The incidence of asthma, a heterogeneous inflammatory disease affecting over 300 million people worldwide, continues to increase in developed countries. Human epithelial cells (ECs) express the alarmin-type cytokine thymic stromal lymphopoietin (TSLP) following tissue injury triggered by several environmental insults, which include allergens, smoke, pollutants, or other irritants. Furthermore, TSLP has an emerging but well-documented pathogenic role in asthma. TSLP has been called a “master switch” of allergic inflammation at the epithelial-dendritic cell (DC) interface, where it supports T helper 2 (Th2) inflammatory polarization and promotes the maintenance of Th2 memory responses. Therefore, targeting TSLP/TSLP-mediated signaling may represent an attractive therapeutic strategy for asthma. Several studies of anti-TSLP drugs are ongoing; the first-in-class anti-TSLP monoclonal antibody (mAb) tezepelumab, the immunoglobulin G1 antibody fragment CSJ117, or TSLP-traps [a combination of anti-interleukin-13 (anti-IL-13) and anti-TSLP mAbs] all represent promising new treatment approaches. This article reviews the characteristics of TSLP and discusses the treatment of severe asthma through TSLP-associated mechanisms.
The incidence of asthma, a heterogeneous inflammatory disease affecting over 300 million people worldwide, continues to increase in developed countries. Human epithelial cells (ECs) express the alarmin-type cytokine thymic stromal lymphopoietin (TSLP) following tissue injury triggered by several environmental insults, which include allergens, smoke, pollutants, or other irritants. Furthermore, TSLP has an emerging but well-documented pathogenic role in asthma. TSLP has been called a “master switch” of allergic inflammation at the epithelial-dendritic cell (DC) interface, where it supports T helper 2 (Th2) inflammatory polarization and promotes the maintenance of Th2 memory responses. Therefore, targeting TSLP/TSLP-mediated signaling may represent an attractive therapeutic strategy for asthma. Several studies of anti-TSLP drugs are ongoing; the first-in-class anti-TSLP monoclonal antibody (mAb) tezepelumab, the immunoglobulin G1 antibody fragment CSJ117, or TSLP-traps [a combination of anti-interleukin-13 (anti-IL-13) and anti-TSLP mAbs] all represent promising new treatment approaches. This article reviews the characteristics of TSLP and discusses the treatment of severe asthma through TSLP-associated mechanisms.
DOI: https://doi.org/10.37349/eaa.2023.00002
Aim:
Evaluation of asthma control is the first step in the management of pediatric patient symptoms. The aim of this study was to a) validate the accuracy of the Greek version of the Asthma Control Questionnaire (ACQ) in quantifying asthma status in Greek pediatric patients; b) compare the 6-item with the 7-item ACQ; and c) explore the discriminatory power of the ACQ in relation to medication use.
Methods:
Cross-sectional analysis of pulmonary data from 64 primary school children with mild asthma (51% boys). At baseline and 6 months, pulmonary function was recorded using spirometry and asthma control using the Greek version of the ACQ. Validity was assessed using Cronbach’s alpha.
Results:
Cronbach’s alpha showed good internal consistency for both the 7-item and 6-item ACQ (alpha = 0.67, 0.74 respectively). No differences in scores were observed in the presence/or absence of medication therapy.
Conclusions:
The findings of this study showed good precision and internal consistency of the 6-item ACQ in measuring recent asthma control in Greek children of the mild-asthma phenotype, independent of forced expiratory volume in 1 second (FEV1) and medication use. This suggests that the 6-item questionnaire alone is potentially a robust tool in assessing asthma symptom control in children when pulmonary function tests (PFTs) are not feasible.
Aim:
Evaluation of asthma control is the first step in the management of pediatric patient symptoms. The aim of this study was to a) validate the accuracy of the Greek version of the Asthma Control Questionnaire (ACQ) in quantifying asthma status in Greek pediatric patients; b) compare the 6-item with the 7-item ACQ; and c) explore the discriminatory power of the ACQ in relation to medication use.
Methods:
Cross-sectional analysis of pulmonary data from 64 primary school children with mild asthma (51% boys). At baseline and 6 months, pulmonary function was recorded using spirometry and asthma control using the Greek version of the ACQ. Validity was assessed using Cronbach’s alpha.
Results:
Cronbach’s alpha showed good internal consistency for both the 7-item and 6-item ACQ (alpha = 0.67, 0.74 respectively). No differences in scores were observed in the presence/or absence of medication therapy.
Conclusions:
The findings of this study showed good precision and internal consistency of the 6-item ACQ in measuring recent asthma control in Greek children of the mild-asthma phenotype, independent of forced expiratory volume in 1 second (FEV1) and medication use. This suggests that the 6-item questionnaire alone is potentially a robust tool in assessing asthma symptom control in children when pulmonary function tests (PFTs) are not feasible.
DOI: https://doi.org/10.37349/eaa.2023.00003
DOI: https://doi.org/10.37349/eaa.2022.00001
Lettuce allergy is uncommon and usually attributed to lipid transfer protein (LTP) sensitization. Most LTP-sensitized patients present with heterogeneous symptoms not only to lettuce, but to a large number of other foods and pollen allergens, including peaches, apples, Platanus, and mugwort, with peach LTP being considered as the primary sensitizer. The case of a medical student with a history of lettuce allergy investigated by skin prick tests (SPTs) and oral food challenge (OFC) is presented in this report. SPTs showed sensitization exclusively to lettuce and not to any other known cross-reacting allergens, which contrasts with previous literature and highlights the uniqueness of this case. During OFC, the patient developed generalized symptoms including abdominal discomfort, bilateral tinnitus, facial flushing, generalized itching, and urticaria. No cardiopulmonary compromise was observed at the time, and the reaction was managed with oral antihistamines. More sophisticated molecular analysis is required to identify the patient’s sensitization profile; however, SPTs and OFCs remain the most practical clinical approach. Lettuce allergy deserves further attention and investigation.
Lettuce allergy is uncommon and usually attributed to lipid transfer protein (LTP) sensitization. Most LTP-sensitized patients present with heterogeneous symptoms not only to lettuce, but to a large number of other foods and pollen allergens, including peaches, apples, Platanus, and mugwort, with peach LTP being considered as the primary sensitizer. The case of a medical student with a history of lettuce allergy investigated by skin prick tests (SPTs) and oral food challenge (OFC) is presented in this report. SPTs showed sensitization exclusively to lettuce and not to any other known cross-reacting allergens, which contrasts with previous literature and highlights the uniqueness of this case. During OFC, the patient developed generalized symptoms including abdominal discomfort, bilateral tinnitus, facial flushing, generalized itching, and urticaria. No cardiopulmonary compromise was observed at the time, and the reaction was managed with oral antihistamines. More sophisticated molecular analysis is required to identify the patient’s sensitization profile; however, SPTs and OFCs remain the most practical clinical approach. Lettuce allergy deserves further attention and investigation.
DOI: https://doi.org/10.37349/eaa.2023.00004
Coronavirus disease 2019 (COVID-19) pandemic was a great challenge for healthcare professionals globally and also for allergists/immunologists. The Pegaso low-care COVID center's experience in managing a low-care center for COVID-19 patients was reported, trying to bring out the relevance of this type of structure in reducing the length of stay of patients in high-care settings with the consequent effect of avoiding the collapse of major hospitals. The experience of managing a low-care setting with a day hospital service inside emphasizes, even more, the role of the allergists/immunologists during the COVID-19 pandemic contributing to keeping the medical staff's specialty in a strategic role in the battle against this common enemy. Sharing all the information on public health organizations is crucial to cope in the best possible way with the present and future challenges.
Coronavirus disease 2019 (COVID-19) pandemic was a great challenge for healthcare professionals globally and also for allergists/immunologists. The Pegaso low-care COVID center's experience in managing a low-care center for COVID-19 patients was reported, trying to bring out the relevance of this type of structure in reducing the length of stay of patients in high-care settings with the consequent effect of avoiding the collapse of major hospitals. The experience of managing a low-care setting with a day hospital service inside emphasizes, even more, the role of the allergists/immunologists during the COVID-19 pandemic contributing to keeping the medical staff's specialty in a strategic role in the battle against this common enemy. Sharing all the information on public health organizations is crucial to cope in the best possible way with the present and future challenges.
DOI: https://doi.org/10.37349/eaa.2023.00005
Eosinophilic granulomatosis with polyangiitis (EGPA) is a multiorganic syndrome that affects the cardiovascular, neurologic, renal, and gastrointestinal systems with an incidence ranging from 0 case to 67 cases per one million person-years, and its pathophysiology remains unknown. It is believed that genetic factors, the environment, and changes in immune system function contribute to the development of EGPA, overlapping the immune mechanisms of vasculitides and the pathologic mechanisms in eosinophilic syndromes. This disease is commonly divided into two phenotypes depending on the presence of antineutrophil cytoplasmic antibodies (ANCA). ANCA-positive patients usually have more vasculitic manifestations like peripheral neuropathy, purpura, renal involvement, and biopsy-proven vasculitis. The keystone of EGPA therapy is systemic corticosteroids (CS) as monotherapy or in combination with other immunosuppressive treatments, and recently the efficacy of eosinophil-targeted biotherapy, anti-interleukin-5 (IL-5), has been shown to be efficacious in EGPA. Although this phenotype/phase distinction has not yet had an impact on the current treatment strategies, emerging targeted biotherapies under evaluation could lead to a phenotype-based approach and personalised treatment regimens for EGPA patients. The present review describes the new therapeutical approaches with biological drugs for EGPA.
Eosinophilic granulomatosis with polyangiitis (EGPA) is a multiorganic syndrome that affects the cardiovascular, neurologic, renal, and gastrointestinal systems with an incidence ranging from 0 case to 67 cases per one million person-years, and its pathophysiology remains unknown. It is believed that genetic factors, the environment, and changes in immune system function contribute to the development of EGPA, overlapping the immune mechanisms of vasculitides and the pathologic mechanisms in eosinophilic syndromes. This disease is commonly divided into two phenotypes depending on the presence of antineutrophil cytoplasmic antibodies (ANCA). ANCA-positive patients usually have more vasculitic manifestations like peripheral neuropathy, purpura, renal involvement, and biopsy-proven vasculitis. The keystone of EGPA therapy is systemic corticosteroids (CS) as monotherapy or in combination with other immunosuppressive treatments, and recently the efficacy of eosinophil-targeted biotherapy, anti-interleukin-5 (IL-5), has been shown to be efficacious in EGPA. Although this phenotype/phase distinction has not yet had an impact on the current treatment strategies, emerging targeted biotherapies under evaluation could lead to a phenotype-based approach and personalised treatment regimens for EGPA patients. The present review describes the new therapeutical approaches with biological drugs for EGPA.
DOI: https://doi.org/10.37349/eaa.2023.00006
This article belongs to the special issue The Era of Biologics in Allergy
Aim:
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex disease with different subtypes that affect patients’ quality of life. This study aim to evaluate the severity of CRSwNP and the risk of treatment resistance using the “Japanese epidemiological survey of refractory eosinophilic chronic rhinosinusitis” (JESREC) algorithm in outpatients at a university hospital.
Methods:
A retrospective study was conducted reviewing the medical records of CRSwNP outpatients. Clinical data including age, sex, blood eosinophilia, computered tomography (CT) scans, presence of asthma, and nonsteroidal anti-inflammatory drug (NSAID) use were assessed.
Results:
Medical records of 83 patients diagnosed with CRSwNP were analyzed, with 44 (53%) females and 39 (47%) males. The mean age was 61.8 years ± 14.1 years (range: 19–90 years). According to the JESREC algorithm, 9 (10.8%) patients were categorized as non-eosinophilic chronic rhinosinusitis (neCRS), and 74 (89%) were classified as eosinophilic chronic rhinosinusitis (eCRS). Among the eCRS patients, 13 (17.6%) were mild, 32 (43.2%) were moderate, and 29 (39.2%) were severe. Asthma was identified as a comorbidity in 57 patients (68.6%).
Conclusions:
A predominance of eCRS with moderate to severe risk of treatment resistance was confirmed. Considering the heterogeneity of chronic rhinosinusitis (CRS), the JESREC algorithm comes up as an instrument that uses objective criteria to assess higher risks of recurrency and refractoriness among patients before surgical treatment, helping to predict type2-driven biologics need.
Aim:
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex disease with different subtypes that affect patients’ quality of life. This study aim to evaluate the severity of CRSwNP and the risk of treatment resistance using the “Japanese epidemiological survey of refractory eosinophilic chronic rhinosinusitis” (JESREC) algorithm in outpatients at a university hospital.
Methods:
A retrospective study was conducted reviewing the medical records of CRSwNP outpatients. Clinical data including age, sex, blood eosinophilia, computered tomography (CT) scans, presence of asthma, and nonsteroidal anti-inflammatory drug (NSAID) use were assessed.
Results:
Medical records of 83 patients diagnosed with CRSwNP were analyzed, with 44 (53%) females and 39 (47%) males. The mean age was 61.8 years ± 14.1 years (range: 19–90 years). According to the JESREC algorithm, 9 (10.8%) patients were categorized as non-eosinophilic chronic rhinosinusitis (neCRS), and 74 (89%) were classified as eosinophilic chronic rhinosinusitis (eCRS). Among the eCRS patients, 13 (17.6%) were mild, 32 (43.2%) were moderate, and 29 (39.2%) were severe. Asthma was identified as a comorbidity in 57 patients (68.6%).
Conclusions:
A predominance of eCRS with moderate to severe risk of treatment resistance was confirmed. Considering the heterogeneity of chronic rhinosinusitis (CRS), the JESREC algorithm comes up as an instrument that uses objective criteria to assess higher risks of recurrency and refractoriness among patients before surgical treatment, helping to predict type2-driven biologics need.
DOI: https://doi.org/10.37349/eaa.2023.00007
This article belongs to the special issue Precision Medicine in Allergy and Rhinology
Nutritional therapy through exclusive enteral nutrition (EEN) is successful with Crohn’s disease (CD), but most patients relapse when returning to a normal diet. Personalized and sustainable diets over time have not been tried. This pioneering case report shows the successful response to the use of a skin prick test (SPT) with a 0.5 mm cutoff and a combination of parameters to guide the diet of a child with CD, ensuring continued remission and a regular diet over a follow-up period of 3 years. The 5-year-old patient had a history of chronic diarrhea. Laboratory showed anemia, hypoalbuminemia, high erythrocyte sedimentation rate (ESR), and fecal calprotectin (FCP) > 2,100 µg/g. Endoscopies revealed duodenal ulcer scar and ulcerative pancolitis. Simple endoscopic score for CD score (SES-CD) = 16 (severe). Pathology showed CD. EEN started with a polymeric formula, later moving to an elemental formula due to a suboptimal response. Medication included prednisolone, mesalazine, azathioprine, and methotrexate. Foods were introduced guided by the SPT and included 54 protein extracts from food tested every 3–4 months. The patient has clinical and histological remission despite having lamb, turkey, eggs, cereals (including wheat), and fish in his diet. FCP has been measured with every change in diet and maintained at < 100 µg/g with the reintroduction of food, with the exception of fish and eggs which, despite a negative SPT, gave mild symptoms and raised FCP to 223 µg/g. Both eggs and fish were successfully reintroduced (FCP < 100 µg/g) after 7 and 11 months respectively from failed reintroduction. This innovative approach based on SPT and strict clinical and follow-up inflammatory markers can potentially ensure remission, reintroducing foods with objective parameters, and improving the patient’s quality of life.
Nutritional therapy through exclusive enteral nutrition (EEN) is successful with Crohn’s disease (CD), but most patients relapse when returning to a normal diet. Personalized and sustainable diets over time have not been tried. This pioneering case report shows the successful response to the use of a skin prick test (SPT) with a 0.5 mm cutoff and a combination of parameters to guide the diet of a child with CD, ensuring continued remission and a regular diet over a follow-up period of 3 years. The 5-year-old patient had a history of chronic diarrhea. Laboratory showed anemia, hypoalbuminemia, high erythrocyte sedimentation rate (ESR), and fecal calprotectin (FCP) > 2,100 µg/g. Endoscopies revealed duodenal ulcer scar and ulcerative pancolitis. Simple endoscopic score for CD score (SES-CD) = 16 (severe). Pathology showed CD. EEN started with a polymeric formula, later moving to an elemental formula due to a suboptimal response. Medication included prednisolone, mesalazine, azathioprine, and methotrexate. Foods were introduced guided by the SPT and included 54 protein extracts from food tested every 3–4 months. The patient has clinical and histological remission despite having lamb, turkey, eggs, cereals (including wheat), and fish in his diet. FCP has been measured with every change in diet and maintained at < 100 µg/g with the reintroduction of food, with the exception of fish and eggs which, despite a negative SPT, gave mild symptoms and raised FCP to 223 µg/g. Both eggs and fish were successfully reintroduced (FCP < 100 µg/g) after 7 and 11 months respectively from failed reintroduction. This innovative approach based on SPT and strict clinical and follow-up inflammatory markers can potentially ensure remission, reintroducing foods with objective parameters, and improving the patient’s quality of life.
DOI: https://doi.org/10.37349/eaa.2024.00033
This article belongs to the special issue The Different Faces of Food Allergy
Aim:
Asthma represents a significant health burden in Kuwait, with high prevalence rates among adults and children. Most asthma patients rely on government healthcare facilities for management, so there is a pressing need to optimize asthma care and treatment strategies. A cross-sectional paper-based survey was conducted to gather insights from allergists and pulmonologists across various healthcare facilities in Kuwait.
Methods:
Twenty-six medical professionals participated, sharing their perspectives on asthma management practices and adherence to the Global Initiative for Asthma (GINA) 2022 guidelines through answering a modified single round Delphi survey.
Results:
A high level of consensus on the practicality of guideline changes and the importance of spirometry in diagnosis were reported. However, agreement varied regarding optimal management strategies and medication preferences, indicating areas of divergence among experts. Notably, while there was strong support for inhaled corticosteroid (ICS)-long-acting β2 agonist (LABA) therapy during exacerbations, opinions differed on the use of short-acting β2 agonist (SABA) inhalers as rescue medication. Additionally, the study highlighted challenges in achieving higher levels of agreement, particularly regarding the frequency of inhaler technique checks and specialist referrals for severe asthma cases.
Conclusions:
This study provided valuable insights into current asthma management practices in Kuwait and identified opportunities for consensus-driven strategies aligned with GINA guidelines. By incorporating diverse perspectives from expert allergists and pulmonologists, it contributed to the enhancement of asthma care and patient outcomes in Kuwaiti healthcare settings.
Aim:
Asthma represents a significant health burden in Kuwait, with high prevalence rates among adults and children. Most asthma patients rely on government healthcare facilities for management, so there is a pressing need to optimize asthma care and treatment strategies. A cross-sectional paper-based survey was conducted to gather insights from allergists and pulmonologists across various healthcare facilities in Kuwait.
Methods:
Twenty-six medical professionals participated, sharing their perspectives on asthma management practices and adherence to the Global Initiative for Asthma (GINA) 2022 guidelines through answering a modified single round Delphi survey.
Results:
A high level of consensus on the practicality of guideline changes and the importance of spirometry in diagnosis were reported. However, agreement varied regarding optimal management strategies and medication preferences, indicating areas of divergence among experts. Notably, while there was strong support for inhaled corticosteroid (ICS)-long-acting β2 agonist (LABA) therapy during exacerbations, opinions differed on the use of short-acting β2 agonist (SABA) inhalers as rescue medication. Additionally, the study highlighted challenges in achieving higher levels of agreement, particularly regarding the frequency of inhaler technique checks and specialist referrals for severe asthma cases.
Conclusions:
This study provided valuable insights into current asthma management practices in Kuwait and identified opportunities for consensus-driven strategies aligned with GINA guidelines. By incorporating diverse perspectives from expert allergists and pulmonologists, it contributed to the enhancement of asthma care and patient outcomes in Kuwaiti healthcare settings.
DOI: https://doi.org/10.37349/eaa.2024.00034
This article belongs to the special issue The Global Picture of Asthma after Guideline Changes and the COVID Pandemics
Seaweed, a rich source of bioactive compounds, has gained increasing attention for its potential therapeutic applications in allergy and inflammation. This review examines the current scientific literature investigating the effects of seaweed derived food and diet factors on allergic and inflammatory conditions. Seaweed is abundant in polysaccharides, peptides, polyphenols, and fatty acids, which possess anti-inflammatory, antioxidant, and immunomodulatory properties. These bioactive compounds have the capacity to modulate immune responses and mitigate allergic reactions, rendering seaweed a promising candidate for the development of functional foods and dietary interventions targeting allergy and inflammation. Explorations into the effects of seaweed consumption on allergic conditions such as allergic rhinitis, asthma, and atopic dermatitis have shown encouraging results. Factors found in seaweed have the potential to alleviate symptoms, reduce inflammation, and boost immune function in allergy sufferers. Furthermore, inquiries into the effectiveness of diets incorporating seaweed in preventing and managing chronic inflammatory conditions like inflammatory bowel disease and rheumatoid arthritis have been undertaken. The mechanisms underlying the therapeutic effects of seaweed derived compounds are being unraveled, revealing their ability to modulate immune cell activity, regulate cytokine production, inhibit inflammatory mediators, and promote gut microbiota balance. Understanding these molecular mechanisms is crucial for targeted interventions and the identification of specific bioactive compounds responsible for the observed therapeutic effects. Seaweed derived food and diet factors hold significant promise as natural interventions for the prevention and management of allergic and inflammatory conditions. However, further research is required to establish the optimal dosage, formulation, and long-term effects of seaweed-based interventions. Additionally, clinical trials are necessary to validate their efficacy and safety in diverse patient populations. This review emphasizes the therapeutic potential of seaweed derived compounds and underscores the importance of incorporating seaweed into dietary strategies to combat allergy and inflammation.
Seaweed, a rich source of bioactive compounds, has gained increasing attention for its potential therapeutic applications in allergy and inflammation. This review examines the current scientific literature investigating the effects of seaweed derived food and diet factors on allergic and inflammatory conditions. Seaweed is abundant in polysaccharides, peptides, polyphenols, and fatty acids, which possess anti-inflammatory, antioxidant, and immunomodulatory properties. These bioactive compounds have the capacity to modulate immune responses and mitigate allergic reactions, rendering seaweed a promising candidate for the development of functional foods and dietary interventions targeting allergy and inflammation. Explorations into the effects of seaweed consumption on allergic conditions such as allergic rhinitis, asthma, and atopic dermatitis have shown encouraging results. Factors found in seaweed have the potential to alleviate symptoms, reduce inflammation, and boost immune function in allergy sufferers. Furthermore, inquiries into the effectiveness of diets incorporating seaweed in preventing and managing chronic inflammatory conditions like inflammatory bowel disease and rheumatoid arthritis have been undertaken. The mechanisms underlying the therapeutic effects of seaweed derived compounds are being unraveled, revealing their ability to modulate immune cell activity, regulate cytokine production, inhibit inflammatory mediators, and promote gut microbiota balance. Understanding these molecular mechanisms is crucial for targeted interventions and the identification of specific bioactive compounds responsible for the observed therapeutic effects. Seaweed derived food and diet factors hold significant promise as natural interventions for the prevention and management of allergic and inflammatory conditions. However, further research is required to establish the optimal dosage, formulation, and long-term effects of seaweed-based interventions. Additionally, clinical trials are necessary to validate their efficacy and safety in diverse patient populations. This review emphasizes the therapeutic potential of seaweed derived compounds and underscores the importance of incorporating seaweed into dietary strategies to combat allergy and inflammation.
DOI: https://doi.org/10.37349/eaa.2024.00035
This article belongs to the special issue The Different Faces of Food Allergy
Food protein-induced enterocolitis syndrome (FPIES) is an allergic disorder that manifests as reproducible gastrointestinal symptoms within hours of ingestion of the causative food, which can progress to dehydration and hypotension. Historically, FPIES has been recognized as a disease affecting the pediatric population but it can also develop de novo in adults. The pathophysiology is not well understood; however, the local adaptive immune system and gene expression linked to innate immune activation are implicated. Adult-onset FPIES has some differences with pediatric FPIES. Vomiting may be absent, while abdominal pain is the most common manifestation. A clear predominance in women occurs, being seafood the most common trigger, although many other foods have also been implicated. Diagnosis of adult-onset FPIES is based on a thorough clinical history but in many cases, it should be followed by an oral food challenge (OFC), due to the absence of vomiting in some patients and the lack of confirmatory diagnostic test. The first-line treatment for acute FPIES reactions is fluid replacement, by the oral route in mild to moderate reactions or via the intravenous route in severe reactions. Ondansetron may be effective in shortening the duration of emesis. Management of patients after diagnosis includes dietary advice and follow-up with supervised OFC at regular intervals to monitor for resolution. Tolerance to the trigger food in children is commonly achieved, a finding not so common in adult-onset FPIES. The aim of this article is to review the most important current concepts in epidemiology, pathophysiology, diagnosis, and management of FPIES.
Food protein-induced enterocolitis syndrome (FPIES) is an allergic disorder that manifests as reproducible gastrointestinal symptoms within hours of ingestion of the causative food, which can progress to dehydration and hypotension. Historically, FPIES has been recognized as a disease affecting the pediatric population but it can also develop de novo in adults. The pathophysiology is not well understood; however, the local adaptive immune system and gene expression linked to innate immune activation are implicated. Adult-onset FPIES has some differences with pediatric FPIES. Vomiting may be absent, while abdominal pain is the most common manifestation. A clear predominance in women occurs, being seafood the most common trigger, although many other foods have also been implicated. Diagnosis of adult-onset FPIES is based on a thorough clinical history but in many cases, it should be followed by an oral food challenge (OFC), due to the absence of vomiting in some patients and the lack of confirmatory diagnostic test. The first-line treatment for acute FPIES reactions is fluid replacement, by the oral route in mild to moderate reactions or via the intravenous route in severe reactions. Ondansetron may be effective in shortening the duration of emesis. Management of patients after diagnosis includes dietary advice and follow-up with supervised OFC at regular intervals to monitor for resolution. Tolerance to the trigger food in children is commonly achieved, a finding not so common in adult-onset FPIES. The aim of this article is to review the most important current concepts in epidemiology, pathophysiology, diagnosis, and management of FPIES.
DOI: https://doi.org/10.37349/eaa.2024.00036
This article belongs to the special issue The Different Faces of Food Allergy
The Finnish Asthma Program, which ran between 1994 and 2004, has long been heralded as a benchmark of success in how to improve management and reduce asthma-related health service utilization. In Australia, there were 38,792 asthma hospitalizations in 2017–18, and 80% of these were considered avoidable (J Asthma Allergy. 2021;14:797–808. doi: 10.2147/JAA.S311721). To address this issue, Asthma Australia has set a strategic objective of halving avoidable asthma presentations to hospital by 2030. This article provides an overview of the Finnish Asthma Program, including an evaluation of critical success factors, outputs, and outcomes, followed by a synthesis of these findings for relevance and applicability to the contemporary Australian context that will inform policy and practice recommendations. Early diagnosis, effective anti-inflammatory medication, guided self-management, and monitoring disease control are still the keys to mitigating asthma burden. In the spirit of the Finnish Program, the digital transformation of healthcare and social media is enabling a new kind of systematic approach, both for patients and professionals.
The Finnish Asthma Program, which ran between 1994 and 2004, has long been heralded as a benchmark of success in how to improve management and reduce asthma-related health service utilization. In Australia, there were 38,792 asthma hospitalizations in 2017–18, and 80% of these were considered avoidable (J Asthma Allergy. 2021;14:797–808. doi: 10.2147/JAA.S311721). To address this issue, Asthma Australia has set a strategic objective of halving avoidable asthma presentations to hospital by 2030. This article provides an overview of the Finnish Asthma Program, including an evaluation of critical success factors, outputs, and outcomes, followed by a synthesis of these findings for relevance and applicability to the contemporary Australian context that will inform policy and practice recommendations. Early diagnosis, effective anti-inflammatory medication, guided self-management, and monitoring disease control are still the keys to mitigating asthma burden. In the spirit of the Finnish Program, the digital transformation of healthcare and social media is enabling a new kind of systematic approach, both for patients and professionals.
DOI: https://doi.org/10.37349/eaa.2024.00037
Indoor air pollution (IAP) is an important cause of concern for human health, leading to millions of deaths worldwide each year. Since people spend most of their time indoor the quality of the air inhaled during routine activities is of primary importance. IAP include particulate matter (PM), volatile organic compounds (VOCs), chemical gases, heavy metals, and biological contaminants. Unfortunately, their sources are various and widespread all over the household and other indoor environments, causing relevant health consequences. This narrative review aims to provide a comprehensive framework of the indoor pollutants effects on subjects affected by asthma, allergic rhinitis, and atopic dermatitis. As pivotal barriers against pollutants, in fact, respiratory and cutaneous districts can be particularly affected by IAP, especially in case of atopic diseases. On the other hand, the application of targeted adjustments, such as the avoidance of cigarette smoking, the use of hoods while cooking, the choice of adequate ventilation systems, and the use of low-emitting building materials and furniture may result in the improvement of indoor quality.
Indoor air pollution (IAP) is an important cause of concern for human health, leading to millions of deaths worldwide each year. Since people spend most of their time indoor the quality of the air inhaled during routine activities is of primary importance. IAP include particulate matter (PM), volatile organic compounds (VOCs), chemical gases, heavy metals, and biological contaminants. Unfortunately, their sources are various and widespread all over the household and other indoor environments, causing relevant health consequences. This narrative review aims to provide a comprehensive framework of the indoor pollutants effects on subjects affected by asthma, allergic rhinitis, and atopic dermatitis. As pivotal barriers against pollutants, in fact, respiratory and cutaneous districts can be particularly affected by IAP, especially in case of atopic diseases. On the other hand, the application of targeted adjustments, such as the avoidance of cigarette smoking, the use of hoods while cooking, the choice of adequate ventilation systems, and the use of low-emitting building materials and furniture may result in the improvement of indoor quality.
DOI: https://doi.org/10.37349/eaa.2024.00038
Aim:
This study aims at assessing dupilumab’s response in severe chronic rhinosinusitis with nasal polyps (CRSwNP) and its impact on concurrent mild to moderate asthma.
Methods:
The study involved severe, uncontrolled CRSwNP patients starting dupilumab treatment (300 mg/2 weeks) at the Allergy unit in University General Hospital “Attikon” in Athens, Greece, from May 2020 to July 2022. Assessments were conducted at baseline (week 0) and weeks 2, 4, 16, 24, and 52, covering 22-item Sino-Nasal Outcome Test (SNOT22), blood eosinophil counts, fractional exhaled nitric oxide (FeNO) concentration, Lund-Mackay CT scores (weeks 0, 16, and 52), Asthma Control Test (ACT) scores (weeks 0, 16, and 52), and forced expiratory volume in one second (FEV1) measurements (weeks 0, 16, and 52). Systemic corticosteroid usage, nasal surgeries, and anosmia improvements were also monitored throughout the study.
Results:
Six patients (50% male, mean age 53.1 years) with severe CRSwNP had severe uncontrolled baseline symptoms: complete anosmia, impaired quality of life (mean SNOT22: 71.6 ± 16.2), and Lund-Mackay CT score of 19.3 ± 2. Within the past year, 83.3% received over three courses of systemic corticosteroids for CRSwNP, and 50% had more than three polypectomies. After two weeks of dupilumab treatment, notable improvements were seen: reduced SNOT22 scores (week 2: 32.5, week 4: 18.1, week 16: 14, week 24: 13.8, week 52: 9.3), improved olfaction (weeks 4–16), reduced polyp size based on Lund-Mackay CT score (week 16: 13.3, week 52: 12.8), and enhanced lung function (FEV1 baseline: 3.15 L, week 16: 3.22 L, week 52: 3.22 L). Control was achieved by week 16 (ACT: 25/25). FeNO levels decreased [week 2: (18.2 ± 8.7) ppb, week 4: (16.5 ± 7.4) ppb, week 16: (16.9 ± 7.8) ppb, week 24: (13.7 ± 8.3) ppb, week 52: (13.4 ± 5.6) ppb]. No patients required nasal surgery.
Conclusions:
Dupilumab effectively targets interleukin 4 (IL4) and IL13, controlling type 2 inflammation spectrum, thus providing significant disease control for CRSwNP patients. Moreover, it improves asthma, even in mild to moderate cases, showcasing its broader therapeutic benefits.
Aim:
This study aims at assessing dupilumab’s response in severe chronic rhinosinusitis with nasal polyps (CRSwNP) and its impact on concurrent mild to moderate asthma.
Methods:
The study involved severe, uncontrolled CRSwNP patients starting dupilumab treatment (300 mg/2 weeks) at the Allergy unit in University General Hospital “Attikon” in Athens, Greece, from May 2020 to July 2022. Assessments were conducted at baseline (week 0) and weeks 2, 4, 16, 24, and 52, covering 22-item Sino-Nasal Outcome Test (SNOT22), blood eosinophil counts, fractional exhaled nitric oxide (FeNO) concentration, Lund-Mackay CT scores (weeks 0, 16, and 52), Asthma Control Test (ACT) scores (weeks 0, 16, and 52), and forced expiratory volume in one second (FEV1) measurements (weeks 0, 16, and 52). Systemic corticosteroid usage, nasal surgeries, and anosmia improvements were also monitored throughout the study.
Results:
Six patients (50% male, mean age 53.1 years) with severe CRSwNP had severe uncontrolled baseline symptoms: complete anosmia, impaired quality of life (mean SNOT22: 71.6 ± 16.2), and Lund-Mackay CT score of 19.3 ± 2. Within the past year, 83.3% received over three courses of systemic corticosteroids for CRSwNP, and 50% had more than three polypectomies. After two weeks of dupilumab treatment, notable improvements were seen: reduced SNOT22 scores (week 2: 32.5, week 4: 18.1, week 16: 14, week 24: 13.8, week 52: 9.3), improved olfaction (weeks 4–16), reduced polyp size based on Lund-Mackay CT score (week 16: 13.3, week 52: 12.8), and enhanced lung function (FEV1 baseline: 3.15 L, week 16: 3.22 L, week 52: 3.22 L). Control was achieved by week 16 (ACT: 25/25). FeNO levels decreased [week 2: (18.2 ± 8.7) ppb, week 4: (16.5 ± 7.4) ppb, week 16: (16.9 ± 7.8) ppb, week 24: (13.7 ± 8.3) ppb, week 52: (13.4 ± 5.6) ppb]. No patients required nasal surgery.
Conclusions:
Dupilumab effectively targets interleukin 4 (IL4) and IL13, controlling type 2 inflammation spectrum, thus providing significant disease control for CRSwNP patients. Moreover, it improves asthma, even in mild to moderate cases, showcasing its broader therapeutic benefits.
DOI: https://doi.org/10.37349/eaa.2024.00039
Aim:
Chronic migraine (CM) is a condition characterized by attacks of severe headaches leading to an increase in time off work, decrease in work productivity and in physical functioning. The aim of this study was to investigate the role of sinus anatomic variants (SAV) on the evolution of migraine from episodic to chronic form.
Methods:
Two hundred and seven migraineurs [110 with episodic migraine (EM) and 97 with CM] with no evidence of nasal septal deviation with a contact point on the lateral nasal wall were evaluated for endoscopic, radiologic and anatomic variant (AV) abnormalities using Lund-Kennedy endoscopy (LKES) and Lund-Mackay radiology scores (LMRS). Headache day frequency, duration, severity and lost time at work were compared with regard to the presence of any AV and concha bullosa (CB) as well.
Results:
There was a very significant difference between EM and CM patients with regard to overall SAV and endoscopy scores. However, no significant difference was seen between the groups with regard to radiology scores and headache pain severity. The presence of one AV increased headache day frequency, severity and days off work in all patients. CB was found to worsen headache severity and lost time at work in all patients.
Conclusions:
Patients with CM have more SAV and worse endoscopy scores than patients with EM. The presence of any of the AVs increases headache day frequency, pain severity and days off work in migraineurs.
Aim:
Chronic migraine (CM) is a condition characterized by attacks of severe headaches leading to an increase in time off work, decrease in work productivity and in physical functioning. The aim of this study was to investigate the role of sinus anatomic variants (SAV) on the evolution of migraine from episodic to chronic form.
Methods:
Two hundred and seven migraineurs [110 with episodic migraine (EM) and 97 with CM] with no evidence of nasal septal deviation with a contact point on the lateral nasal wall were evaluated for endoscopic, radiologic and anatomic variant (AV) abnormalities using Lund-Kennedy endoscopy (LKES) and Lund-Mackay radiology scores (LMRS). Headache day frequency, duration, severity and lost time at work were compared with regard to the presence of any AV and concha bullosa (CB) as well.
Results:
There was a very significant difference between EM and CM patients with regard to overall SAV and endoscopy scores. However, no significant difference was seen between the groups with regard to radiology scores and headache pain severity. The presence of one AV increased headache day frequency, severity and days off work in all patients. CB was found to worsen headache severity and lost time at work in all patients.
Conclusions:
Patients with CM have more SAV and worse endoscopy scores than patients with EM. The presence of any of the AVs increases headache day frequency, pain severity and days off work in migraineurs.
DOI: https://doi.org/10.37349/eaa.2024.00040
This article belongs to the special issue Update on Chronic RhinoSinusitis
Eosinophilic gastrointestinal diseases (EGIDs) are a group of chronic conditions, characterized by an excessive accumulation of eosinophils in various areas of the mucosal of the gastrointestinal (GI) tract. EGIDs encompass a spectrum of diseases, including eosinophilic esophagitis (EoE), eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC), each affecting different segments of the GI tract. The pathogenesis of EGIDs is multifaceted and involves an intricate interplay between genetic predisposition, environmental triggers, and dysregulated immune responses. Although the exact etiology behind EGIDs is not fully understood, it is clear that they are immune-mediated, with eosinophils having a central role in inflammation and tissue damage of GI mucosal. Clinical manifestations depend on the organ that is affected by the disease and on the depth of the eosinophil infiltration of the bowel wall. They range from mild discomfort to severe dysphagia, abdominal pain, malnutrition, and growth failure, particularly in pediatric cases. Regarding EGID management, it is a challenging issue to achieve clinical and histologic remission using pharmacotherapy and dietary elimination. Corticosteroids and proton pump inhibitors can be selected as an effective first-line treatment for certain patients and six-food elimination diet (6-FED) has been proven effective in inducing remission. Furthermore, biologic therapies have emerged as essential tools in controlling eosinophilic-driven inflammation. This review focuses on the complex pathogenesis and treatment of these inflammatory diseases, especially EoE.
Eosinophilic gastrointestinal diseases (EGIDs) are a group of chronic conditions, characterized by an excessive accumulation of eosinophils in various areas of the mucosal of the gastrointestinal (GI) tract. EGIDs encompass a spectrum of diseases, including eosinophilic esophagitis (EoE), eosinophilic gastritis (EoG), eosinophilic enteritis (EoN), and eosinophilic colitis (EoC), each affecting different segments of the GI tract. The pathogenesis of EGIDs is multifaceted and involves an intricate interplay between genetic predisposition, environmental triggers, and dysregulated immune responses. Although the exact etiology behind EGIDs is not fully understood, it is clear that they are immune-mediated, with eosinophils having a central role in inflammation and tissue damage of GI mucosal. Clinical manifestations depend on the organ that is affected by the disease and on the depth of the eosinophil infiltration of the bowel wall. They range from mild discomfort to severe dysphagia, abdominal pain, malnutrition, and growth failure, particularly in pediatric cases. Regarding EGID management, it is a challenging issue to achieve clinical and histologic remission using pharmacotherapy and dietary elimination. Corticosteroids and proton pump inhibitors can be selected as an effective first-line treatment for certain patients and six-food elimination diet (6-FED) has been proven effective in inducing remission. Furthermore, biologic therapies have emerged as essential tools in controlling eosinophilic-driven inflammation. This review focuses on the complex pathogenesis and treatment of these inflammatory diseases, especially EoE.
DOI: https://doi.org/10.37349/eaa.2024.00041
There are no plausible arguments to consider that the best evidence-based asthma treatment should be different in low- and middle-income countries (LMICs). A few decades ago, the recognition of asthma as an inflammatory disease of the airways positioned the inhaled corticosteroids (ICS) as the cornerstone of the treatment of this disease, maintaining bronchodilators, especially the short-acting beta-agonists (SABA), as symptom-reliever medications for use as needed. However, adherence to regular use of ICS is very low, especially in LMICs, favoring the overuse of SABA, which has been related to an excess of exacerbations and mortality. Recently, the Global Initiative for Asthma (GINA) strategy has recommended the mandatory use of ICS every time a bronchodilator is used as needed (for symptoms relief), whether only as needed or with a background of regular dose of ICS, and has named it: anti-inflammatory reliever (AIR) therapy. This form of therapy, which has been related to a significant reduction of asthma exacerbations, is very attractive for LMICs where patients do not have guaranteed a proper medical follow-up and the access to on-the-counter medications is high. However, the implementation of AIR therapy in LMICs will face many of the already recognized barriers for the diagnosis and treatment of asthma in these countries, especially related to limited access to care in very different health systems, low education level of patients and communities, insufficient health personnel training in asthma in primary care, the unfordable cost of medications, and the lack of political commitment. This review analyzes some of these challenges and strategies for facing them in LMICs.
There are no plausible arguments to consider that the best evidence-based asthma treatment should be different in low- and middle-income countries (LMICs). A few decades ago, the recognition of asthma as an inflammatory disease of the airways positioned the inhaled corticosteroids (ICS) as the cornerstone of the treatment of this disease, maintaining bronchodilators, especially the short-acting beta-agonists (SABA), as symptom-reliever medications for use as needed. However, adherence to regular use of ICS is very low, especially in LMICs, favoring the overuse of SABA, which has been related to an excess of exacerbations and mortality. Recently, the Global Initiative for Asthma (GINA) strategy has recommended the mandatory use of ICS every time a bronchodilator is used as needed (for symptoms relief), whether only as needed or with a background of regular dose of ICS, and has named it: anti-inflammatory reliever (AIR) therapy. This form of therapy, which has been related to a significant reduction of asthma exacerbations, is very attractive for LMICs where patients do not have guaranteed a proper medical follow-up and the access to on-the-counter medications is high. However, the implementation of AIR therapy in LMICs will face many of the already recognized barriers for the diagnosis and treatment of asthma in these countries, especially related to limited access to care in very different health systems, low education level of patients and communities, insufficient health personnel training in asthma in primary care, the unfordable cost of medications, and the lack of political commitment. This review analyzes some of these challenges and strategies for facing them in LMICs.
DOI: https://doi.org/10.37349/eaa.2024.00042
Atopic dermatitis (AD), also referred to eczema, is a common inflammatory skin disease that usually presents during infancy or childhood but affects patients of all ages. It is a pruritic, chronic/relapsing condition that may significantly impact the patients’ quality of life and can be associated with other atopic comorbidities including asthma and rhinoconjunctivitis. Inflammation in AD is mostly sustained by type 2 inflammation. Most patients are satisfactorily managed with a combination of emollients, avoidance of triggering factors, topical glucocorticoids, and/or topical calcineurin inhibitors. However, a proportion of patients with moderate or severe AD might require phototherapy or systemic immunosuppressants, which are limited in time due to possible safety concerns and progressive efficacy loss. In recent years, the availability of T helper 2 (Th2)-blocking agents dupilumab and tralokinumab has revolutionized the long-term treatment of moderate-to-severe AD. Here are discussed recent advances in the clinical development of biologic treatments for AD. The clinical implementation of these novel drugs has the potential not only to greatly improve the quality of life of patients with this chronic and disabling condition but also to clarify the biological processes underlying AD, in turn enabling further development of more effective, safer treatments. This research paper aims to provide an overview of biological therapies currently in use and under investigation in the setting of AD.
Atopic dermatitis (AD), also referred to eczema, is a common inflammatory skin disease that usually presents during infancy or childhood but affects patients of all ages. It is a pruritic, chronic/relapsing condition that may significantly impact the patients’ quality of life and can be associated with other atopic comorbidities including asthma and rhinoconjunctivitis. Inflammation in AD is mostly sustained by type 2 inflammation. Most patients are satisfactorily managed with a combination of emollients, avoidance of triggering factors, topical glucocorticoids, and/or topical calcineurin inhibitors. However, a proportion of patients with moderate or severe AD might require phototherapy or systemic immunosuppressants, which are limited in time due to possible safety concerns and progressive efficacy loss. In recent years, the availability of T helper 2 (Th2)-blocking agents dupilumab and tralokinumab has revolutionized the long-term treatment of moderate-to-severe AD. Here are discussed recent advances in the clinical development of biologic treatments for AD. The clinical implementation of these novel drugs has the potential not only to greatly improve the quality of life of patients with this chronic and disabling condition but also to clarify the biological processes underlying AD, in turn enabling further development of more effective, safer treatments. This research paper aims to provide an overview of biological therapies currently in use and under investigation in the setting of AD.
DOI: https://doi.org/10.37349/eaa.2023.00020
This article belongs to the special issue The Era of Biologics in Allergy
Numerous methods for functional diagnostics of nasal obstruction provide various information on nasal airway resistance and may aim to replace physically based methods by so-called simplifications or solely on subjective score systems. This may lead to nonsatisfying results in nasal surgery and prolonged postoperative care. An interdisciplinary analysis of contemporary methods for measurement was the task of the German-Austrian research program “Rhinodiagnost”. This review is intended to discuss basic and wide-spread errors playing a significant role during daily practice and proposes a step program for functional rhinological diagnostics with some modifications to be applied in case of allergic nasal disease. With regard to the content of “position paper on the standardization of nasal allergen challenges (2018)” of the European Academy of Allergology and Clinical Immunology (EAACI) and the results of the consensus conference of Riga in 2016, the differences between of “classic” and 4-phase-rhinomanometry (4PR) and their differences are clarified. The parameters of logarithmic effective resistance (LReff) allow a classification of the obstruction obtained during 36,500 measurements which are correlated to the subjective sensing of obstruction. The classification can be adapted for age and size and is valid for the Caucasian and Chinese populations.
Numerous methods for functional diagnostics of nasal obstruction provide various information on nasal airway resistance and may aim to replace physically based methods by so-called simplifications or solely on subjective score systems. This may lead to nonsatisfying results in nasal surgery and prolonged postoperative care. An interdisciplinary analysis of contemporary methods for measurement was the task of the German-Austrian research program “Rhinodiagnost”. This review is intended to discuss basic and wide-spread errors playing a significant role during daily practice and proposes a step program for functional rhinological diagnostics with some modifications to be applied in case of allergic nasal disease. With regard to the content of “position paper on the standardization of nasal allergen challenges (2018)” of the European Academy of Allergology and Clinical Immunology (EAACI) and the results of the consensus conference of Riga in 2016, the differences between of “classic” and 4-phase-rhinomanometry (4PR) and their differences are clarified. The parameters of logarithmic effective resistance (LReff) allow a classification of the obstruction obtained during 36,500 measurements which are correlated to the subjective sensing of obstruction. The classification can be adapted for age and size and is valid for the Caucasian and Chinese populations.
DOI: https://doi.org/10.37349/eaa.2023.00021
This article belongs to the special issue Precision Medicine in Allergy and Rhinology
Asthma is the most common chronic disease during childhood. While most of characteristic structural changes in asthma have been identified in the large airways, there is a growing recognition of peripheral airway dysfunction as a crucial factor in the development of asthma. This dysfunction is a defining feature in adults with persistent asthma. However, little is known about the contribution of small airway impairment in children with asthma due to the relatively low sensitivity of conventional lung function tests, such as spirometry. Recently, new diagnostic tools that are sensitive to both large and small airway function and inflammation have been introduced in clinical practice. The most widely studied of these tools in preschool and school-aged children is impulse oscillometry (IOS). This review addresses the latest findings on the usefulness of IOS in identifying small airway dysfunction, predicting the risk of uncontrolled asthma, and ultimately improving the diagnosis and management of asthma in children.
Asthma is the most common chronic disease during childhood. While most of characteristic structural changes in asthma have been identified in the large airways, there is a growing recognition of peripheral airway dysfunction as a crucial factor in the development of asthma. This dysfunction is a defining feature in adults with persistent asthma. However, little is known about the contribution of small airway impairment in children with asthma due to the relatively low sensitivity of conventional lung function tests, such as spirometry. Recently, new diagnostic tools that are sensitive to both large and small airway function and inflammation have been introduced in clinical practice. The most widely studied of these tools in preschool and school-aged children is impulse oscillometry (IOS). This review addresses the latest findings on the usefulness of IOS in identifying small airway dysfunction, predicting the risk of uncontrolled asthma, and ultimately improving the diagnosis and management of asthma in children.
DOI: https://doi.org/10.37349/eaa.2023.00022
