Allergy Asthma and Clinical Immunology最新文献

Anaphylaxis is an acute, potentially fatal systemic hypersensitivity reaction with varied mechanisms and clinical presentations. Although prompt recognition and treatment of anaphylaxis are imperative, both patients and healthcare professionals often fail to recognize and diagnose its early signs. Clinical manifestations vary widely, however, the most common signs are cutaneous symptoms, including urticaria and angioedema. Immediate intramuscular administration of epinephrine into the anterolateral thigh is first-line therapy, and is always safe even if the diagnosis is uncertain. The mainstays of long-term management include specialist assessment, allergen avoidance measures, and the provision of an epinephrine auto-injector with an individualized anaphylaxis emergency plan. This article provides an overview of the causes, clinical features, diagnosis, and acute as well as long-term management of anaphylaxis.

Urticaria (hives) is a common disorder that may be associated with angioedema (swelling that occurs beneath the skin). It is generally classified as acute or chronic, and chronic urticaria is further classified as spontaneous or inducible Second-generation, non-sedating histamine type 1 (H1)-receptor antihistamines represent the mainstay of therapy for both acute and chronic urticaria. Second-line treatment for uncontrolled chronic urticaria includes omalizumab (a monoclonal anti-immunoglobulin E [IgE] antibody). In this article, we review the causes, diagnosis and management of urticaria (with or without angioedema).

This position statement addresses the critical concerns and recommended practices surrounding the use of panel food testing for diagnosing food allergies. Food allergies are a significant public health concern, and the misdiagnosis of food allergies remains a prevalent concern, made worse by the ongoing use of panel food testing. The practice of screening patients for multiple food allergens, regardless of clinical relevance, is commonly referred to as "panel food testing." Fundamentally, a panel food test is not simply a single test; a panel food test is a series of several distinct tests for multiple foods, each with its own variable predictive value. These tests have not been adequately validated as screening tests and carry a considerable false positive rate. The resulting false diagnoses lead to unnecessary dietary restrictions, increased healthcare costs, and significant psychosocial distress for patients and their families.

Background: Asthma is a chronic, heterogeneous disease characterized by airway inflammation. Asthma exacerbations significantly increase the disease burden, necessitating new therapeutic approaches. Emerging evidence suggests probiotics, through the gut-lung axis, may benefit asthma management by modulating immune responses and reducing inflammation.

Methods: This systematic review and meta-analysis adhered to PRISMA guidelines and was registered with PROSPERO (CRD42023480098). A comprehensive search of PubMed, Scopus, Web of Science, and Embase was conducted up to March 2024. Inclusion criteria encompassed randomized controlled trials (RCTs) evaluating probiotic interventions in asthma patients. Statistical analysis was done using RevMan 5.3, with odds ratios (OR) and 95% confidence intervals (CI) calculated, and heterogeneity assessed using I² statistics.

Results: Twelve RCTs, comprising 1401 participants, met the inclusion criteria. The probiotic strains investigated included various Lactobacillus and Bifidobacterium species. Meta-analysis revealed significant improvements in asthma control test scores (OR 1.18, 95% CI: 1.18-3.64, p = 0.0001) following probiotic supplementation. Probiotics also improved fractional exhaled nitric oxide (FeNO) in one study, but pooled FeNO and eosinophil data were not statistically significant (p = 0.46 and p = 0.29, respectively). One study observed fewer asthma exacerbations in the probiotic group (24/212) compared to placebo (67/210), with no difference in exacerbation duration.

Conclusion: Probiotic supplementation may be beneficial in improving asthma symptom control with no significant impact on lung function indices or eosinophil levels. Probiotics can be a potential adjunctive therapy in asthma management, particularly for asthma symptom control.

Background and methods: The Zéro allergie research clinic (Saguenay, Canada) is a clinical and research initiative in oral immunotherapy (OIT) for managing IgE-mediated food allergy (FA). A total of 183 children with FA and 27 non-allergic siblings were recruited to date in the Zéro allergie cohort (ZAC) to better understand biological mechanisms underlying FA and OIT prognosis. The primary aims are to (a) better understand the genetic, epigenetic, transcriptomic, metabolomic, and microbial diversity associated with FA; (b) establish the multi-omics and microbial diversity profiles of children following OIT to identify predictive prognosis biomarkers, (c) make OIT more accessible to the population of the Saguenay-Lac-Saint-Jean region, and (d) build a biobank of data and biological material.

Results: The ZAC constitutes a unique and rich biobank of biological samples (blood, buccal swabs, microbiota samples [intestinal, buccal, nasal, and cutaneous]) combined with clinical data and more than 75 phenotypic characteristics.

Conclusions: This represents an innovative interdisciplinary initiative by researchers, allergists, and paediatricians to make FA care accessible to a greater number of children with IgE-mediated FA. Ultimately, it will contribute to provide more accessible treatment options with greater chances of success through a better understanding of the biological nature of FA and OIT.

Background: Rasburicase, a recombinant urate oxidase enzyme, has potent efficacy in controlling uric acid and is widely used to prevent tumor lysis syndrome in high-risk patients owing to its low toxicity profile. However, it has been associated with a risk of anaphylaxis, especially on re-exposure, owing to its immunogenic potential.

Case presentation: A 71-year-old Japanese female diagnosed with diffuse large B cell lymphoma with a large tumor burden experienced anaphylactic shock leading to death upon initial administration of rasburicase. The pre-and postmortem examination revealed that the cause of death was a cascade of events starting with anaphylaxis-induced distributive shock leading to obstructive shock due to the collapse of the heart, which was compressed by the post-mediastinal tumor. This was further compounded by massive bleeding from the tumor and tension hemothorax, resulting in circulatory collapse.

Conclusions: Although extremely rare, rasburicase can cause fatal anaphylaxis, even on first exposure.

Background: Peanut allergy is a common food allergy with potentially life-threatening implications. Early oral immunotherapy for peanut allergy (P-EOIT) has been shown to be effective and safe in research and specialty clinic settings. Provision of P-EOIT in primary care would make it available to more patients. We sought to assess the safety of P-EOIT in a primary care setting by documenting the rates of peanut-related allergic reactions leading to emergency department (ED) visits and use of epinephrine. We also examined adherence by assessing the percentage of patients reaching maintenance phase and continuing ingestion after one year of P-EOIT.

Methods: This retrospective study included all patients aged less than 36 months who started P-EOIT at a primary care allergy clinic in New Brunswick, Canada, from 2016 to 2020. The population included patients who (1) had a history of an allergic reaction to peanuts with a positive skin prick test or positive peanut specific IgE level (ps-IgE) or (2) no history of ingestion and a baseline ps-IgE ≥5 kU/L. Patients had biweekly clinic visits with graded increases in peanut protein up to a maintenance dose of 300 mg of peanut protein daily. A blinded retrospective review of paper charts and electronic medical records was conducted along with phone interviews regarding ED visits and epinephrine use.

Results: All 69 consented patients reached maintenance dose over a median of 29 weeks, and 66 patients (95.7%) were still regularly consuming peanut protein after 1 year of maintenance. One patient had a peanut ingestion-related ED visit requiring epinephrine during the escalation phase of peanut protein dosing (1.4%). During the first year of maintenance phase, no patients had peanut ingestion-related ED visits nor required epinephrine.

Conclusion: Early oral immunotherapy for peanut allergy in a primary care setting appears to be safe and our findings suggest that it does not lead to an increased burden of emergency department visits. Our population had high adherence rates, with the majority achieving maintenance dose and staying on this dose for one year.

Background: Patients with asthma with an eosinophilic phenotype may be eligible for additional treatment options to improve disease control; however, the prevalence and frequency of eosinophil testing is unknown. This study assessed blood eosinophil count testing prevalence in patients with asthma by exacerbation frequency and healthcare provider (HCP) type.

Methods: This was a retrospective, longitudinal, real-world study (GSK ID: 214470) utilizing the Merative Explorys^® Universe electronic health records database. Eligible patients had ≥ 2 asthma diagnostic codes (January 2016-December 2018) (Index date: first asthma diagnosis). Outcomes included patient demographics and clinical characteristics (12 months pre-index [baseline]), and prevalence of blood eosinophil count testing, stratified by exacerbation frequency (infrequent exacerbations [< 2]) or frequent exacerbations [≥ 2] or primary HCP (Allergist/Pulmonologist, a primary care physician [PCP] or other HCP) during the 12 months post-index (follow-up).

Results: Of 400,254 patients included (mean age: 51.2 years; 70.8% female), the most common provider type at baseline was a PCP (76.8%). A higher proportion of patients with frequent exacerbations had blood eosinophil count tests at baseline (55.4-69.5%) and follow-up (67.9-75.1%), compared with patients with infrequent exacerbations (55.5-63.7%, 62.4-67.3%). Significantly more patients in the Allergist/Pulmonologist subgroup had ≥ 1 blood eosinophil count test result compared with patients in the PCP subgroup at both baseline (59.9% vs. 50.7%; p < 0.001) and follow-up (59.0% vs. 56.2%; p < 0.001). In the total population, the mean (SD) number of tests ordered was 3.4 (5.3) and 4.1 (6.4) during the baseline and follow-up periods, respectively. A greater mean number of tests were ordered for patients with frequent exacerbations, most apparently in the Allergist/Pulmonologist subgroup during baseline and follow-up (7.4 vs. 4.9). For patients with frequent exacerbations and blood eosinophil count test results, the mean (SD) number of tests ranged from 3.1 (4.6) to 5.8 (8.3) at baseline and 5.1 (8.5) to 7.4 (10.6) during follow-up.

Conclusions: The prevalence of blood eosinophil count testing in patients with asthma remains suboptimal. Routine blood eosinophil count testing should be considered by HCPs for patients with asthma to increase identification of the eosinophilic asthma phenotype, which may inform the decision to advance to targeted biologic therapy.

Background: Penicillin allergy adversely impacts patient care, yet most cases do not have true allergies. Clinicians require efficient, reliable clinical tools to identify low risk patients who can be safely de-labeled. Our center implemented the FIRSTLINE electronic point-of-care decision support tool to help non-allergist practitioners risk stratify patients with penicillin allergy. We sought to explore the reliability and validity of this tool in relation to allergist assessment and actual patient outcomes. We additionally compared it with two other published stratification tools, JAMA and PENFAST, to assess ability to accurately identify low risk patients appropriate for direct oral challenge.

Methods: In this single-center, retrospective, observational study, 181 pregnant females with self-reported penicillin allergy between July 2019 to June 2021 at BC Women's Hospital, Vancouver, Canada were used to assess the reliability and validity of all three tools. Physician-guided history of penicillin use and symptoms were used for scoring. Results and recommendations were compared to actual patient outcomes after clinician decision for direct oral challenge or intradermal tests. We compared the performance of JAMA, PENFAST and FIRSTLINE.

Results: 181 patients were assessed. 176/181 (97.2%) patients were deemed not allergic. Each risk stratification tool labelled majority of patients as low risk with 88.4% of patients PENFAST 0-2, 60.2% of patients JAMA low risk, 86.7% of patients FIRSTLINE very low risk.

Conclusion: We demonstrate that our point-of-care electronic algorithm is reliable in identifying low risk pregnant patients, as compared to an allergist assessment. To our knowledge, this is the first study to provide direct comparison between multiple decision support tools using the same population, minimizing participant bias. Providing clinical algorithms to risk stratify patients, can enable healthcare professionals to safely identify individuals who may be candidates for direct penicillin oral challenges versus needing referral to specialists. This increases the generalizability and efficiency of penicillin allergy de-labeling.

Background: Oral immunotherapy (OIT) is an increasingly utilized management strategy for IgE-mediated food allergy. Despite promising efficacy and effectiveness, there is still a lack of data surrounding the reasons for discontinuation of OIT. The primary reason stated in the literature for discontinuation is adverse gastrointestinal effects. Social factors contributing to OIT discontinuation have not been well reported. We hypothesize that social considerations are significant contributors to treatment discontinuation.

Methods: We completed a retrospective chart review of 50 patients treated in community pediatric allergy practices who discontinued OIT out of 507 patients who were started on OIT between October 1, 2017-October 27, 2022. Reasons for discontinuation were identified and classified into five main categories: unsafe care decisions, anxiety, adverse effects of OIT, uncontrolled comorbidity and social factors. Categories were not exclusive.

Results: 507 patients were started on OIT, with data available for 50 patients who discontinued OIT, aged 10 months to 18 years and 2 months. The overall discontinuation rate was 9.8%, of which 40 patients (80%) discontinued during buildup, 9 patients (18%) discontinued during maintenance and one patient on two food OIT discontinued one food during buildup and one during maintenance (2%). Thirty-four patients (68%) had multiple reasons for discontinuing OIT. Social factors were the most common reason for discontinuation and were identified in 32 patients (64%). Twenty-four patients (48%) discontinued OIT due to adverse effects. Gastrointestinal symptoms were the most prevalent, while anaphylaxis contributed to discontinuation in 15 patients (30%). Anxiety led to discontinuation in 17 patients (34%).

Conclusions: Our data highlights the importance of social factors and anxiety in the success of OIT completion. Our results support the need to consider not only the patient's medical history, but also their social history and support networks when selecting patients who are good candidates for OIT to optimize the successful completion of OIT.