器（表 1）相比，目前还没有市售的 ICS/LAMA 联合吸入器。我们知道，通过简化治疗方案可以最大限度地提高哮喘患者的依从性，因此增加第二个吸入器来提供 LAMA 很可能会降低依从性，从而降低哮喘控制率。在本综述包括的两项 LAMA 研究中，一项研究排除了有不依从风险的参与者[6]，另一项研究指出，临床试验中的依从性高于常规临床实践[7]。据估计，50% 的患者对药物的依从性不完全[2]，因此，尽管本综述发现 ICS/LABA 与 ICS/LAMA 的影响没有显著差异，但在实践中，含有 ICS/LABA 的单一组合装置可能更胜一筹。Baigel博士在攻读过敏与免疫学硕士学位时获得了利洁时公司和ALK公司的资助，并获得了利洁时公司提供的出席国际会议的资助。
{"title":"Cochrane Corner: Addition of Long-Acting Beta2 Agonists or Long-Acting Muscarinic Antagonists Versus Doubling the Dose of Inhaled Corticosteroids (ICS) in Adolescents and Adults With Uncontrolled Asthma With Medium-Dose ICS","authors":"Rachel Baigel, Ian Gregory","doi":"10.1111/cea.14554","DOIUrl":"10.1111/cea.14554","url":null,"abstract":"<p>Asthma is a common chronic respiratory illness worldwide, consisting of longstanding airway inflammation with acute exacerbations. Traditionally, asthma has been managed in a step-wise fashion, with older guidance recommending short-acting beta-agonists (SABAs) as required for mild cases, and the addition of regular inhaled corticosteroids (ICS) for more persistent symptoms [<span>1</span>]. Since 2019, GINA has highlighted the risks of SABA-only treatment, and advised for a combination ICS and long-acting beta agonist (LABA), to be used as required with mild symptoms, and regularly for more persistent symptoms [<span>2</span>]. Long-acting muscarinic agonists (LAMAs) are considered a later add-on therapy if initial stages of therapy are not sufficient to control symptoms.</p><p>This Cochrane review addresses the approach to a patient with residual asthma symptoms despite the use of a first-line preventer therapy (MD-ICS), a common consultation in both the primary and secondary care setting.</p><p>We included 38,276 participants from 35 studies (median duration 24 weeks [range 12–78]; mean age 44.1; 38% male; 69% white; mean forced expiratory volume in one second 2.1 L and 68% of predicted).</p><p>MD- and HD-ICS/LABA likely reduce and MD-ICS/LAMA possibly reduces moderate to severe asthma exacerbations compared to MD-ICS (hazard ratio [HR] 0.70, 95% credible interval [CrI] 0.59–0.82; moderate certainty; HR 0.59, 95% CrI 0.46–0.76; moderate certainty; and HR 0.56, 95% CrI 0.38–0.82; low certainty, respectively), whereas HD-ICS probably does not (HR 0.94, 95% CrI 0.70–1.24; moderate certainty). There is no clear evidence to suggest that any combination therapy or HD-ICS reduces severe asthma exacerbations compared to MD-ICS (low to moderate certainty).</p><p>This study suggests no clinically meaningful differences in the symptom or quality of life score between dual combinations and monotherapy (low to high certainty).</p><p>MD- and HD-ICS/LABA increase or likely increase the odds of Asthma Control Questionnaire (ACQ) responders at 6 and 12 months compared to MD-ICS (odds ratio [OR] 1.47, 95% CrI 1.23–1.76; high certainty; and OR 1.59, 95% CrI 1.31–1.94; high certainty at 6 months; and OR 1.61, 95% CrI 1.22–2.13; moderate certainty and OR 1.55, 95% CrI 1.20–2.00; high certainty at 12 months, respectively).</p><p>MD-ICS/LAMA probably increases the odds of ACQ responders at 6 months (OR 1.32, 95% CrI 1.11–1.57; moderate certainty). No data were available at 12 months. There is no clear evidence to suggest that HD-ICS increases the odds of ACQ responders or improves the symptom or quality of life score compared to MD-ICS (very low to high certainty).</p><p>There is no evidence to suggest that ICS/LABA or ICS/LAMA reduces asthma-related or all-cause serious adverse events (SAEs) compared to MD-ICS (very low to high certainty). HD-ICS results in or likely results in little or no difference in the included safety outcomes compared to MD-ICS as well as","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 9","pages":"647-650"},"PeriodicalIF":6.3,"publicationDate":"2024-08-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cea.14554","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142016531","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
M P Morales-Palacios, J M Núñez-Córdoba, E Tejero, O Matellanes, C M D'Amelio, G Gastaminza
{"title":"Evaluation of a Novel Automated Allergy Intradermal Skin Test Reader: A Diagnostic Accuracy Study.","authors":"M P Morales-Palacios, J M Núñez-Córdoba, E Tejero, O Matellanes, C M D'Amelio, G Gastaminza","doi":"10.1111/cea.14553","DOIUrl":"https://doi.org/10.1111/cea.14553","url":null,"abstract":"","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":" ","pages":""},"PeriodicalIF":6.3,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141995425","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kirsten Stewart, Chris RuiWen Kuo, Rory Chan, Brian Lipworth
{"title":"Onset and Offset of Early Dupilumab Response Using Domiciliary Monitoring in Type 2 High Unified Airway Disease.","authors":"Kirsten Stewart, Chris RuiWen Kuo, Rory Chan, Brian Lipworth","doi":"10.1111/cea.14550","DOIUrl":"https://doi.org/10.1111/cea.14550","url":null,"abstract":"","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":" ","pages":""},"PeriodicalIF":6.3,"publicationDate":"2024-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975232","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Marta Alexandra Martins Ferreira, Adalberto Fernandes dos Santos, Bernardo Sousa-Pinto, Luís Taborda-Barata
<div> <section> <h3> Objective</h3> <p>Digital interventions such as remote monitoring of symptoms and physiological measurements have the potential to reduce the economic burden of asthma and chronic obstructive pulmonary disease (COPD) but their cost-effectiveness remains unclear. This systematic review of randomised controlled trials (RCT) aims to assess whether digital health interventions can be cost-effective in these patients.</p> </section> <section> <h3> Design</h3> <p>Systematic review of RCTs. Study quality was assessed using RoB2 tool.</p> </section> <section> <h3> Data Sources</h3> <p>Systematic search in three databases: PubMed, Scopus and Web of Science.</p> </section> <section> <h3> Eligibility Criteria</h3> <p>Studies were eligible if they were RCTs with health economic evaluations assessing participants with asthma and/or COPD and comparing a digital health intervention to standard of care.</p> </section> <section> <h3> Results</h3> <p>We included 35 RCTs, of which 21 were related to COPD, 13 to asthma and one to both diseases. Overall, studies assessed four categories of digital health interventions: (i) Electronic patient diaries (<i>n</i> = 4), (ii) real-time monitoring (<i>n</i> = 19), (iii) teleconsultations (<i>n</i> = 6) and (iv) others (<i>n</i> = 6). Eleven studies performed a full economic evaluation analysis, while 24 studies performed a partial economic analysis. Most studies involving real-time monitoring or teleconsultations presented economic results in favour of digital health interventions (indicating them to be cost-effective or less expensive than the standard of care). Mixed results were obtained for electronic patient diaries. In the studies that conducted a full economic analysis, the incremental cost-effectiveness ratio (ICER) ranged from 3530,93€/QALY and 286,369,28€/QALY. In the studies that conducted a partial economic analysis, the cost differences between the intervention group and the control group ranged from 0,12€ and 85,217,86€. Half studies with low risk of bias concluded that the intervention was economically favourable.</p> </section> <section> <h3> Conclusion</h3> <p>Although costs varied based on intervention type, follow-up period and country, most studies report digital health interventions to be affordable or associated with decreased costs.</p> </section> <section> <h3> Trial Registration</h3> <p>PROSPERO: CRD42023439195</p>
{"title":"Cost-Effectiveness of Digital Health Interventions for Asthma or COPD: Systematic Review","authors":"Marta Alexandra Martins Ferreira, Adalberto Fernandes dos Santos, Bernardo Sousa-Pinto, Luís Taborda-Barata","doi":"10.1111/cea.14547","DOIUrl":"10.1111/cea.14547","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Digital interventions such as remote monitoring of symptoms and physiological measurements have the potential to reduce the economic burden of asthma and chronic obstructive pulmonary disease (COPD) but their cost-effectiveness remains unclear. This systematic review of randomised controlled trials (RCT) aims to assess whether digital health interventions can be cost-effective in these patients.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>Systematic review of RCTs. Study quality was assessed using RoB2 tool.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources</h3>\u0000 \u0000 <p>Systematic search in three databases: PubMed, Scopus and Web of Science.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Eligibility Criteria</h3>\u0000 \u0000 <p>Studies were eligible if they were RCTs with health economic evaluations assessing participants with asthma and/or COPD and comparing a digital health intervention to standard of care.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>We included 35 RCTs, of which 21 were related to COPD, 13 to asthma and one to both diseases. Overall, studies assessed four categories of digital health interventions: (i) Electronic patient diaries (<i>n</i> = 4), (ii) real-time monitoring (<i>n</i> = 19), (iii) teleconsultations (<i>n</i> = 6) and (iv) others (<i>n</i> = 6). Eleven studies performed a full economic evaluation analysis, while 24 studies performed a partial economic analysis. Most studies involving real-time monitoring or teleconsultations presented economic results in favour of digital health interventions (indicating them to be cost-effective or less expensive than the standard of care). Mixed results were obtained for electronic patient diaries. In the studies that conducted a full economic analysis, the incremental cost-effectiveness ratio (ICER) ranged from 3530,93€/QALY and 286,369,28€/QALY. In the studies that conducted a partial economic analysis, the cost differences between the intervention group and the control group ranged from 0,12€ and 85,217,86€. Half studies with low risk of bias concluded that the intervention was economically favourable.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Although costs varied based on intervention type, follow-up period and country, most studies report digital health interventions to be affordable or associated with decreased costs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Trial Registration</h3>\u0000 \u0000 <p>PROSPERO: CRD42023439195</p>\u0000 ","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 9","pages":"651-668"},"PeriodicalIF":6.3,"publicationDate":"2024-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141970746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Felicity Norris, Amrit Dhesi, Shifa Shaikh, Andrew T. Clark, Gary Stiefel
<p>Since the publication of the BSACI guideline on the management of nut allergy (NA) in 2017 [<span>1</span>], little is known regarding current practice across the United Kingdom (UK). Between 07 December 2022 and 03 February 2023, an online survey was disseminated through the BSACI and local allergy networks to BSACI members and non-members. Respondents completed a survey (available via link below) covering resources and case vignettes to assess approaches to diagnosis and management of NA. Aims of the survey included to audit compliance with the published diagnostic pathways, and to establish current dietary and medical management. Finally, we assessed regional differences in service provision and management of NA.</p><p>A total of 249 healthcare professionals (HCPs) responded to the survey. Of respondents, 190 (76%) were BSACI members and 59 (24%) were non-members. The response rate amongst BSACI members was 19% (190/979). 219/249 (88%) of respondents exclusively managed paediatric patients; 105/190 (55%) of the BSACI members were paediatric allergists/paediatricians with allergy interest.</p><p>Amongst respondents from the different UK regions, at least 92% had access to skin prick testing (SPT), 95% to specific IgE (sIgE) testing and 93% to written allergy plans. Overall, ≥99% respondents had access to a dietitian via a referral process except in the North (<i>referring to Health Education England's</i> North East and North West regions). There was a large observed disparity in access to a dietitian in clinic; 74% in London compared to 35% in the North. Only respondents from 3 NHS trusts (Ireland, Wales and London) reported psychologist access in clinic.</p><p>Diagnostic accuracy to three case vignettes was determined by correct interpretation and application of the published diagnostic algorithm [<span>1</span>]. Only BSACI member responses were audited (<i>n</i> = 190). Responses resulting in diagnostic accuracy for primary peanut allergy (PA) were 140/149 (94%) and 142/148 (96%) for pollen food syndrome (PFS). Despite typical histories of PA and PFS, 43/149 (29%) and 105/148 (71%), respectively, suggested component resolved diagnostics (CRD), which are not recommended. Only 89/146 (61%) suggested CRD for a case of PFS/primary hazelnut allergy (diagnostic uncertainty), although the algorithm supports its use.</p><p>Medical and dietary management was evaluated in BSACI members (<i>n</i> = 190). Prescribing AAIs for cases of anaphylaxis to peanut (147/149 (99%)) and PFS with no asthma (17/153 (11%)) were consistent across respondents. In example cases 1, 3 & 4 (Figure 1) there was large variation with 98/154 (64%), 82/154 (53%) and 94/154 (61%), respectively, recommending AAIs. Over 90% of respondents in all regions except the Midlands & East (62%) would advise patients to carry two AAIs at all times in a case of anaphylaxis to peanut.</p><p>Dietary advice for avoidance of the index nut was consistent using a case of PA and tree NA
{"title":"BSACI Nut Allergy Guideline Audit by National Survey: A Summary of Findings","authors":"Felicity Norris, Amrit Dhesi, Shifa Shaikh, Andrew T. Clark, Gary Stiefel","doi":"10.1111/cea.14549","DOIUrl":"10.1111/cea.14549","url":null,"abstract":"<p>Since the publication of the BSACI guideline on the management of nut allergy (NA) in 2017 [<span>1</span>], little is known regarding current practice across the United Kingdom (UK). Between 07 December 2022 and 03 February 2023, an online survey was disseminated through the BSACI and local allergy networks to BSACI members and non-members. Respondents completed a survey (available via link below) covering resources and case vignettes to assess approaches to diagnosis and management of NA. Aims of the survey included to audit compliance with the published diagnostic pathways, and to establish current dietary and medical management. Finally, we assessed regional differences in service provision and management of NA.</p><p>A total of 249 healthcare professionals (HCPs) responded to the survey. Of respondents, 190 (76%) were BSACI members and 59 (24%) were non-members. The response rate amongst BSACI members was 19% (190/979). 219/249 (88%) of respondents exclusively managed paediatric patients; 105/190 (55%) of the BSACI members were paediatric allergists/paediatricians with allergy interest.</p><p>Amongst respondents from the different UK regions, at least 92% had access to skin prick testing (SPT), 95% to specific IgE (sIgE) testing and 93% to written allergy plans. Overall, ≥99% respondents had access to a dietitian via a referral process except in the North (<i>referring to Health Education England's</i> North East and North West regions). There was a large observed disparity in access to a dietitian in clinic; 74% in London compared to 35% in the North. Only respondents from 3 NHS trusts (Ireland, Wales and London) reported psychologist access in clinic.</p><p>Diagnostic accuracy to three case vignettes was determined by correct interpretation and application of the published diagnostic algorithm [<span>1</span>]. Only BSACI member responses were audited (<i>n</i> = 190). Responses resulting in diagnostic accuracy for primary peanut allergy (PA) were 140/149 (94%) and 142/148 (96%) for pollen food syndrome (PFS). Despite typical histories of PA and PFS, 43/149 (29%) and 105/148 (71%), respectively, suggested component resolved diagnostics (CRD), which are not recommended. Only 89/146 (61%) suggested CRD for a case of PFS/primary hazelnut allergy (diagnostic uncertainty), although the algorithm supports its use.</p><p>Medical and dietary management was evaluated in BSACI members (<i>n</i> = 190). Prescribing AAIs for cases of anaphylaxis to peanut (147/149 (99%)) and PFS with no asthma (17/153 (11%)) were consistent across respondents. In example cases 1, 3 & 4 (Figure 1) there was large variation with 98/154 (64%), 82/154 (53%) and 94/154 (61%), respectively, recommending AAIs. Over 90% of respondents in all regions except the Midlands & East (62%) would advise patients to carry two AAIs at all times in a case of anaphylaxis to peanut.</p><p>Dietary advice for avoidance of the index nut was consistent using a case of PA and tree NA","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 11","pages":"936-938"},"PeriodicalIF":6.3,"publicationDate":"2024-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cea.14549","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141896867","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>Whether childhood food allergy (FA) has increased in recent years continues to be a potential source of debate [<span>1</span>]. Demand for allergy-related medications and anaphylaxis-related hospital services have steadily increased in recent decades in many high-income countries [<span>2, 3</span>]. By contrast, population-based studies of food sensitization, fatal food anaphylaxis rates or challenge-confirmed FA demonstrate inconsistent evidence of increase [<span>1-3</span>]. The perception that childhood FA incidence may have increased over the last three decades is largely underpinned by data derived from changes in hospital emergency room use and admission rates for treatment of anaphylaxis, and to a lesser extent, demand for outpatient services [<span>2, 3</span>]. Most studies show an acceleration in anaphylaxis hospital presentation and/or admission rates in the last two decades, with the highest burden falling on young children aged 0–4 years. Significant country-to-country differences in estimated FA and anaphylaxis prevalence rates and common food triggers have been described, with lower rates previously observed in Asia compared to other regions [<span>4</span>].</p><p>That situation, however, may be changing. In this issue, Goh et al. describe an approximate doubling in hospital presentations coded as anaphylaxis in those aged 0–19 years in Singapore from 2015 to 2022 [<span>5</span>]. Rates quadrupled in those aged 0–4 years, mirroring patterns previously reported from high-income countries outside of Asia. There was a parallel increase in anaphylaxis admission rates but no overall increase in severity, as assessed by the presence of shock, doses of adrenaline required or the need for higher levels of care [<span>5</span>]. The authors also reported no overall increase in attendances for total “allergy-related” presentations from 2015 to 2019; the rise was only seen for presentations coded as anaphylaxis. There were also no changes in total emergency room attendances for all medical or trauma cases, suggesting the trends observed were not an artefact of higher presentation rates overall. Adrenaline was administered in 88% of cases. Ethnic variation was observed, with higher presentation rates noted in the 24% of the population without Chinese/Malay ethnic background. Consistent with studies from high-income countries outside of Asia, the highest rates occurred in children aged 0–4 years, with the increase predominantly driven by allergy to egg, peanut, tree nuts, dairy products and shellfish. Their most recent rates of 38.8/10<sup>5</sup> population is comparable with those described in Europe, and Northern America/South West Pacific countries [<span>3, 4</span>], albeit this increase occurring a decade after similar observations in these other regions.</p><p>A small number of studies suggest that FA/anaphylaxis presentations may be increasing in Asia in line with other countries. Even within Asia, there is significant heteroge
{"title":"Childhood Anaphylaxis in Asia","authors":"Raymond James Mullins","doi":"10.1111/cea.14533","DOIUrl":"10.1111/cea.14533","url":null,"abstract":"<p>Whether childhood food allergy (FA) has increased in recent years continues to be a potential source of debate [<span>1</span>]. Demand for allergy-related medications and anaphylaxis-related hospital services have steadily increased in recent decades in many high-income countries [<span>2, 3</span>]. By contrast, population-based studies of food sensitization, fatal food anaphylaxis rates or challenge-confirmed FA demonstrate inconsistent evidence of increase [<span>1-3</span>]. The perception that childhood FA incidence may have increased over the last three decades is largely underpinned by data derived from changes in hospital emergency room use and admission rates for treatment of anaphylaxis, and to a lesser extent, demand for outpatient services [<span>2, 3</span>]. Most studies show an acceleration in anaphylaxis hospital presentation and/or admission rates in the last two decades, with the highest burden falling on young children aged 0–4 years. Significant country-to-country differences in estimated FA and anaphylaxis prevalence rates and common food triggers have been described, with lower rates previously observed in Asia compared to other regions [<span>4</span>].</p><p>That situation, however, may be changing. In this issue, Goh et al. describe an approximate doubling in hospital presentations coded as anaphylaxis in those aged 0–19 years in Singapore from 2015 to 2022 [<span>5</span>]. Rates quadrupled in those aged 0–4 years, mirroring patterns previously reported from high-income countries outside of Asia. There was a parallel increase in anaphylaxis admission rates but no overall increase in severity, as assessed by the presence of shock, doses of adrenaline required or the need for higher levels of care [<span>5</span>]. The authors also reported no overall increase in attendances for total “allergy-related” presentations from 2015 to 2019; the rise was only seen for presentations coded as anaphylaxis. There were also no changes in total emergency room attendances for all medical or trauma cases, suggesting the trends observed were not an artefact of higher presentation rates overall. Adrenaline was administered in 88% of cases. Ethnic variation was observed, with higher presentation rates noted in the 24% of the population without Chinese/Malay ethnic background. Consistent with studies from high-income countries outside of Asia, the highest rates occurred in children aged 0–4 years, with the increase predominantly driven by allergy to egg, peanut, tree nuts, dairy products and shellfish. Their most recent rates of 38.8/10<sup>5</sup> population is comparable with those described in Europe, and Northern America/South West Pacific countries [<span>3, 4</span>], albeit this increase occurring a decade after similar observations in these other regions.</p><p>A small number of studies suggest that FA/anaphylaxis presentations may be increasing in Asia in line with other countries. Even within Asia, there is significant heteroge","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 8","pages":"532-533"},"PeriodicalIF":6.3,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cea.14533","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141874339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
David J. Jackson, Hassan Burhan, Hitasha Rupani, Paul E. Pfeffer, Ian J. Clifton, Shoaib Faruqi, Jaideep Dhariwal, Pujan Patel, Tamsin Morris, Joseph Lipworth, Michael Watt, Charlotte Lupton, Sabada Dube, Joe Hickey, Alexandra M. Nanzer
Background
Benralizumab has been reported to lead to clinical remission of severe eosinophilic asthma (SEA) at 1 year in some patients. However, whether this is maintained over a longer term remains unclear. Additionally, the impact of pulmonary and extrapulmonary comorbidities on the ability to meet remission is poorly understood.
Methods
Clinical outcomes including remission of SEA with benralizumab at 1 and 2 years were assessed retrospectively in a real-world UK multi-centre severe asthma cohort. The presence of clinically relevant pulmonary and extrapulmonary comorbidities associated with respiratory symptoms was recorded. Analyses to identify factors associated with the ability to meet remission were performed.
Results
In total, 276 patients with SEA treated with benralizumab including 113 patients who had switched from a previous biologic to benralizumab were included. Overall, clinical remission was met in 17% (n = 31/186) and 32% (n = 43/133) of patients at 1 and 2 years, respectively. This increased to 28% at 1 year and 49% at 2 years once patients with pulmonary and/or extrapulmonary comorbidities were excluded. Body mass index (BMI) and maintenance OCS (mOCS) use demonstrated a negative association with clinical remission at 1 (BMI: OR: 0.89, 95% CI: 0.82–0.96, p < 0.01; mOCS: OR: 0.94, 95% CI: 0.89–0.99, p < 0.05) and 2 years (BMI: OR: 0.93, 95% CI: 0.87–0.99, p < 0.05; mOCS: OR: 0.95, 95% CI: 0.89–0.99, p < 0.05).
Conclusions
In this long-term, real-world study, patients with SEA demonstrated the ability to meet and sustain clinical remission when treated with benralizumab. The presence of comorbidities including obesity, which are known to be independently associated with respiratory symptoms, reduced the likelihood of meeting clinical remission.
{"title":"Overcoming Barriers to Remission in Severe Eosinophilic Asthma: Two-Year Real-World Data With Benralizumab","authors":"David J. Jackson, Hassan Burhan, Hitasha Rupani, Paul E. Pfeffer, Ian J. Clifton, Shoaib Faruqi, Jaideep Dhariwal, Pujan Patel, Tamsin Morris, Joseph Lipworth, Michael Watt, Charlotte Lupton, Sabada Dube, Joe Hickey, Alexandra M. Nanzer","doi":"10.1111/cea.14544","DOIUrl":"10.1111/cea.14544","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Benralizumab has been reported to lead to clinical remission of severe eosinophilic asthma (SEA) at 1 year in some patients. However, whether this is maintained over a longer term remains unclear. Additionally, the impact of pulmonary and extrapulmonary comorbidities on the ability to meet remission is poorly understood.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Clinical outcomes including remission of SEA with benralizumab at 1 and 2 years were assessed retrospectively in a real-world UK multi-centre severe asthma cohort. The presence of clinically relevant pulmonary and extrapulmonary comorbidities associated with respiratory symptoms was recorded. Analyses to identify factors associated with the ability to meet remission were performed.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>In total, 276 patients with SEA treated with benralizumab including 113 patients who had switched from a previous biologic to benralizumab were included. Overall, clinical remission was met in 17% (<i>n</i> = 31/186) and 32% (<i>n</i> = 43/133) of patients at 1 and 2 years, respectively. This increased to 28% at 1 year and 49% at 2 years once patients with pulmonary and/or extrapulmonary comorbidities were excluded. Body mass index (BMI) and maintenance OCS (mOCS) use demonstrated a negative association with clinical remission at 1 (BMI: OR: 0.89, 95% CI: 0.82–0.96, <i>p</i> < 0.01; mOCS: OR: 0.94, 95% CI: 0.89–0.99, <i>p</i> < 0.05) and 2 years (BMI: OR: 0.93, 95% CI: 0.87–0.99, <i>p</i> < 0.05; mOCS: OR: 0.95, 95% CI: 0.89–0.99, <i>p</i> < 0.05).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>In this long-term, real-world study, patients with SEA demonstrated the ability to meet and sustain clinical remission when treated with benralizumab. The presence of comorbidities including obesity, which are known to be independently associated with respiratory symptoms, reduced the likelihood of meeting clinical remission.</p>\u0000 </section>\u0000 </div>","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 10","pages":"734-746"},"PeriodicalIF":6.3,"publicationDate":"2024-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cea.14544","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141859198","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mojca Bizjak, Mitja Košnik, Riccardo Asero, Emek Kocatürk, Ana M. Giménez-Arnau, Marcus Maurer
<p>Circulating blood numbers of lymphocytes in chronic spontaneous urticaria (CSU) have not been given sufficient attention. Histopathological analysis of wheals in CSU has demonstrated an increased number of mast cells (MCs) and a perivascular infiltrate of T lymphocytes along with variable numbers of basophils, eosinophils, monocytes and neutrophils [<span>1</span>]. Grattan et al. reported lower blood lymphocyte counts in CSU patients than in healthy controls [<span>2</span>].</p><p>Autoimmune CSU (aiCSU), in which MCs and basophils are activated by immunoglobulin G (IgG) autoantibodies against the high-affinity receptor FcεRI for immunoglobulin E (IgE) or against IgE, is characterised by high disease activity and poor response to standard treatments [<span>3</span>]. An early attempt to define aiCSU using three criteria (i.e. a positive basophil activation test or histamine release, a positive autologous serum skin test [ASST] and a positive immunoassay for IgG anti-FcεRI or IgE), which are not usually available in clinical practice, did not incorporate clinical features now known to be important [<span>4</span>]. Several recently described features of aiCSU, such as blood basopenia and eosinopenia, high levels of IgG against thyroid peroxidase (anti-TPO) and low total serum IgE levels [<span>3, 4</span>], can assist in identifying patients with aiCSU, but there is still a need for additional parameters. We aimed to search for new routinely available markers of aiCSU in a substantial cohort of patients.</p><p>This study involved 300 CSU patients aged 17 years and older (68% female; mean age 45.0 years, SD 15.6 years), all assessed by the same dermatologist at Clinic Golnik. CSU was diagnosed clinically [<span>5</span>]. Exclusion criteria included prior omalizumab treatment, systemic glucocorticosteroid treatment within 7 days of venesection, predominant chronic inducible urticaria, wheals persisting more than 48 h and bradykinin-mediated angioedema. Data on demographics, patient history and laboratory tests were obtained at the initial visit as part of routine clinical care, based on the guidelines and clinical suspicion of comorbidities. The following laboratory tests were done at the Clinic Golnik laboratory: automated complete blood count (CBC) with differential (<i>n</i> = 300; Sysmex XN 3100, Sysmex), C-reactive protein (CRP; <i>n</i> = 292), total serum IgE (<i>n</i> = 149), anti-TPO (<i>n</i> = 184), antinuclear antibodies (ANA; <i>n</i> = 86) and IgG against complement component C1q (anti-C1q; <i>n</i> = 81). All patients were followed up for a minimum of 3 months, and responses to standard treatments were assessed. Uncontrolled CSU was defined as the Urticaria Control Test (UCT) score of 0–11 [<span>5</span>]. The study was approved by the Slovenian National Medical Ethics Committee (KME78/09/14). These data were systematically collected from patients' charts with their consent, in a retrospective manner, and analysed using IBM SPSS
{"title":"Lymphopenia in Chronic Spontaneous Urticaria is Linked to Basopenia and Eosinopenia","authors":"Mojca Bizjak, Mitja Košnik, Riccardo Asero, Emek Kocatürk, Ana M. Giménez-Arnau, Marcus Maurer","doi":"10.1111/cea.14538","DOIUrl":"10.1111/cea.14538","url":null,"abstract":"<p>Circulating blood numbers of lymphocytes in chronic spontaneous urticaria (CSU) have not been given sufficient attention. Histopathological analysis of wheals in CSU has demonstrated an increased number of mast cells (MCs) and a perivascular infiltrate of T lymphocytes along with variable numbers of basophils, eosinophils, monocytes and neutrophils [<span>1</span>]. Grattan et al. reported lower blood lymphocyte counts in CSU patients than in healthy controls [<span>2</span>].</p><p>Autoimmune CSU (aiCSU), in which MCs and basophils are activated by immunoglobulin G (IgG) autoantibodies against the high-affinity receptor FcεRI for immunoglobulin E (IgE) or against IgE, is characterised by high disease activity and poor response to standard treatments [<span>3</span>]. An early attempt to define aiCSU using three criteria (i.e. a positive basophil activation test or histamine release, a positive autologous serum skin test [ASST] and a positive immunoassay for IgG anti-FcεRI or IgE), which are not usually available in clinical practice, did not incorporate clinical features now known to be important [<span>4</span>]. Several recently described features of aiCSU, such as blood basopenia and eosinopenia, high levels of IgG against thyroid peroxidase (anti-TPO) and low total serum IgE levels [<span>3, 4</span>], can assist in identifying patients with aiCSU, but there is still a need for additional parameters. We aimed to search for new routinely available markers of aiCSU in a substantial cohort of patients.</p><p>This study involved 300 CSU patients aged 17 years and older (68% female; mean age 45.0 years, SD 15.6 years), all assessed by the same dermatologist at Clinic Golnik. CSU was diagnosed clinically [<span>5</span>]. Exclusion criteria included prior omalizumab treatment, systemic glucocorticosteroid treatment within 7 days of venesection, predominant chronic inducible urticaria, wheals persisting more than 48 h and bradykinin-mediated angioedema. Data on demographics, patient history and laboratory tests were obtained at the initial visit as part of routine clinical care, based on the guidelines and clinical suspicion of comorbidities. The following laboratory tests were done at the Clinic Golnik laboratory: automated complete blood count (CBC) with differential (<i>n</i> = 300; Sysmex XN 3100, Sysmex), C-reactive protein (CRP; <i>n</i> = 292), total serum IgE (<i>n</i> = 149), anti-TPO (<i>n</i> = 184), antinuclear antibodies (ANA; <i>n</i> = 86) and IgG against complement component C1q (anti-C1q; <i>n</i> = 81). All patients were followed up for a minimum of 3 months, and responses to standard treatments were assessed. Uncontrolled CSU was defined as the Urticaria Control Test (UCT) score of 0–11 [<span>5</span>]. The study was approved by the Slovenian National Medical Ethics Committee (KME78/09/14). These data were systematically collected from patients' charts with their consent, in a retrospective manner, and analysed using IBM SPSS","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 10","pages":"770-773"},"PeriodicalIF":6.3,"publicationDate":"2024-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cea.14538","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141791997","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Simon Schneekloth, Mogens Krøigaard, Johannes K. Boysen, Holger Mosbech, Birgitte B. Melchiors, Lene H. Garvey
<p>Blue dyes are a common cause of perioperative hypersensitivity (POH) reactions, with studies reporting 1:300 patients having reactions ranging from localised urticaria to circulatory collapse [<span>1</span>].</p><p>Sentinel lymph node biopsy (SLNB) is the gold standard in early-stage breast cancer detection, using the combination of blue dye and isotope tracing with an identification rate of 98.8% [<span>2</span>]. The mode of sensitisation to patent blue V (PBV) is unknown as patients typically react on their first subcutaneous exposure. PBV is also used to colour products such as textiles, food and cosmetics, and exposure to PBV is almost inevitable in daily life. However, no information is available regarding potential risks of allergic reactions to PBV, through such exposure, after confirmed allergy to subcutaneous exposure. After a suspected POH reaction, it is important to refer patients for allergy investigation to identify the culprit drug and find a safe alternative [<span>3</span>].</p><p>The aims of this single-centre retrospective study were to identify patients investigated for suspected POH to PBV, characterise reactions, determine the proportion of patients with confirmed allergy to PBV and to evaluate the frequency of oral tolerance among patients with confirmed allergy to subcutaneously administered PBV.</p><p>Data were collected from the Danish Anaesthesia Allergy Centre (DAAC) database from 2004 to 2023 and included clinical history, symptoms from the POH reaction, results of skin tests, in-vitro tests and drug provocation in 843 patients.</p><p>In total, 843 patients had been investigated and 75 (8.9%) had been exposed to PBV prior to the suspected POH reaction and were included in the study. Included patients were predominantly women (<i>n</i> = 68, 91%, mean age: 56 years) with breast cancer. Of the 75 patients, 54 (72%) were diagnosed with PBV hypersensitivity. Symptoms occurred <30 min after injection in 30 cases (67%) and >30 min after injection in 15 cases (33%), unknown in 9 patients. Of the 21 patients testing negative to PBV, two tested positive to dicloxacillin and chlorhexidine, respectively. Of patients testing positive to PBV 28 (52%) suffered grade III reactions (modified Ring and Messmer classification [<span>3</span>]), meeting the criteria for anaphylaxis; 19 had grade I reactions, of which 6 had localised urticaria and 10 had generalised urticaria.</p><p>Diagnosis of allergy to PBV were made by skin prick test (SPT) in concentrations of 0.25, 2.5 and 25 mg/mL and intradermal test (IDT) in concentrations of 0.025 and 0.25 mg/mL. In total, 52 out of 54 patients with proven hypersensitivity to PBV underwent titrated sublingual and oral provocation up to 30 mg of PBV. This was tolerated by all patients. The protocol used for oral challenge with PBV is shown in Figure 1.</p><p>To our knowledge, this retrospective single-centre study presents the largest series of patients with PBV allergy so far and prov
{"title":"Oral Tolerance in Patients With Allergy to Patent Blue V—A 20-Year Single Centre Experience","authors":"Simon Schneekloth, Mogens Krøigaard, Johannes K. Boysen, Holger Mosbech, Birgitte B. Melchiors, Lene H. Garvey","doi":"10.1111/cea.14534","DOIUrl":"10.1111/cea.14534","url":null,"abstract":"<p>Blue dyes are a common cause of perioperative hypersensitivity (POH) reactions, with studies reporting 1:300 patients having reactions ranging from localised urticaria to circulatory collapse [<span>1</span>].</p><p>Sentinel lymph node biopsy (SLNB) is the gold standard in early-stage breast cancer detection, using the combination of blue dye and isotope tracing with an identification rate of 98.8% [<span>2</span>]. The mode of sensitisation to patent blue V (PBV) is unknown as patients typically react on their first subcutaneous exposure. PBV is also used to colour products such as textiles, food and cosmetics, and exposure to PBV is almost inevitable in daily life. However, no information is available regarding potential risks of allergic reactions to PBV, through such exposure, after confirmed allergy to subcutaneous exposure. After a suspected POH reaction, it is important to refer patients for allergy investigation to identify the culprit drug and find a safe alternative [<span>3</span>].</p><p>The aims of this single-centre retrospective study were to identify patients investigated for suspected POH to PBV, characterise reactions, determine the proportion of patients with confirmed allergy to PBV and to evaluate the frequency of oral tolerance among patients with confirmed allergy to subcutaneously administered PBV.</p><p>Data were collected from the Danish Anaesthesia Allergy Centre (DAAC) database from 2004 to 2023 and included clinical history, symptoms from the POH reaction, results of skin tests, in-vitro tests and drug provocation in 843 patients.</p><p>In total, 843 patients had been investigated and 75 (8.9%) had been exposed to PBV prior to the suspected POH reaction and were included in the study. Included patients were predominantly women (<i>n</i> = 68, 91%, mean age: 56 years) with breast cancer. Of the 75 patients, 54 (72%) were diagnosed with PBV hypersensitivity. Symptoms occurred <30 min after injection in 30 cases (67%) and >30 min after injection in 15 cases (33%), unknown in 9 patients. Of the 21 patients testing negative to PBV, two tested positive to dicloxacillin and chlorhexidine, respectively. Of patients testing positive to PBV 28 (52%) suffered grade III reactions (modified Ring and Messmer classification [<span>3</span>]), meeting the criteria for anaphylaxis; 19 had grade I reactions, of which 6 had localised urticaria and 10 had generalised urticaria.</p><p>Diagnosis of allergy to PBV were made by skin prick test (SPT) in concentrations of 0.25, 2.5 and 25 mg/mL and intradermal test (IDT) in concentrations of 0.025 and 0.25 mg/mL. In total, 52 out of 54 patients with proven hypersensitivity to PBV underwent titrated sublingual and oral provocation up to 30 mg of PBV. This was tolerated by all patients. The protocol used for oral challenge with PBV is shown in Figure 1.</p><p>To our knowledge, this retrospective single-centre study presents the largest series of patients with PBV allergy so far and prov","PeriodicalId":10207,"journal":{"name":"Clinical and Experimental Allergy","volume":"54 10","pages":"763-765"},"PeriodicalIF":6.3,"publicationDate":"2024-07-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/cea.14534","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141791998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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