Annals of Allergy Asthma & Immunology最新文献

Background: Food protein-induced enterocolitis syndrome (FPIES) affects approximately 0.5% of US children. Oral food challenges (OFCs) are frequently conducted to assess FPIES resolution in an observed setting, given the risk of severe reactions. However, it is unclear whether the observed OFC is universally cost-effective in all contexts vs gradually titrated home OFCs when caregivers are willing to accept a risk-to-benefit tradeoff.

Objective: To characterize the health and economic benefits of at-home vs supervised reintroduction OFC in patients with a history of mild-moderate index FPIES.

Methods: Cohort analyses evaluated the cost-effectiveness of a gradually titrated home vs clinical or hospital OFC using population simulations (n = 200,000 patients) and simulations in a rural New England population (n = 105). Severe FPIES reactions were defined as necessitating intravenous fluids. Fatality rates were defined as occurring approximately in 1/1,000,000 FPIES OFCs. Motor vehicle fatality rates were applied based on the travel distance to the OFC site. The cost-effectiveness threshold was set at $10,000,000 per fatality prevented.

Results: In the population simulation, the supervised OFC costs reached $411,088,445, with 18,680 severe reactions occurring (per-patient mean 0.093, SD 0.025), at a cost-per-fatality prevented of $124,233,328. In a simulation of a rural New England population with FPIES, the cost per severe reaction ranged from $11,790 to $46,304.

Conclusion: A requirement for universally conducting FPIES challenges in an office-based or in-hospital setting is not cost-effective given extremely low FPIES reaction fatality rates, especially when compared with travel-based motor vehicle fatality rates. A shared decision-making approach may be appropriate to determine the challenge setting for patients with lower risk of severe reactions.

Background: Inducible laryngeal obstruction (ILO) is confirmed by observing paradoxical vocal fold movement (PVFM) on laryngoscopy, but test sensitivity is reduced by its intermittent nature. Specificity of isolated expiratory PVFM is also unclear, possibly denoting a physiological response to lower airway obstruction.

Objective: To clarify laryngoscopic diagnosis in suspected ILO through mannitol provocation.

Methods: In patients with suspected ILO, we assessed rates of laryngoscopic PVFM, both at baseline and after mannitol provocation, defined as any inspiratory adduction, more than or equal to 50% expiratory adduction, or both. We also studied accentuation of laryngoscopic findings after mannitol provocation, defined as new or increased PVFM. We explored relationships between isolated expiratory PVFM, lower airway obstruction on spirometry, and bronchial hyperresponsiveness to mannitol. We also studied healthy volunteers.

Results: Among 80 patients with suspected ILO, PVFM rates were 42 (52.5%) at baseline and 58 (72.5%) after mannitol. Mannitol accentuated laryngoscopic findings in 45 of 80 (56%), with new PVFM in 17 of 80 (21%) and increased PVFM in 28 of 80 (35%) and 28 of 42 (67%) of patients with PVFM at baseline. Among patients with baseline isolated expiratory PVFM, 21 of 30 had accentuation by mannitol and there was no relationship with airway obstruction or bronchial hyperresponsiveness. Among healthy volunteers, PVFM rates were identical at baseline and after mannitol (4/15, 27%, all 4 with isolated expiratory PVFM); none (0/15) had accentuation by mannitol.

Conclusion: Accentuation of laryngoscopic findings after mannitol provocation is more useful than PVFM at baseline laryngoscopy in distinguishing patients with suspected ILO from healthy volunteers. Isolated expiratory PVFM without accentuation by mannitol can be a normal finding and unrelated to bronchial obstruction or hyperresponsiveness.