Allergy Asthma and Clinical Immunology最新文献

Background: Many clinicians feel uncomfortable with de-labelling penicillin allergies despite ample safety data. Point of care tools effectively support providers with de-labelling. This study's objective was to increase the number of providers intending to pursue a penicillin oral challenge by 15% by February 2023.

Methods: A validated de-labelling algorithm was translated into an electronic point of care tool and disseminated to eight healthcare institutions. Applying the Model for Improvement Framework, three PDSA cycles were conducted, where collected data and completed surveys were analysed to implement changes. Number of providers intending to pursue an oral challenge, tool usage as well as number of clinicians who felt satisfied with the tool and felt confident in its ability to risk-stratify patients was collected.

Results: 50.4% of providers intended to give an oral challenge of penicillin with version 1, which improved to 65.5% with version 2, representing a 15.1% increase. With version 1 of the tool, there was an average of 61.3 counts of tool usage per month. 73.1% of providers felt satisfied with the tool and 76.9% felt confident in its ability to risk-stratify patients. With version 2 of the tool, after implementing changes through three PDSA cycles, monthly usage counts increased to an average of 98.6. Furthermore, 100.0% of providers felt satisfied with the tool and 98.1% felt confident with the tool's ability to risk-stratify patients.

Conclusion: Our quality improvement approach demonstrated improvement in the percentage of providers that intended to pursue an oral challenge and felt satisfied and confident in the risk-stratification capabilities of penicillin allergy de-labelling tool. Electronic tools should be further incorporated into institutional penicillin de-labelling protocols.

Eosinophilic esophagitis (EoE) is an atopic condition of the esophagus that has become increasingly recognized. Diagnosis of the disorder is dependent on the patient's clinical manifestations and must be confirmed by histologic findings on esophageal mucosal biopsies. The epidemiology, pathophysiology, diagnosis, treatment, and prognosis of EoE are discussed in this review.

Food allergy typically begins early in life and persists as a lifelong condition. Delayed introduction of allergenic foods followed by years of hesitancy to introduce these foods early may have contributed to the increase in food allergy prevalence in recent decades. Most infant feeding guidelines focus on the importance of early introduction of allergenic foods in infants at around age 4-6 months. However, regular, ongoing ingestion of allergenic foods is also critical for the primary prevention of food allergy. Similarly, intermittent exposure to cow's milk formula (CMF) in early infancy increases the risk of cow's milk allergy (CMA), while regular exposure (if it is introduced) prevents it. Families hesitant to introduce allergenic foods to their infant at home (despite education) should be offered introduction in a primary care clinic. Infants who have failed primary prevention should be referred to an allergist for consideration of early infant oral immunotherapy (OIT).

The body has a collection of physical barriers to prevent infection, but once these are overcome, we rely on our immune systems to protect us against a wide variety of infections. The complex mechanisms through which this is achieved are grouped into two lines of defense called the "innate" and "adaptive" immune systems. The innate immune system provides a rapid and tailored response to infection or injury often associated with inflammation. Innate immunity also promotes the development of acquired immunity. Specific, long-lasting responses against a particular infection are dependent on acquired immunity, and these provide immune memory, such that if we encounter the same pathogen again, we are better protected. Many diseases are related to defects in immune function which can lead to either a weakened or overactive immune response. Autoimmune diseases (where the immune system attacks tissues or organs) and allergies (where the immune system responds inappropriately to substances in our environment) are just two examples of conditions resulting from immune function defects. Improved understanding of immune processes provides tremendous opportunities for enhanced immunization strategies and immune-based therapies. This article provides an overview of the main components and functions of the immune system, and also serves as a primer to help readers understand the immunopathological disorders discussed in the remainder of this supplement.

Non-immunoglobulin E (IgE)-mediated food allergies are characterized by delayed gastrointestinal (GI) manifestations that occur after exposure to an inciting food protein; they include food protein-induced allergic proctocolitis (FPIAP), food protein-induced enteropathy (FPE), and food protein-induced enterocolitis syndrome (FPIES). Although the exact mechanisms underlying these disorders are not well understood, non-IgE-mediated food allergies likely represent a spectrum of disease with shared pathophysiological processes. Typically, these non-IgE-mediated food allergies begin in infancy or early childhood, although FPIES can present across the lifespan, with increasing reports in adults in recent years. Diagnosing non-IgE-mediated food allergies can be challenging due to the lack of noninvasive confirmatory tests or biomarkers for most of these disorders and the non-specific nature of GI symptoms. Thus, the diagnosis is usually made clinically, and relies on a constellation of typical symptoms that improve upon removal of the culprit food. The primary approach to management of FPIAP, FPE and FPIES is avoidance of the triggering food, and a multidisciplinary management approach that includes allergy/immunology may be required to avoid unnecessary food restriction and guide food reintroduction. This review outlines the clinical manifestations, epidemiology, pathophysiology, diagnosis, management, and prognosis of these non-IgE-mediated food allergies.

Background: Eosinophilic gastrointestinal diseases (EGIDs) are chronic immune-mediated inflammatory disorders characterized by gastrointestinal symptoms and eosinophilic inflammation in specific regions of the gastrointestinal tract. "Eosinophilic gastritis" (EoG) refers to the condition in which the stomach is involved. In patients with EoG, approved treatment options are restricted despite the high mortality associated with the condition. Dupilumab is a human monoclonal antibody directed against the interleukin (IL)-4 receptor α subunit and inhibits the signaling pathways of both IL-4 and IL-13. The real-world data on the effectiveness of dupilumab for EoG are limited. We present the case of a patient with EoG and accompanying severe asthma who demonstrated improvement with dupilumab administration.

Case presentation: A 35-year-old woman who had been treated for asthma complained of worsening intermittent upper abdominal pain. Her dyspnea aggravated and she was admitted to our hospital for asthma exacerbation. Despite the improvement in her asthma symptoms with systemic corticosteroids, her abdominal pain persisted. Upper gastrointestinal endoscopic mucosal biopsy revealed eosinophilic cell infiltration; therefore, the patient was diagnosed with EoG. Dupilumab administration was initiated for asthma, while improvement of secondary EoG was expected. Following dupilumab administration, both EoG and asthma symptoms, disease control, laboratory findings, endoscopic findings, and pathological findings improved. No adverse events have been reported after the dupilumab treatment.

Conclusion: This case report supports that dupilumab could be an effective treatment option for EoG and accompanying severe asthma.

Background: Oral food challenge (OFC) is the gold standard for diagnosing food allergies (FAs) but carries the risk of anaphylactic reaction. Stepwise OFC, starting with a low dose of allergen and progressing to medium and full doses, is effective in determining a tolerable dose. We retrospectively evaluated the results of a stepwise OFC for hen's egg (HE) to demonstrate its safety and efficacy. We discuss whether early low-dose administration of HE induces early immune tolerance in HE allergy.

Methods: We included 2,058 children (median, 2.6 years) who underwent HE-OFC between 2017 and 2021 at two institutes in Japan. The target challenge dose of OFC was classified as low (less than 1/8 of a cooked egg), medium (1/8 or more but less than 1/2), or full (1/2 or more). If the low-dose OFC was negative, subjects were allowed to consume the same dose of HE and underwent medium-dose OFC within 12 months. Even if positive, individuals were recommended to consume previously-tolerated amounts of HE and repeat OFC at the same dose within 12 months. We evaluated the correlation between their OFC results and response.

Results: A total of 526 (25.6%) children presented positive reactions. There were no cases of anaphylactic shock. Higher serum egg white (EW)- (P < 0.001) and ovomucoid (OVM)- specific IgE (P < 0.001) (sIgE) levels were associated with positive OFC. The low-dose OFC group had more positive reactions (P < 0.001), younger children (P < 0.001), higher EW-sIgE (P < 0.001) and OVM-sIgE (P < 0.001), and more histories of anaphylaxis (P = 0.014). OFC-positive children were younger than OFC-negative children, particularly in low-dose OFC (P = 0.010). OFC results between complete and partial elimination of HE groups across all EW- or OVM-sIgE classes were similar (P > 0.05).

Conclusions: Stepwise OFC is safe and effective in diagnosing HE allergy and facilitates the earlier introduction of HE in children. This study suggests the limited potential of early consumption of lower doses of HE to induce earlier immune tolerance, such that other strategies to induce earlier tolerance in infants with HE allergy should be considered.

Allergen immunotherapy (AIT) is a potentially disease-modifying therapy that is effective for the treatment of allergic rhinitis/conjunctivitis, allergic asthma and stinging insect hypersensitivity. The decision to proceed with AIT should be made on a case-by-case basis, based on a comprehensive evaluation of the patient, allergy testing and a thorough discussion with the patient about treatment goals, risks vs. benefits, and long-term commitment to the treatment plan. For those with allergic rhinitis and/or asthma, it is also important to consider individual patient factors, such as the degree to which symptoms can be reduced by avoidance measures and pharmacological therapy, the amount and type of medication required to control symptoms, the adverse effects of pharmacological treatment, and patient preferences.Since AIT is associated with a risk of anaphylaxis, it should only be prescribed by physicians who are adequately trained in the treatment of allergic conditions. Furthermore, for subcutaneous therapy, injections must be given under medical supervision in clinics that are equipped to manage anaphylaxis. In this article, we review the indications and contraindications, patient selection criteria, and details regarding the administration, safety and efficacy of AIT for allergens other than foods. Immunotherapy for food allergy will be discussed in the Oral Immunotherapy article in this supplement.

Angioedema can occur in the absence of urticaria and can be broadly divided into three main categories: mast cell-mediated (e.g., histamine), non-mast-cell-mediated (bradykinin-induced) and idiopathic angioedema. Non-mast-cell-mediated angioedema is largely driven by bradykinin. Bradykinin-induced angioedema can be hereditary, acquired or drug-induced, such as with angiotensin-converting enzyme (ACE) inhibitors. Although bradykinin-mediated angioedema can be self-limited, it can cause significant morbidity and laryngeal involvement may lead to fatal asphyxiation. The mainstays of management for angioedema are: (1) to avoid specific triggers (if possible and where known) and (2) treatment with medication (if indicated). For hereditary angioedema (HAE), there are specifically licensed treatments that can be used for the management of attacks, or for prophylaxis in order to prevent attacks. In this article, the authors will review the causes, diagnosis and management of angioedema.

Atopic dermatitis (AD) is a common, chronic skin disorder that can significantly impact the quality of life (QoL) of affected individuals as well as their families. Although the pathogenesis of the disorder is not yet completely understood, it appears to result from the complex interplay between defects in skin barrier function, environmental and infectious agents, and immune dysregulation. There are no diagnostic tests for AD; therefore, the diagnosis is based on specific clinical criteria that take into account the patient's history and clinical manifestations. Successful management of the disorder requires a multifaceted approach that involves education, optimal skin care practices, anti-inflammatory treatment with topical corticosteroids, topical calcineurin inhibitors (TCIs) and/or phosphodiesterase-4 (PDE-4) inhibitors, the management of pruritus, and the treatment of skin infections. Systemic immunosuppressive agents may also be used, but are generally reserved for severe flare-ups or more difficult-to-control disease. Newer systemic agents, such as Janus Kinase (JAK) inhibitors and biologics, have a more favourable safety and efficacy profile than the older, traditional systemic immunosuppressives. Topical corticosteroids are the first-line pharmacologic treatments for AD, and evidence suggests that these agents may also be beneficial for the prophylaxis of disease flare-ups. Although the prognosis for patients with AD is generally favourable, those patients with severe, widespread disease and concomitant atopic conditions, such as asthma and allergic rhinitis, are likely to experience poorer outcomes. Newer systemic agents have been approved which are greatly improving the QoL of these patients.