Journal of Allergy and Clinical Immunology-In Practice最新文献

Background: Nearly 80% of patients with eosinophilic esophagitis (EoE) have coexisting atopic disease, yet a subset do not. It is unclear if this lack of atopy impacts presentation or response to therapy.

Objectives: To characterize the presentation and response to therapy in atopic versus nonatopic pediatric patients with EoE.

Methods: A case-control study of patients with EoE aged 6 months to 18 years (between 2018 and 2021) was performed. Patients were eligible if they had allergy testing, assessment of atopic history, and at least 1 endoscopy after initiation of treatment. Patients were considered nonatopic if they had negative allergy testing and no history of significant atopy. Response to therapy was classified as complete (peak eosinophils [eos] <15/high power field [hpf]), partial (≥15 eos/hpf but at least a 50% reduction in peak eos), or nonresponse.

Results: A total of 168 participants were enrolled. The majority were White (n = 141, 84%), male (n = 124, 74%), and non-Hispanic (n = 158, 95%). The mean age at diagnosis was 9.4 years (standard deviation: ±4.8 years). A total of 123 participants (73.2%) were atopic, and 45 (26.8%) were nonatopic. There was no significant difference between atopic and nonatopic for most demographics or presenting symptoms. Nonatopic participants were younger than atopic participants (8.14 vs 9.8 years, P = .046). Swallowed topical corticosteroids (STC) and food elimination diets (FED) were used at a similar rate. There were no differences in treatment response between atopic/nonatopic participants in regard to STC, FED, or STC+FED.

Conclusions: Atopic status does not significantly impact presentation or response to treatment in pediatric EoE, but a lack of atopy may be a risk for earlier onset of disease.

Background: Documented penicillin allergies are associated with increased morbidity, increased hospital stay, and an increase in resistant infections. Penicillin allergy evaluations using a direct oral challenge with or without skin testing has been recommended as a delabeling strategy for patients with penicillin reaction histories. Barriers for achieving equitable access, however, exist. Understanding patient perceptions regarding their penicillin allergy across diverse populations is crucial to mitigate potential obstacles to penicillin allergy testing (PAT) and the use of penicillin-like antibiotics after delabeling.

Objective: The objective of this study was to gather perceptions of patients delabeled of their penicillin allergy after testing through a PAT program.

Methods: Patients who underwent PAT and had a subsequent allergy removal due to a negative result were interviewed using closed and open-ended questions.

Results: A total of 100 patient interviews were completed. Awareness of the risks associated with unnecessary penicillin avoidance and PAT was low. Initial concerns regarding PAT were common but were frequently alleviated with targeted education. Most patients undergoing testing reported a positive experience and would recommend PAT to others. A minority of patients continued to have discordant perceptions regarding their penicillin allergy label with mistrust in the negative result being a critical theme identified.

Conclusions: Future interventions increasing the awareness of penicillin allergy labels and the risks and benefits of PAT in the general population are needed and must consider health literacy levels, languages, and cultural contexts. Measures to offer PAT within a clinical setting that has built high levels of patient trust will likely achieve the greatest long-term success.

Poor adherence to controller therapies is a universal challenge to asthma control. Several high-risk groups, including adolescents, pregnant women, and older adults, have their own unique challenges to adherence. The rates of asthma controller therapy use are low in each of these populations, but secondary to different causes. Adolescents have increased independence and a transition to new self-management responsibilities; pregnant women may be concerned about adverse effects of medications to the fetus; and older adults may have age-related physical and cognitive challenges to effectively taking medication. Only by understanding the nuances of care in these populations can health care professionals develop strategies to address barriers to adherence. Tailored education focused on empowering patients and dispelling misconceptions can serve as tools to improve adherence and ultimately asthma control.

Background: No specific description of monoclonal gammopathies of undetermined significance (MGUS)-associated angioedema due to acquired C1 inhibitor deficiency (AAE-C1-INH) has been reported yet.

Objective: To describe the biological and clinical characteristics, evolution, and response to treatment of MGUS-associated AAE-C1-INH.

Materials and methods: We conducted a French national retrospective observational study on MGUS-associated acquired angioedema spanning a 30-year period.

Results: Forty-one patients with MGUS-associated AAE-C1-INH at diagnosis were included; 68% displayed anti-C1-INH antibodies. The monoclonal component was an IgM in 24 patients, IgG in 11, and IgA in 6 patients. The mean age at first angioedema attack was 63 years (standard deviation [SD] = 13 years) and at diagnosis 66 years (SD = 11 years). A total of 88% patients benefited from acute attack treatments, and 77% from long-term prophylaxis, either danazol, tranexamic acid, or lanadelumab. Median follow-up was 7 years, during which 14 patients (33%) evolved into well-defined malignant hemopathies. Fifty percent of patients were given a hematological treatment, either rituximab alone, indicated by recurrent attacks of angioedema in patients with AAE-C1-INH with anti-C1-INH antibodies, or validated combinations of chemotherapies, indicated by evolution into a lymphoma in 7 patients and a myeloma in 3 patients. Fifteen patients (35%) were in clinical complete remission of angioedema at last visit, of whom 60% had an undetectable serum monoclonal immunoglobulin.

Conclusions: Complete remission of AAE-C1-INH is correlated to complete remission of the underlying hematological malignancy, as defined by an undetectable serum monoclonal immunoglobulin. In our MGUS-associated acquired angioedema cohort, we recorded an incidence of evolution into hematological malignancy of 4% per patient-year. It is therefore crucial to conduct full hematological workup during follow-up at an annual rate, and earlier if AAE relapses or if acute attack frequency increases.

Background: Fatigue is a major concern for patients with severe asthma.

Objective: This observational study aims to assess fatigue severity and associated factors, to explore the effect of pulmonary rehabilitation on fatigue, and to investigate which factors predict persistent severe fatigue.

Methods: Patients with severe, uncontrolled asthma referred for alpine altitude climate treatment (AACT) between 2007 and 2018 were systematically assessed before and after rehabilitation regarding clinical, inflammatory, functional, and psychological characteristics. Fatigue severity was assessed by Checklist Individual Strength (CIS-Fatigue). Multivariable regression analyses were used to identify factors associated with fatigue severity and persistence.

Results: A total of 420 patients were assessed, of whom 91% reported severe fatigue (CIS-Fatigue ≥36). Stepwise multiple regression explained 35% of variance in initial fatigue severity. Significant contributing factors were higher Asthma Control Questionnaire (ACQ) (36%), sleeping problems (21%), female sex (19%), reflux (12%), and lower fractional exhaled nitric oxide (12%). AACT led to significant improvements in CIS-Fatigue (median [IQR] 50 [11] to 27 [21]) (P < .001), ACQ (3.0 [1.3] to 1.2 [1.3]) (P < .001), and other asthma outcomes. However, 27% of patients reported persistent severe fatigue, correlating with less improvement in asthma outcomes. Daily oral corticosteroid use (odds ratio [OR] [95% confidence interval (CI)]: 2.4 [1.4-4.1]), sleeping problems (OR [95% CI]: 2.7 [1.6-4.5]), initial very severe fatigue (OR [95% CI]: 3.1 [1.6-6.3]), and older age (OR [95% CI]: 1.02 [1.0-1.04]) were independent predictors of persistent severe fatigue.

Conclusions: Severe fatigue is highly prevalent in patients with severe, uncontrolled asthma. AACT results in recovered fatigue and improved asthma control in most patients. Predicting factors of persistent fatigue suggest exploring the effect of targeted treatment strategies beyond the asthma domain.