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

Background: Mucus plugging has been identified as an important feature of severe asthma contributing to airway obstruction and disease severity. Recently, improvement of mucus plugging has been found upon treatment with several biologic therapies.

Objective: We aimed to analyze associations of baseline characteristic with mucus plugging score (MPS) and asked whether MPS at baseline predicts the clinical and functional response to biologic treatment in patients with severe asthma.

Methods: We retrospectively analyzed biologic-naïve patients with a suitable CT scan available at baseline. We calculated the MPS and analyzed correlations with baseline parameters and improvements of biomarkers, pulmonary function and clinical parameters after 4 months of biologic therapy.

Results: We included n=113 patients in the baseline cohort, hereof n=101 patients with sufficient data after 4-months of biologic therapy for the follow-up analysis. CT showed mucus plugging in 77% of patients with a median MPS of 4. Multivariate regression analysis showed correlation of MPS with lower FEV1 (rho= -0.24, p=0.009) and DLCO (rho=-0.26 , p= 0.01), and higher FeNO (rho=0.36 p=0.0003) at baseline. Patients received treatment with anti-IgE (8.8%), anti-IL5 (27.4%), anti-IL5R (37.2%), anti-IL4R (25.7%) and anti-TSLP (0,9%) in clinical routine. Baseline MPS correlated with improvements of FEV1 (beta=0.72; p=0.01) and ACT (beta= 0.24; p= 0.001) in multivariate regression analysis.

Conclusion: Our study suggests that higher MPS correlates with worse pulmonary function at baseline, but also predicts a larger clinical and pulmonary function response to biologic therapies in severe asthma.

Evaluating penicillin allergy labels and expanding access to preferred treatment options safely is of critical public health importance. Most patients with penicillin allergy labels are not allergic, and even in those with verified allergy, sensitization wanes over time. However, sensitization is complex and while a patient may have a negative penicillin allergy evaluation (including a drug challenge), resensitization can occur, raising a risk of a subsequent reaction upon exposure. In this pro/con debate we deliberate on whether patients who have had negative penicillin allergy evaluations should undergo retesting for sensitization prior to subsequent administrations. The pro position is presented by Drs. Inmaculada Doña, María Salas, and María Torres, while the con position is described by Drs. Ami Belmont and Roland Solensky.

Digital health is an umbrella term for components of health care using computer platforms, software, connectivity, and sensors to augment the recording, documentation, and communication of clinical information. The functions of digital health may be viewed in three domains: (1) the repository for patient information, (2) monitoring devices, and (3) communication tools. Monitoring devices have provided robust information as diagnostic and prognostic tools in office and hospital settings. In this review, as a case study, we will discuss the research and our direct clinical experience of electronic medication monitoring technology and the potential benefits to patient care, and the opportunities and perils encountered in using this approach for patients with moderate to severe asthma, including issues related to patient uptake and concerns for bias, impacts on the provider-patient relationship, and discussions regarding monitoring of rescue medication use in exacerbations. Additionally, although there is evidence for improvements in various aspects of patient care afforded by electronic medication monitoring, these devices have not yet seen widespread uptake in clinical settings, and we will discuss the steps needed to address these barriers and keep these important devices available for patient use in the future.

Background: Otitis media with effusion (OME) is associated with comorbidities such as allergic rhinitis, gastroesophageal reflux disease, asthma, and more. Many of these comorbidities can be caused by type 2 inflammation (T2I). This study aims to determine the risk of undergoing OME surgery in patients with and without T2I disease.

Objective: To determine whether T2I disease is associated with an increased incidence of OME surgery.

Methods: This retrospective, matched-cohort study involved the retrospective recruitment of patients with T2I disease (n = 31,603) and non-T2I disease (n = 31,603) from 2010 to 2019, using the Taiwan National Health Insurance Research Database. Statistical analyses were performed using t tests, Cox proportional regression models, Kaplan-Meier estimators, and log-rank tests.

Results: Among patients with OME, those with T2I disease had a greater risk of undergoing OME surgery, with an adjusted hazard ratio of 9.84 (95% confidence interval [CI], 8.90-10.88), than those without T2I disease. The adjusted relative risk for the number of OME surgeries in patients with T2I disease was 11.14 (95% CI, 10.30-12.05). Kaplan-Meier analysis showed consistently higher cumulative incidence curves in patients with T2I disease throughout the follow-up period (log-rank test: P < .001).

Conclusions: OME patients with T2I disease had a significantly higher incidence of undergoing surgery due to failed conservative treatment, indicating that T2I may play an important role in middle ear disorders. Further research on this topic should be considered significant and worthy of investigation.

Background: Antimicrobial stewardship (AMS) is crucial for optimising antimicrobial use and restraining emergence of antimicrobial resistance. The overall increase in reported antibiotic allergies in children can pose a significant barrier to AMS, but its impact on clinical AMS care in children has not been addressed.

Objective: Compare the clinical outcomes for children with a reported antibiotic allergy label (AAL) with those with no AAL reviewed by AMS.

Method: A retrospective cohort study conducted in a paediatric tertiary hospital, capturing 1590 inpatient admissions reviewed under the AMS between 2017-2019. Logistic, log-binomial and Cox regression analyses were undertaken. Data collected included documented AAL, antibiotic prescriptions, principal diagnosis, admitting specialty, hospital length of stay, intensive care admissions and hospital readmissions.

Results: All 1590 paediatric patients were prescribed at least one antibiotic. AALs were recorded in 6.6% of patients; majority were beta-lactam (82%), mostly penicillins (71%). AALs increased with age (p<0.001); no gender effect was seen. Patients with AALs received more quinolones (p<0.001), lincosamides (p=0.001), aminoglycosides (p<0.001), and metronidazole (p=0.015), than patients with no AALs. In contrast, children with no AAL received more penicillin (p<0.001). Children with any AAL had marginally longer hospital length of stay, median (IQR) 7.0 (4.0, 15.0) days, than those without (median (IQR) 5.0 (3.75, 11.0) days, p=0.027).

Conclusion: This study is the first to show how AALs impact clinical outcomes in children under an AMS program. With recent advances in delabelling, early intervention in cases of AAL should target children under AMS services who are in immediate need of optimal antibiotic management.

Background: The prevalence and clinical implications of chronic cough (CC) in patients with severe asthma receiving asthma treatment remain relatively unknown.

Objective: This study aimed to evaluate the relationships between CC and asthma control and quality of life (QoL) in patients with severe asthma through longitudinal analysis.

Methods: Baseline and 6-month follow-up data from the Korean Severe Asthma Registry were analyzed. CC was defined as a cough visual analog scale (VAS) score of ≥40 at both baseline and 6 months. Demographic parameters and clinical outcomes were compared between patients with severe asthma and CC and those without CC. Generalized estimating equation (GEE) analysis was performed to identify associations of CC with asthma control and QoL scores.

Results: Of the total 286 participants with severe asthma, 116 (40.6%) were defined as having CC. Patients with CC had higher baseline cough and wheeze severity VAS scores (all P < .001), poorer asthma control (P < .001), and worse QoL (Severe Asthma Questionnaire [SAQ] and Euro-QoL 5-Dimension [EQ-5D] index, all P < .001) than those without CC. During the follow-up, patients with CC were more frequently exposed to oral corticosteroids (58.6% vs 38.6%, P = .010) and experienced more frequent asthma exacerbations (48.3% vs 28.6%, P = .009) than those without CC. GEE analysis revealed that CC was independently associated with poor asthma control, lower SAQ scores, and a lower EQ-5D index after adjusting for confounders.

Conclusion: The presence of CC was associated with worse asthma control and QoL in patients with severe asthma. Further studies are warranted to better evaluate and manage CC in these patients.

Background: Clinical studies of biologics in severe asthma exclude smokers or ex-smokers (ExS) with over 10 pack-years (py). Thus, the effectiveness of this therapy in ExS with severe asthma is not well understood.

Objectives: To assess the impact of smoking on clinical efficiency of biologics in patients with severe asthma from the German Asthma Net, a comprehensive international registry.

Methods: This analysis included 1129 patients (55.8% female, mean age: 53.82 ± 14.67 years), of whom 56% were never-smokers (NS), whereas 44% were ExS (<10 py: 22.9%, 10-20 py: 10.3%, and >20 py: 10.6%). They received benralizumab (38.3%), dupilumab (28.9%), mepolizumab (18.3%), omalizumab (14%), or reslizumab (0.5%).

Results: Biologic therapy significantly improved asthma control, measured by change in Asthma Control Test, Asthma Control Questionnaire-5, and Mini-Asthma Quality of Life Questionnaire, lung function, reduced exacerbations, and daily oral prednisolone dose in all patients at week 52. Of note, no significant differences in asthma control between NS and ExS at week 52 (P = .48, .09, and .15, respectively) were observed. Also, lung function improvement (forced expiratory volume in 1 second, forced vital capacity, total lung capacity, peak expiratory flow, mean expiratory flow at 50%, P > .05), and reduction in acute exacerbation (P = .8) and oral corticosteroid doses (P = .15) were comparable in NS and ExS. Markers of type 2 inflammation, such as fraction of exhaled nitric oxide and blood eosinophils, decreased in ExS similar to NS (P = .29 and P = .48, respectively).

Conclusion: ExS with severe asthma experienced similar improvements in asthma control, exacerbations, lung function, and biomarkers as NS after 1 year of biologics, suggesting that severe asthmatics even with a substantial smoking history can benefit from biologic therapy.

Background: Data on oral immunotherapy (OIT) for hazelnut allergy is limited and its potential to cross-desensitize for other nuts is unknown.

Objective: To study the efficacy and safety of hazelnut OIT in desensitizing to hazelnut and additional tree nuts.

Methods: This was a prospective observational study of 30 hazelnut-allergic patients aged 4 years or older who underwent hazelnut OIT. Full desensitization (4,000 mg protein) rates were compared with those of 14 observational controls, and immunologic changes during OIT were measured. We determined cross-desensitization in cases of walnut and cashew co-allergy (n = 12). Inhibition of IgE binding to walnut by hazelnut was evaluated by ELISA in a separate set of dual walnut-hazelnut allergic patients.

Results: The rate of full hazelnut desensitization following OIT was 96.7% (29 of 30 patients) compared with 14.3% (two of 14) in controls (odds ratio = 25.7; 95% CI, 3.7-178.7; P < .001). Five patients (16.7%) were treated with injectable epinephrine for home reactions. Hazelnut skin prick test and specific IgE to hazelnut and its main components, Cor a 9, 14 and 16, decreased whereas specific IgG₄ increased during OIT. A maintenance dose of 1,200 mg hazelnut protein was sufficient to maintain full desensitization. No cross-desensitization was noted in dual hazelnut-cashew allergic patients (n = 6). In dual hazelnut-walnut allergic patients, an increase in the walnut eliciting dose was observed in two of six patients (33.2%) (to 1,200 and 4,200 mg, respectively). Similarly, by cross-inhibition ELISA, hazelnut competed for IgE-binding to walnut in five of 25 (20%) hazelnut-walnut co-allergic patients (20%).

Conclusions: Hazelnut OIT is highly effective, with a safety profile similar to that of OIT to other nuts. Cross-desensitization to walnut and cashew is unlikely.

The art of clinical negotiation is an important, yet underappreciated aspect of medicine. Key components of negotiation include the need to consider principles over personalities; to explore all options before deciding on the best course; to realize that, if consensus cannot be achieved, then compromise may still be possible; to work from evidence to incorporate contextual factors; and to stay evidence based. These principles can be helpful in many settings, including contract negotiation, drug pricing, and research. Negotiating the balance between patient safety and efficient research methodology is central to discussions with institutional review boards and public and private researchers. When guidelines are developed using the Grading of Recommendations Assessment, Development and Evaluation approach, shared decision making and negotiation of treatment plans can be seamlessly incorporated into patient conversations for conditional recommendations, and negotiation skills may facilitate clinical adoption of strong recommendation as well.