Is immunotherapy safe for treatment of severe asthma.

PURPOSE OF REVIEW: The benefits of allergen immunotherapy (AIT), including subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT), for IgE-mediated asthma are well established, especially for dust mite. This review will explore whether the benefits of AIT outweigh the risks in severe asthmatic patients. RECENT FINDINGS: Studies have mostly included mild and moderate asthmatic patients, but at least a few studies do show improvements in asthma symptoms and medication use in severe asthmatic patients. Asthma, and especially uncontrolled asthma, is a major risk factor for severe and fatal systemic reactions from SCIT. Uncontrolled asthma is an absolute contraindication for SCIT. It is less clear whether the benefits of SCIT and SLIT may outweigh the risks in well controlled, severe asthmatic patients, and further study is needed in this area. Asthma biologics, especially Omalizumab, may improve outcomes in severe, controlled asthmatic patients on SCIT, but further data are needed regarding timing of initiation and duration of treatment. SUMMARY: Although severe asthmatic patients may benefit from AIT, significant risks exist, especially in those with uncontrolled asthma. Further study is needed regarding optimal strategies to minimize risks.

Systemic Allergic Reactions and Anaphylaxis Associated with Allergen Immunotherapy.

Subcutaneous allergen immunotherapy (SCIT) is a proven treatment of allergic rhinitis, asthma, atopic dermatitis, and prevention of Hymenoptera venom anaphylaxis. The known benefit of SCIT, however, must be considered in each patient relative to the potential risks of systemic allergic reactions (SRs). A mean of 1 SR per 1000 injection visits (0.1%) was estimated to occur between 2008 and 2018. Life-threatening anaphylactic events are estimated to occur in 1/160,000 injection visits. The factors that contribute to SRs and fatal reactions (FRs) are reviewed. Risk management strategies are proposed to prevent and decrease future SCIT associated with SRs, anaphylaxis, and FR.

Safety of allergen immunotherapy in North America from 2008-2017: Lessons learned from the ACAAI/AAAAI National Surveillance Study of adverse reactions to allergen immunotherapy.

In 2004, it was estimated that one fatal anaphylactic reaction (FR) occurred in every 2.4 million subcutaneous immunotherapy (SCIT) injection visits. Uncontrolled asthma was the most commonly cited factor that contributed to FRs. Results of the annual American College of Allergy, Asthma, and Immunology/American Academy of Allergy, Asthma and Immunology sponsored survey conducted among practicing allergists suggest that one nonfatal systemic reactions (SR) occurred in 0.15% of injection visits and in 0.7% of patients who were treated. Analysis of recent data indicated that FRs are 3.75-fold less frequent. Life-threatening grade 4 anaphylactic reactions are estimated to occur in 0.005% of patients who receive SCIT (or 1/160,000 injection visits). Analysis of data from annual surveys identified the following possible risk factors for SRs: a history of SRs to SCIT, the administration of injections in patients with uncontrolled asthma, use of accelerated buildup regimens, and never adjusting doses during the height of the allergy season. Delayed-onset SRs beginning >30 minutes after injections represented 15% of all SRs in clinics with 30-minute observation periods. The safety profile of sublingual immunotherapy is favorable, with no FRs yet identified for sublingual tablet or liquid formulations. Risk management should focus mainly on patients with uncontrolled asthma by withholding injections in such patients, with recent worsening in asthma symptoms and lung function (e.g., peak expiratory flow rate). Because nearly all FRs and SRs occur within 30 minutes of injections, a 30-minute observation period is recommended. Routinely prescribing epinephrine for all patients did not prevent severe SRs, likely due to poor adherence when SRs occurred. Also, no local or systemic infections were identified in 2.3 million patients attending 24.5 million injection visits, which allayed concerns over infections associated with compounding of allergen extracts by practicing allergists.

[Radical D2,D3 lymph node excision of stomach carcinoma in situs inversus totalis and malrotation of the colon]. / Radikale D2,D3-Lymphadenektomie eines Magenkarzinoms bei Situs inversus totalis und Malrotation des Kolons.

The combination of Situs inversus totalis (SIT) with incomplete rotation of the colon is an extremely rare anomaly and especially of interest when presented with advanced gastric cancer. The routine en-bloc resection of gastric cancer with D2,D3 lymphadenectomy according to the recommendations of the Japanese Research Society for Gastric Cancer [5] can, as in this case, present tactical operative problems, due to the mirror-image anatomy and potential vessel anomalies, which might complicate the operative procedure. The preoperative diagnosis of SIT is not only essential to allow an adequate operative approach but furthermore to prevent vessel injury.

Bovine dowels for anterior cervical fusion: experience in 66 patients with a note on postoperative CT and MRI appearance.

Anterior cervical discectomy and vertebral interbody fusion is a widely used technique in the treatment of radicular or cord compression. Instead of using autologous bone removed from the iliac crest, a heterologous bovine dowel was used for fusion. Sixty-six patients presenting with radicular pain or myelopathy were entered into the study retrospectively. Medial herniated, soft or calcified disc, osteophytes with and without herniated disc material, and bony stenosis at one or two levels were shown by CT or MRI studies. Postoperatively, 88% of the patients noted relief of pain and motor improvement. Most of the patients' sensory deficits and myelopathy improved within 6-12 months. No complications occurred and only one re-operation had to be performed at the same level. In the follow-up period between 1-4 years, no cases of instability after surgery were reported. Operating time and postoperative pain were reduced because bone harvest from the iliac crest was not necessary. In postoperatively performed CT and MRI, the bovine dowel was surrounded by a "halo"-like structure and the specific structure of the bovine implant was still present. No real bony fusion occurred, but clinical stability was equivalent to autologous bone fusion reported in the literature. However, there was no MRI evidence of "living bone tissue" within the bovine dowel. This finding is in contrast to the current belief that the bovine implant is replaced or infiltrated by bony growth.

[Spontaneous rupture of an infected kidney cyst]. / Spontanruptur einer infizierten Nierenzyste.

Spontaneous or traumatic rupture of renal cysts is a rare occurrence. The contents of the cyst can perforate into the renal calyx system or into the perirenal space. Perforation into the peritoneal cavity has also been described (1, 2, 4, 5).

[Computed tomographic diagnosis of the diaphragmatic lymph nodes in malignant lymphomas]. / Computertomographische Diagnostik diaphragmaler Lymphknoten bei malignen Lymphomen.

132 patients with malignant lymphomas were studied retrospectively. In 11.3% CT revealed involvement of diaphragmatic lymph nodes. The anatomy and CT appearance of these lymph nodes when involved are discussed.

Sonographic demonstration of lumbar disc herniation.

In a limited series of examinations the capability of ultrasonography in the assessment of intervertebral disc herniation by a transabdominal approach is evaluated. Normal anatomical findings on transabdominal spinal sonography are demonstrated. Two cases of disc herniation proved either by operation or lumbar myelography and spinal computed tomography are reported. The potential capabilities and known limitations of ultrasonography in this field are discussed.

[Intracranial hemorrhages in mature and premature infants. Computer tomography and clinical follow-up studies]. / Intrakranielle Blutungen bei reifen und unreifen Neugeborenen. Computertomographische und klinische Verlaufsuntersuchungen.

The findings of CT-follow-up-studies on a group of 94 infants, who had suffered intracranial hemorrhage, were correlated with the clinical and neurological outcome. Purpose of the retrospective study was to work out prognostic criteria dependent on the typ and location of the hemorrhage. Among the infants with intraventricular hemorrhage, there was a direct relationship between the severity of the hemorrhage and major handicaps on the one hand and the mortality rate on the other hand. Neurologic sequelae were noted in 16.5% of the infants with tentorial hemorrhages, in 56% of the infants with intracerebral hemorrhages and 37.5% of the infants with subarachnoid hemorrhages. Our results indicate, that the outcome of infants with intracranial hemorrhages is not dependent on the typ and severity of the bleeding only, but is also influenced by additional factors, like perinatal asphyxia.

[CT diagnosis of the retrocaval ureter]. / CT-Diagnostik des retrokavalen Ureters.

The article describes the value of CT in the diagnosis of the circumcaval ureter. The clinical symptoms of the rare anomaly are discussed.

Uncommon intraspinal space occupying lesion (foreign-body granuloma) in the lumbosacral region.

An intraspinal extradural foreign-body granuloma following surgical removal of herniated intervertebral disc is demonstrated by myelography, spinal computed tomography and transabdominal spinal sonography. The radiologic findings and differential diagnoses are discussed.

Does acute endoscopic evacuation improve the outcome of patients with spontaneous intracerebral hemorrhage?

A new endoscopic technique is presented, which allows burr hole evacuation of intracerebral hematomas under video control. Clot removal is achieved using a suction-irrigation system built in the 6-mm-diameter endoscope; in addition, an ultrasonic morcellement device has been developed for transendoscopic application. Small bleeding vessels in the hematoma cavity can be coagulated using a 1.5 mm Neodym YAG Laser microprobe introduced through the endoscope under visual control. A randomized prospective study has been started to raise again the question of indications for the surgical treatment of intracerebral hemorrhages, comparing medical treatment with the new surgical technique.

[Transabdominal sonography of the lumbar intervertebral disks and intraspinal structures]. / Transabdominale Sonographie lumbaler Bandscheiben und intraspinaler Strukturen.

This paper reports a prospective study on 64 patients in whom sonography was used to diagnose pathological changes in lumbar discs and intraspinal space occupying lesions; the results were compared with myelography and computer assisted tomography (CAT). The sonographic device used was a mechanical sector scanner with a medium focused transducer with a frequency of 3.5 MHz. The normal and pathological anatomy as shown by ultrasound was correlated to the known anatomy of CAT-scanning; the nerve roots, the dural sac and the intervertebral discs were recognizable in sonography and in CAT. The extent of an intraspinal lesion beyond the upper and lower limiting planes of the intervertebral discs were not demonstrable by ultrasound. The sonographic study was at least partially successful in 55 of 64 patients (86%). It failed in 14% (9 cases) because of obesity or because of diminution of the intervertebral space. The study revealed a specificity and sensitivity of transabdominal spinal sonography of 0.86 respectively 0.84.

[Pancreas cancer: staging with dynamic computerized tomography]. / Pankreaskarzinom: Staging mittels dynamischer CT.

Carcinoma of the pancreas continues to present a most unfavorable prognosis. 90% of the tumours cannot be operated on and the survival time of these patients is 2-6 months. In a prospective study based on 23 patients it was investigated whether comprehensive staging of the carcinoma of the pancreas can be performed via computed tomography so that operable carcinomas alone must be presented for laparotomy. Results of CT were compared with those of angiography and laparotomy. Differentiation between stage 1 (tumour restricted to organ) and stage 2 (limited lymph node metastasising) is limited if effected via CT. However, it was possible to differentiate between the non-operable stages 3 and 4 with a sensitivity of 88% and a specificity of 78%. CT showed particularly high sensitivity in patients with vascular involvement.

[Involvement of diaphragmatic lymph nodes in Hodgkin's disease]. / Befall diaphragmaler Lymphknoten bei Morbus Hodgkin.

The authors report on a case of Hodgkin's disease with enlargement of diaphragmal lymph nodes. Detailed attention is paid to the anatomy, radiological diagnosis and differential diagnosis of these mediastinal lymph nodes. The clinical importance of this group of lymph nodes in Hodgkin's disease and in non-Hodgkin lymphomas is discussed.

[Sonographic visualization of the left ovarian vein. A contribution to the diagnosis of compression syndrome of the left renal vein]. / Sonographische Darstellung der linken Ovarialvene. Beitrag zur Diagnostik des "Kompressionssyndroms der linken Nierenvene".

Amongst 737 sonographic and CT examinations of women aged 18 to 60 years of age, seven cases of ectasia of the left ovarian vein were found (0.95%). The aetiology and significance of this finding in the context of the "compression syndrome of the left renal vein" are discussed. The value to sonography in elucidating this condition is stressed.

[Prenatal diagnosis of the Dandy-Walker syndrome using sonography and computed tomography]. / Pränatale Diagnostik des Dandy-Walker-Syndroms durch Sonographie und Computertomographie.

A case of Dandy-Walker-syndrome is presented, comparing the value of sonography and CT in intrauterine diagnosis. Together with a review of the literature of the subject, pathogenesis, morphology and prognosis in regard to the psychomotoric development are discussed.

[Sonographic demonstration of an ectopic ureter orifice]. / Sonographische Darstellung einer ektopen Uretermündung.

In a case report an ectopic ureter evaluated by means of ultrasound and proved by surgery is discussed with respect to its embryologic development, incidence and clinical aspects. Sonography is shown to be of diagnostic value in localizing the orifice of an ectopic ureter.