Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs in adults: Beyond current classification.

BACKGROUND: Hypersensitivity reactions (HSRs) to nonsteroidal anti-inflammatory drugs (NSAIDs) are a significant clinical issue. Several classifications have been proposed to categorize these reactions, including the current European Academy of Allergy and Clinical Immunology/European Network for Drug Allergy (EAACI/ENDA) classification. This study aimed to evaluate the applicability of this classification in a real-world clinical setting. METHODS: We conducted a national multicenter study involving patients from nine hospitals in four major urban centers in Turkey. All patients had a suggestive clinical history of hypersensitivity reactions to NSAIDs. Researchers collected data using a structured form and classified reactions based on the EAACI/ENDA classification. Oral provocation tests with several NSAIDs were performed using a single-blind challenge per EAACI/ENDA guidelines. RESULTS: Our retrospective study included 966 adult patients with a history of hypersensitivity to NSAIDs. The most common triggers were Acetylsalicylic Acid (ASA), paracetamol, and metamizole. The most prevalent acute NSAID hypersensitivity group was NSAID-induced urticaria/angioedema (NIUA) (34.3%). However, 17.3% of patients did not fit neatly into the current EAACI/ENDA classification. Notably, patients with underlying asthma or allergic rhinoconjunctivitis exhibited unusual reactions, such as urticaria and/or angioedema induced by multiple chemical groups of NSAIDs, blended mixed reactions, and isolated periorbital angioedema in response to multiple chemical groups of NSAIDs. CONCLUSIONS: While the EAACI/ENDA classification system stratifies NSAID-induced hypersensitivity reactions into five distinct endotypes or phenotypes, it may not fully capture the diversity of these reactions. Our findings suggest a need for further research to refine this classification system and better accommodate patients with atypical presentations.

The perspective of allergy and immunology specialists on the innovations of metaverse: A survey study.

BACKGROUND: New technologies have resulted in dramatic shifts in the field of medicine, and it stands to reason that metaverse will also affect the practice of allergy and immunology. This study aimed to determine the attitudes of allergists and raise awareness about metaverse applications in allergy and immunology. METHODS: A nationwide survey-based study was conducted in Turkey. First, a 28-item questionnaire was developed and sent to Turkish allergists. After completing the first questionnaire, the participants were asked to watch a 5-min informative video about the metaverse. Lastly, a second survey was conducted to evaluate the changes in the views of the participants. RESULTS: A total of 148 allergy doctors in Turkey participated in the survey. After watching a video containing updated information about the metaverse, there was a significant increase in the importance that participants attributed to the use of virtual reality and augmented reality applications in the field of immunology and allergy (P < 0.05). Additionally, there was a significant increase in the percentage of participants who thought that Metaverse applications could be integrated into the existing system and said that this possibility excited them (P < 0.05). There was also a significant increase in the percentage of participants who thought this innovative technology could be helpful in patient examination, student and physician education, allergy testing, and patient education (P < 0.05). CONCLUSIONS: Our results demonstrate that providing information to professionals working in the field can positively influence physicians' views on the potential of the metaverse, which is a valuable tool in the field of immunology and allergy.

The perspective of allergy and immunology specialists on the innovations of metaverse: A survey study

Background: New technologies have resulted in dramatic shifts in the field of medicine, and it stands to reason that metaverse will also affect the practice of allergy and immunology. This study aimed to determine the attitudes of allergists and raise awareness about metaverse applications in allergy and immunology.Methods: A nationwide survey-based study was conducted in Turkey. First, a 28-item questionnaire was developed and sent to Turkish allergists. After completing the first questionnaire, the participants were asked to watch a 5-min informative video about the metaverse. Lastly, a second survey was conducted to evaluate the changes in the views of the participants.Results: A total of 148 allergy doctors in Turkey participated in the survey. After watching a video containing updated information about the metaverse, there was a significant increase in the importance that participants attributed to the use of virtual reality and augmented reality applications in the field of immunology and allergy (P < 0.05). Additionally, there was a significant increase in the percentage of participants who thought that Metaverse applications could be integrated into the existing system and said that this possibility excited them (P < 0.05). There was also a significant increase in the percentage of participants who thought this innovative technology could be helpful in patient examination, student and physician education, allergy testing, and patient education (P < 0.05).Conclusions: Our results demonstrate that providing information to professionals working in the field can positively influence physicians’ views on the potential of the metaverse, which is a valuable tool in the field of immunology and allergy. (AU)

Field sting reactions in patients receiving Hymenoptera venom immunotherapy: real-life experience.

BACKGROUND: Hymenoptera stings can cause systemic allergic reactions (SARs) that are prevented by venom immunotherapy (VIT). Sting challenge tests or field stings are used to evaluate the outcome of VIT. OBJECTIVE: The aim of the study was to investigate the consequences of field stings in patients during or after completion of VIT, and to identify patients at higher risk. METHODS: Patients treated with VIT between 1995 and 2018 were retrospectively evaluated. Contacted patients were invited to the clinic and a questionnaire was conducted regarding the history of field stings. RESULTS: A total of 115 patients (F/M: 45/70, mean age: 38.5 ± 12 years) treated with VIT were included; 74/115 were contacted and asked about field stings after VIT cessation. A history of 73 field stings was reported in 38 patients, 25 of whom were treated with honeybee venom and 13 with common wasp venom. Eighteen of the reactions were SARs [8 with honeybees (1 grade-I, 6 grade-II, 1 grade-III) and 10 with common wasps (1 grade-I, 5 grade-II, 4 grade-III)]. There was no association between the severity of index reactions and field stings with either the honeybee or common wasp. The median duration of VIT was longer in patients showing no reaction than in patients with an SAR. Of the 7 patients on ACE inhibitors or beta-blockers, 1 asthmatic patient developed grade-II SAR due to field stings in the first year of VIT. CONCLUSIONS: This study confirms that VIT lasting at least 3 years is effective in preventing SARs after field stings.

Clinical outcomes of hereditary angioedema on multiparous women.

OBJECTIVE: Significant concerns for patients with hereditary angioedema (HAE) include hormonal fluctuations and drug safety during pregnancy. The impact of the disease on childbearing in multiparous women remains to be elucidated. We aimed to investigate the clinical course and impacts of multiparity on HAE patients. STUDY DESIGN: This observational study included 15 multiparous women with HAE; a total of 88 pregnancies were assessed using a questionnaire and the patient's medical records. RESULTS: The median age was 36 (IQR, 33-39). Of 72 resulted in healthy babies without any congenital abnormalities. In sixteen pregnancies, 12 (13.6%) ended with spontaneous abortion; three resulted in stillbirth and one neonatal death. Two-thirds of the patients (n = 10) enounced a worsening in the frequency of angioedema attacks during pregnancy. There was no statistically significant difference compared with the nonpregnant period (p = 0.283). One-fifth of the patients (n = 3) reported alleviation in attacks. While most deliveries were vaginally (n = 57 babies), 19 deliveries in six patients were by cesarean section. None of the patients were aware of the diagnosis of HAE prior to their first pregnancies. After the diagnosis was made, eight patients received 263 vials of plasma-derived C1-inhibitor concentrate during a total of 13 pregnancies. No adverse events were reported. CONCLUSION: We conclude that our results on clinical course and outcomes of HAE in multiparous patients are consistent with the literature. A greater focus on multiparous HAE patients could produce exciting findings.

ß-blockers and ACE inhibitors are not a risk factor for severe systemic sting reactions and adverse events during venom immunotherapy.

BACKGROUND: There is controversy whether taking ß-blockers or ACE inhibitors (ACEI) is a risk factor for more severe systemic insect sting reactions (SSR) and whether it increases the number or severity of adverse events (AE) during venom immunotherapy (VIT). METHODS: In this open, prospective, observational, multicenter trial, we recruited patients with a history of a SSR and indication for VIT. The primary objective of this study was to evaluate whether patients taking ß-blockers or ACEI show more systemic AE during VIT compared to patients without such treatment. RESULTS: In total, 1,425 patients were enrolled and VIT was performed in 1,342 patients. Of all patients included, 388 (27.2%) took antihypertensive (AHT) drugs (10.4% took ß-blockers, 11.9% ACEI, 5.0% ß-blockers and ACEI). Only 5.6% of patients under AHT treatment experienced systemic AE during VIT as compared with 7.4% of patients without these drugs (OR: 0.74, 95% CI: 0.43-1.22, p = 0.25). The severity of the initial sting reaction was not affected by the intake of ß-blockers or ACEI (OR: 1.14, 95% CI: 0.89-1.46, p = 0.29). In total, 210 (17.7%) patients were re-stung during VIT and 191 (91.0%) tolerated the sting without systemic symptoms. Of the 19 patients with VIT treatment failure, 4 took ß-blockers, none an ACEI. CONCLUSIONS: This trial provides robust evidence that taking ß-blockers or ACEI does neither increase the frequency of systemic AE during VIT nor aggravate SSR. Moreover, results suggest that these drugs do not impair effectiveness of VIT. (Funded by Medical University of Graz, Austria; Clinicaltrials.gov number, NCT04269629).

Rapid Drug Desensitization with Chemotherapeutics (Platins, Taxanes, and Others): A Single-Center Retrospective Study.

BACKGROUND: Rapid drug desensitization (RDD) induces a temporary tolerance to chemotherapeutics that induce hypersensitivity reactions (HSRs). PURPOSE: Our objective is to report our experience with RDD to platins, taxanes, etoposide, doxorubicin, and irinotecan. METHODS: The study was conducted as a retrospective chart review of patients with symptoms of HSRs to chemotherapeutics. HSRs were classified as grade I, II, or III, based on their severity. Skin prick/intradermal tests were performed with implicated chemotherapeutics. A 12-step RDD protocol was used. RESULTS: The study consisted of 38 women and 3 men (mean age 53.3 ± 11.6 years). Patients had ovarian (n = 13, 31.8%), breast (n = 10, 24.4%), colon (n = 7, 17%), lung (n = 4, 9.8%), and other cancers (n = 7; endometrial sarcoma, testicular cancer, uterine cancer, ampulla of Vater tumor, choledochal tumor, peritonitis carcinomatosa, and Merkel cell carcinoma, n = 1, respectively). Twenty-two patients experienced HSRs to platins, 15 to taxanes, and 4 to other chemotherapeutics (doxorubicin, irinotecan, and etoposide). A total of 122 RDDs (47 to platins, 52 to taxanes, 23 to other chemotherapeutics) were performed. In 25 (61%) patients no reactions occurred during RDD, but breakthrough reactions developed in 16 patients (39%) with platins (n = 11), taxanes (n = 3), doxorubicin (n = 1), and irinotecan (n = 1). RDD procedures could not be completed in only 2 patients with grade II breakthrough reactions to carboplatin and oxaliplatin. CONCLUSION: In our experience, 98.3% of 122 RDDs were completed. We found that RDD was safe and effective in this the largest series of RDD with chemotherapeutics in our country.

A Case of Pantoprazole Anaphylaxis with Cross Reactivity to All Proton Pump Inhibitors: Finding a Safe Alternative.

BACKGROUND: Hypersensitivity reactions due to Proton pump inhibitors (PPIs ) are rare, and further anaphylaxis to a PPI with cross-reactivity to all commercially available PPIs is very rare. OBJECTIVE: To present a case of anaphylaxis to pantoprazole with cross-reactivity to all commercially available PPIs. METHODS: Skin prick tests (SPTs), intradermal tests (IDTs) and oral provocation tests (OPTs) were performed with available PPIs according to the method described in previous studies. RESULTS: All tested PPIs except lansoprazole were positive on skin tests either SPT or IDT. The patient was challenged with lansoprazole at increasing doses (7.5 mg, 15 mg, 30 mg capsule) every 60 minutes and she reacted with urticaria to 52.5 mg cumulative dose of lansoprazole. She could tolerate ranitidine and famotidine tablets via OPT. CONCLUSION: In our best knowledge, our case was the first case in this regard and that points the possibility of all cross-reactive pattern in patients with pantoprazole anaphylaxis and the importance of a thorough drug allergy work-up for finding safe alternatives. H2 receptor antagonists are used as safe alternatives in cases with PPI hypersensitivity.

Does the medical diagnosis of occupational asthma coincide with the legal diagnosis?

OBJECTIVE: The incidence of occupational asthma (OA) is increasing worldwide. In this study, we first aimed to document the rate of diagnosis of OA among patients who were referred to our clinic from the Social Security Institution and the factors that affected diagnosis; secondly, we aimed to assess the consistency of the medical and legal diagnoses. METHODS: The study involved 132 consecutive patients who were referred to our clinic for the evaluation of OA between 2010 and 2015. Detailed workplace history, the tools used in the diagnosis such as peak expiratory flow (PEF) monitoring and bronchial provocation tests, and the final medical diagnosis were recorded from case files. RESULTS: Asthma was diagnosed in 75% (n = 99) of the patients. Among them, 22.2% were diagnosed as having OA. The diagnosis was confirmed by serial PEF measurements, non-specific bronchial hyperreactivity assessment or both of the tests both at work and off-work periods. OA diagnosis was mostly established in active workers (72.7%). The legal diagnosis period was completed in 54.5% of these 22 patients, and 50% (n = 11) were officially diagnosed as having OA with a 91.6% concordance with medical diagnosis. CONCLUSION: This study verifies the importance of diagnosing asthma correctly as a first step in the evaluation of OA. Diagnostic tests other than specific provocation tests could be preferential in patients who still work in the same field. We believe that cooperation with the patient's occupational physician and adequate recognition of the work environment will improve the consistency of legal and medical diagnoses.

Rapid Drug Desensitization with Biologics: A Single-Center Experience with Four Biologics.

BACKGROUND: Rapid drug desensitization (RDD) induces a temporary tolerance to biologics which induce hypersensitivity reactions (HSRs). Data are limited regarding the use of RDD outside the USA. Our purpose was to report our data on RDD to rituximab, infliximab, cetuximab, and trastuzumab. METHODS: The study was conducted as a retrospective chart review of patients with symptoms of HSRs to biologics. HSRs were classified as grades I, II, and III, based on their severity. Skin-prick tests/intradermal tests (IDTs) were performed with the implicated biologics. The 12-step RDD protocol was used. RESULTS: The study group comprised 11 women and 6 men (mean age: 47 ± 11.7 years). Fourteen patients experienced HSRs to rituximab; 3 had HSRs to cetuximab, infliximab, and trastuzumab, respectively. HSRs to cetuximab, infliximab, and trastuzumab occurred during the first infusion and were all grade III. Twelve of the 14 patients with rituximab hypersensitivity had a reaction during the first infusion; 10 patients had grade II reactions and 4 had grade III reactions. Respiratory symptoms were the most frequent presentation of HSR. Skin tests with rituximab were performed on 10 patients; only 3 resulted in positive IDTs (with 1:100 dilutions) and the other tests were negative as were those performed with the other biologics. Of 96 RDDs, 89 desensitizations were performed with rituximab, 5 with cetuximab, 1 with infliximab, and 1 with trastuzumab. There were 12 (13.5%) breakthrough reactions, all of which were associated with rituximab and were less severe than the initial reactions. CONCLUSION: RDD was found to be safe and effective in the largest case series of RDDs with biologics in our country, Turkey.

[Attitudes of adult asthma patients towards influenza vaccination]. / Eriskin astimli hastanin influenza asisina yaklasimi farkli mi?

INTRODUCTION: It is known that viral infections trigger exacerbations in asthma patients.There are conflicting reports on whether influenza vaccine is preventive or not. In this study, we aimed to evaluate asthmatic patient's attitude towards influenza vaccine and to determine which factors affect this attitude. MATERIALS AND METHODS: A questionnaire involving data about demographic information, co-morbidities, frequency of viral upper respiratory tract infections, subject's influenza vaccination status and attitude towards vaccination had been filled for our outpatient clinic asthma patients and also for healthy controls. Results were evaluated separately for the two groups and then compared to each other. RESULT: For the study; 108 asthma patients (91 female, 17 male) and 110 non-asthmatic controls (64 female, 46 male) were enrolled. In asthma group, vaccination rates were significantly higher in the previous year (40.7%) and nearly half of them stated that they do regularly have influenza shots every year. Contrast to this find; half of the patients in the control group stated that they do not need to vaccinate themselves and 26.2% said that they don't believe influenza vaccine has any preventive effect. Also in the asthma group, this ratio was similar to the control group (20.3%). In asthma group, 66.7% of the patients who had side effects at their previous shots did not want to vaccinate themselves this year (p= 0.02). More than a half of the patients (53.1%) whom did not have shots had an episode of viral upper respiratory tract infection this year and this rate was significantly lower in the vaccinated group (p= 0.00). This result highlights the preventive effect of vaccination. CONCLUSIONS: We found that asthma patients' knowledge on influenza infection and vaccine were insufficient and also their belief towards the preventive features of the vaccination was low. Informing and encouraging patients about preventive medicine through various activities and meetings would be crucial.

Omalizumab in the treatment of allergic bronchopulmonary aspergillosis: One center's experience with 14 cases.

BACKGROUND: Omalizumab has been a valuable option for patients with severe allergic asthma, but there are only case reports regarding effectiveness of omalizumab in patients with allergic bronchopulmonary aspergillosis (ABPA). OBJECTIVE: To evaluate the clinical and functional effectiveness of omalizumab in patients with asthma and ABPA in long-term follow-up. METHODS: The study was conducted as a retrospective chart review of patients with ABPA who were treated with omalizumab injections between December 2008 and June 2014. Once treatment with omalizumab was started, data were collected at three time points: at baseline, after 1 year, and, in June 2014, at the last follow-up. RESULTS: Fourteen patients with ABPA (seven women and seven men; mean [± standard deviation (SD)] age, 44.21 ± 13.01 years) were included. The treatment period was 31.5 ± 3.99 months (mean ± SD). The difference between the baseline and the last evaluation of the mean percentage of forced expiratory volume in 1 second (FEV1) was significant (p = 0.02). The mean asthma control test score was increased at all-time points compared with the basal score (p = 0.001). After omalizumab treatment was initiated, the patients' mean oral corticosteroid dosage significantly decreased (p = 0.001). The baseline exacerbation rate was 2.7 ± 1.5/y (mean ± SD), and the hospitalization rate was 1.4/y, and both were zero at the last assessment (p = 0.001). Eleven of the patients (78.6%) responded perfectly, and three (21.4%) partially responded to treatment. The patients who had a total immunoglobulin E level of <1000 IU/mL seemed to be more responsive than those whose total immunoglobulin E level was >1000 IU/mL (p = 0.05). CONCLUSION: Omalizumab provided a clinically important reduction in exacerbations and steroid requirement, and improved asthma symptoms and pulmonary function parameters in patients with asthma and ABPA who had previously shown an unsatisfactory response to Global Initiative for Asthma step 4 treatment.

Ultrasound guided fine-needle aspiration biopsy of metastases in nonpalpable supraclavicular lymph nodes in lung cancer patients.

BACKGROUND AND OBJECTIVES: To assess frequency and significance of enlarged nonpalpable supraclavicular lymph nodes with routine ultrasound (US) evaluation and US-guided fineneedle aspiration biopsy (FNAB) for the diagnosis and staging of patients with lung cancer. MATERIALS AND METHODS: 106 consecutive patients with lung cancer and nonpalpable supraclavicular lymph nodes were evaluated with cervical US for the presence of pathological lymph nodes. FNAB was performed in patients with nodes with short-axis > 5 mm, rounded shape and missing echogenic hilum. RESULTS: 27 (25.5%) patients had enlarged supraclavicular lymph nodes on US. Fourteen patients (13.2%) had cytologically proven lymph node involvement. Supraclavicular lymph node metastasis was more frequent in patients with mediastinal invasion (p = 0.0001) and patients with enlarged lymph nodes on upper paratracheal stations on thorax CT (p = 0.0001). No relation was found between supraclavicular lymph node involvement and T stage (p = 0.27), distant metastasis (p = 0.50) or histological type (p = 0.80). Three patients were upstaged from IIIA to IIIB status. US-guided FNAB was the only diagnostic method in 2 patients. CONCLUSION: US-guided FNAB is a simple and safe procedure which can document N3 stage of disease in lung cancer patients. Thereby more invasive and expensive diagnostic procedures can be avoided in selected lung cancer patients.