New developments in allergen immunotherapy.

PURPOSE OF REVIEW: Allergic rhinitis, conjunctivitis, and asthma impact quality of life and cost billions of dollars in lost wages, productivity, and medical expenditures. Allergen immunotherapy is the only therapy that alters the allergen immune response, resulting in fewer symptoms upon natural exposure. This review summarizes recent immunotherapy developments. RECENT FINDINGS: Subcutaneous immunotherapy (SCIT) remains a disease modifying treatment for allergic rhinoconjunctivitis and asthma with rare complications of therapy. Recent evidence suggests that SCIT may be effective in select cases of atopic dermatitis, particularly for patients with dust mite sensitivity. Sublingual immunotherapy (SLIT) tablets are now commercially available for grass and ragweed allergy and appear to have a superior safety profile to SCIT with similar long-term effectiveness, because as with SCIT, symptom improvement persists after the SLIT course is completed. SLIT tablets are administered daily at home (after initial supervised dosing) and may be used shortly before and during the target pollen seasons in a precoseasonal fashion (instead of perennial dosing). Research continues into experimental approaches using oral food allergen immunotherapy (OIT) to modify the natural history of food allergies. Although a proportion of patients in OIT trials experience sustained unresponsiveness, many do not and current recommendations limit the use of OIT to research protocols. SUMMARY: Patients have new well tolerated and effective options for more convenient treatment of asthma and allergic rhinoconjunctivitis associated with grass and ragweed allergy. SCIT remains effective for polysensitized patients and may be an option for some patients with atopic dermatitis. Research continues into novel food allergy treatments.

Surgical management of malignant bowel obstruction: at what price palliation?

Several options exist to palliate malignant obstruction (MBO), none of which have established consensus among surgeons. The purpose of this study was to establish outcomes of diverting stoma (DS), internal bypass (IB), and palliative resection (PR) for a tertiary academic referral surgical oncology service. All patients presenting to a surgical oncology service with malignant bowel obstruction over a 3-year period were identified. Records were reviewed to determine success of diversion, bypass, or resection and associated cost, length of stay (LOS), morbidity, and mortality. Forty-three patients undergoing palliative surgery were identified. The success of each approach was 80, 78, and 63 per cent for diversion, bypass, and resection, respectively. Major morbidity (63%), mortality (16%), and LOS (26 days) were greatest in those undergoing PR, but so was survival (8.4 months). DS and IB had comparable morbidity (40 and 33%), mortality (10 and 0%), and LOS (25 and 21 days), but survival was shorter for DS (5.3 vs 6.5 months). Cost of PR was significantly greater ($79,000) than both DS ($36,000) and IB ($51,000). Escalation in complexity of palliative measures for MBO results in improved survival but at significant cost both economically and physiologically. Quality of life should be discussed with patients when deciding how best to palliate their symptoms.