Multiple allergen simultaneous test is useful in assessing allergen sensitization and its geographic variations by the Geographic Information System-based approach

Purpose@#To evaluate allergen sensitization in Koreans and assess regional differences in it using Geographic Information System (GIS)-based modeling techniques. @*Methods@#We retrospectively analyzed multiple allergen simultaneous test (MAST) results collected from 2,017 clinics and hospitals nationwide between 2018 and 2020. The AdvanSure™ AlloScreen (LG Chem, Seoul, Korea) was used to test for 47 allergens. Then, we created maps to visualize the sensitization prediction rate by using the ordinary kriging method. @*Results@#The total number of participants were 196,419; 104,371 (53.1%) were sensitized to one or more allergens. The most frequent allergen causing sensitization was Dermatophagoides farinae (34.0%), followed by Dermatophagoides pteronyssinus (32.3%), house dust (26.2%), cat dander (13.6%), Acarus siro (12.5%), rye grass pollen (8.8%), and birch tree pollen (8.2%), respectively. Perennial allergens, such as mites and cat dander, were more common than seasonal allergens. Sensitization rates to grasses were generally higher than those to tree and weed allergens. The sensitization rates to Hymenoptera venoms were 4.8% in honey bee and 2.2% in yellow jacket. The sensitization prediction rate against Dermatophagoides farinae calculated by GIS-based mapping showed geographical differences even within the same administrative district. @*Conclusion@#Dermatophagoides farinae and Dermatophagoides pteronyssinus were found to be the most prevalent sensitizing allergens throughout Korea. GIS-based spatial pattern analysis using MAST revealed different sensitization patterns between geographic areas and at the subdistrict level. These data could assist in prevention and management of allergic diseases and provide valuable evidence for environmental and public health policymakers.

Current Status of Patient Education in the Management of Atopic Dermatitis in Korea

Patient education is important for successful management of atopic dermatitis; however, due to limited time and resources, patient education remains insufficient. This study aimed to investigate the current state of education provided by Korean dermatologists, pediatric allergists, and allergists to patients with atopic dermatitis. A questionnaire survey consisting of items regarding educational programs for patients with atopic dermatitis was conducted via e-mail. In total, 153 participants responded to the questionnaires, and 26.8% indicated that they have had separate educational programs. The workforce involved in the educational program included nurses, residents or fellows, dieticians, pharmacists, and clinical psychologists. Most education protocols addressed the characteristics and natural course of atopic dermatitis and environmental management. Overall, 96.7% of the participants replied that an additional charge is needed for education; moreover, additional assistance from an academic society or association, in the form of medical staff, organized data, and advertisement, is required to develop and provide a well-structured educational program. A standardized education protocol will effectively provide appropriate education for patients with atopic dermatitis. Arrangement of education fees, covered by the National Health Insurance Service, will lead to the establishment of a structured educational program and participation of an additional medical workforce.

Real-Life Clinical Use of Symbicort® Maintenance and Reliever Therapy for Asthmatic Patients in Korea

The aim of this study was to examine the daily practice patterns of Symbicort® Maintenance and Reliever Therapy (SMART) in Korean asthmatic patients and to analyze clinical signs related to overuse. This study used an observational, multicenter, noninterventional, prospective, uncontrolled design for examining asthmatic patients prescribed SMART to assess the frequency and pattern of Symbicort® usage as a maintenance and reliever medication. The characteristics of patients showing signs of overuse (frequency of inhalation: 8 or more times per day) were also analyzed. Among the 1,518 patients analyzed, 1,292 (85.1%) completed the trial. The number of mean inhalations per day was 2.14±1.15; the number of patients who had at least 1 as needed usage (PRN) inhalation per day was 843 (55.5%); the mean frequency of PRN use was 0.25±0.67 inhalations per day. The number of patients who overused for at least 1 day was 260 (17.1%). In particular, young patients, patients with limited physical activity, and patients with nocturnal symptoms demonstrated high frequency of overuse. The frequency of overuse during SMART was not high in Korean asthmatic patients and the asthma status of follow-up outpatients improved overall. However, there is a need for careful education targeted toward younger patients, patients with limited physical activity, and patients with nocturnal symptoms owing to their tendency to frequently overuse.

Management and educational status of adult anaphylaxis patients at emergency department

BACKGROUND/AIMS: We evaluated the management and educational status of adult anaphylaxis patients at emergency departments (EDs). METHODS: Anaphylaxis patients who visited ED from 2011 to 2013 were enrolled from three hospitals. We analyzed clinical features, prior history of anaphylaxis, management and provided education for etiology and/or prevention. For analyzing associated factors with epinephrine injection, Pearson chi-square test was used by SPSS version 21 (IBM Co.). RESULTS: A total of 194 anaphylaxis patients were enrolled. Ninety-nine patients (51%) visited ED by themselves. Time interval from symptom onset to ED visit was 62 ± 70.5 minutes. Drug (56.2%) was the most frequent cause of anaphylaxis. Forty-seven patients (24.2%) had prior history of anaphylaxis and 33 patients had same suspicious cause with current anaphylaxis. Cutaneous (88.7%) and respiratory (72.7%) symptoms were frequent. Hypotension was presented in 114 patients (58.8%). Mean observation time in ED was 12 ± 25.7 hours and epinephrine was injected in 114 patients (62%). In 68 patients, epinephrine was injected intramuscularly with mean dose of 0.3 ± 0.10 mg. Associated factor with epinephrine injection was hypotension (p = 0.000). Twenty-three patients (13%) were educated about avoidance of suspicious agent. Epinephrine auto-injectors were prescribed only in five patients. Only 34 (19%) and 72 (40%) patients were consulted to allergist at ED and outpatient allergy department respectively. CONCLUSIONS: We suggested that management and education of anaphylaxis were not fully carried out in ED. An education and promotion program on anaphylaxis is needed for medical staff.

A Case of Recurrent Urticaria Due to Formaldehyde Release from Root-Canal Disinfectant

Although formaldehyde is well known to cause type 4 hypersensitivity, immunoglobulin E (IgE)-mediated hypersensitivity to formaldehyde is rare. Here, we report a case of recurrent generalized urticaria after endodontic treatment using a para-formaldehyde (PFA)-containing root canal sealant and present a review of previous studies describing cases of immediate hypersensitivity reactions to formaldehyde. A 50-year-old man visited our allergy clinic for recurrent generalized urticaria several hours after endodontic treatment. Prick tests to latex, lidocaine, and formaldehyde showed negative reactions. However, swelling and redness at the prick site continued for several days. The level of formaldehyde-specific IgE was high (class 4). Thus, the patient was deemed to have experienced an IgE-mediated hypersensitivity reaction caused by the PFA used in the root canal disinfectant. Accordingly, we suggest that physicians should pay attention to type I hypersensitivity reactions to root canal disinfectants, even if the symptoms occur several hours after exposure.

Korean version of the Cough Symptom Score: clinical utility and validity for chronic cough

BACKGROUND/AIMS: The Cough Symptom Score (CSS) is a simple, useful tool for measuring cough severity. However, there is no standard Korean version of the CSS. We developed a Korean version of the CSS and evaluated its clinical utility and validity for assessing chronic cough severity. METHODS: The CSS was adapted for Korean use following a forward-backward translation procedure. Patients with chronic cough enrolled from five university hospitals were graded using the CSS and a 100-mm linear visual analog scale (VAS) of cough severity at each visit. Patients completed the Leicester Cough Questionnaire (LCQ) upon presentation and completed the LCQ and Global Rating of Change at follow-up visits after 2 to 4 weeks. The concurrent validity, repeatability, and responsiveness of the Korean version of the CSS were determined. RESULTS: Correlation coefficients between the CSS and LCQ, and between the CSS and VAS, were –0.66 and 0.52, respectively. There was a weak correlation between the scores for night and day symptoms (r = 0.24, p = 0.0006). The repeatability of the CSS in patients with no change in cough (n = 23) was high (intra-class correlation coefficient, 0.75; 95% confidence interval [CI], 0.51 to 0.88). Patients who reported an improvement in cough (n = 30) at follow-up visits had a significant improvement in the CSS (median, −2; 95% CI, −3 to −1; p = 0.0003). CONCLUSIONS: The Korean version of the CSS correlated well with other tools for accessing cough severity in chronic cough patients. Therefore, it could be a reliable method for measuring chronic cough severity.

Reliability and Validity of a Korean Version of the Leicester Cough Questionnaire

PURPOSE: There are no specific tools for measurement of the severity of chronic cough in Korea. We developed a Korean version of the Leicester Cough Questionnaire (LCQ) and tested its scaling and clinical properties. METHODS: The LCQ was adapted for Korean conditions following a forward-backward translation procedure. All patients referred to chronic cough clinics at 5 university hospitals between May 2011 and October 2013 completed 2 questionnaires, the LCQ and the Short-Form 36 (SF-36), upon presentation and completed the LCQ and the Global Rating of Change (GRC) upon follow-up visits after 2 or 4 weeks. Concurrent validation, internal consistency, repeatability, and responsiveness were determined. RESULTS: For the concurrent validation, the correlation coefficients (n=202 patients) between the LCQ and SF-36 varied between 0.42 and 0.58. The internal consistency of the LCQ (n=207) was high for each of the domains with a Cronbach's alpha coefficient of 0.82-0.94. The repeatability of the LCQ in patients with no change in cough (n=23) was high, with intra-class correlation coefficients of 0.66-0.81. Patients who reported an improvement in cough (n=30) on follow-up visits demonstrated significant improvement in each of the domains of the LCQ. CONCLUSIONS: The Korean version of the LCQ is a valid and reliable questionnaire for measurement of the severity of cough in patients with chronic cough.

KAAACI Work Group report on the management of chronic urticaria

Chronic urticaria (CU) is defined by the presence of urticaria that has been continuously or intermittently for a period of 6 weeks or longer. The prevalence of CU in the general population has been estimated to range from 0.5% to 5%. Correct diagnosis and proper management for CU is essential to improve the quality of care. To date, several practical guidelines have been available for practitioners. In this article, we reviewed and summarized the epidemiology, pathogenesis, diagnosis, and management based on case reports and studies of CU from Korea and the other part of world, and recently published guidelines. Although there are many controversies, this report for CU would provide a clinical guidance for healthcare professionals in Korea.

Exercise-Related Allergic Diseases / 대한스포츠의학회지

Allergic diseases are common in sports athletes, as they are in the general population. Any physician who involved in the care of athletes will commonly face the management of allergic conditions. Exercise-aggravated or exercise-induced allergic disorders are significant health problems to competitive athletes, although the majority of these disorders are mild and symptomatically annoying, several allergic diseases carry the risk of anaphylaxis and even sudden death. Meticulous approach in the diagnosis and management of allergic conditions is essential for the sports medicine physicians to afford all athletes can compete safely with their highest physical and mental level.

Diagnosis and acute management of anaphylaxis

Anaphylaxis is a severe systemic allergic reaction with a rapid onset that is potentially fatal. The incidence of anaphylaxis is increasing. The diagnosis of anaphylaxis is based primarily on a detailed history-taking of the episode, including information about all exposures and events in the hours preceding the onset of symptoms. Target organ involvement is variable. In general, symptoms occur in 2 or more body systems: the skin and mucous membranes, upper and lower respiratory tract, gastrointestinal tract, cardiovascular system, and central nervous system. Epinephrine is the primary medical therapy, and it must be administered promptly. Intramuscular injection of epinephrine into the antero-lateral thigh is the preferred injection route in an urgent situation. Prevention of recurrence depends primarily on optimal management of patient-related risk factors, plus strict avoidance of the causative allergen or other triggers. When indicated, the practitioner should prescribe self-injectable epinephrine and should educate the patient on how to use it.

A Case of Churg-Strauss Syndrome Manifesting as Colonic Aphthous Ulcers with Granuloma / 대한소화기내시경학회지

Churg-Strauss syndrome is characterized by asthma, peripheral and tissue eosinophilia, extravascular granuloma formation, and vasculitis of multiple organ systems. The gastrointestinal tract may be involved in 20% to 50% of patients, mainly with abdominal pain, diarrhea and GI bleeding. Ulcers in the small and large bowel are an uncommon manifestation, usually detected during laparotomy performed in the setting of bowel perforation. Endoscopically proven segmental colonic aphthous ulcers with typical pathologic findings such as extravascular granuloma formation, eosinophilic infiltration, or vasculitis are a rarer manifestation. We present a patient with Churg-Strauss syndrome and two aphthous ulcers in the sigmoid colon that healed after treatment with high dose steroids and cyclophosphamide.

Skills in Handling Turbuhaler, Diskus, and Pressurized Metered-Dose Inhaler in Korean Asthmatic Patients

PURPOSE: The objective of this study was to evaluate skills in handling inhalers and factors associated with these skills among patients with asthma who had undergone treatment at special asthma and allergy clinics in Korea. METHODS: We enrolled 78 subjects who used Turbuhaler and 145 who used Diskus for asthma control at special clinics in 10 university hospitals and visually assessed their skills in handling these inhalers. We also evaluated skills in 137 subjects who had used pressurized metered-dose inhalers (pMDIs) for symptom relief. Age, sex, duration of asthma and inhaler use, smoking status, monthly income, highest grade completed in school and previous instruction for handling inhalers were also measured to evaluate their association with overall inhaler skills. RESULTS: Performance grade was inadequate for 12.8% of participants using Turbuhaler, 6.2% for Diskus, and 23.4% for pMDIs. The success rates for each step in handling the inhalers were relatively high except for the "exhale slowly to residual volume" step, in which success rates ranged from 24.2% to 28.5%. Older age, male sex, lower educational grade, and absence of previous instruction for handling inhalers were associated with inadequate inhaler technique in univariate analysis; however, only older age and absence of previous instruction remained significant independent risk factors in multivariate analysis. CONCLUSIONS: Among Korean asthmatic patients in special asthma and allergy clinics, skills in handling their inhalers were mostly excellent; meanwhile, older age and absence of previous instruction for handling inhalers were associated with inadequate techniques.

Customized Asthma Control Test with Reflection on Sociocultural Differences

We evaluated the utility and feasibility of customizing Asthma Control Test (ACT) items to generate a Korean Asthma Control Test (KACT) specific for Korean patients. We surveyed 392 asthma patients with 19 items, selected to reflect the Korean sociocultural context. Guideline ratings were integrated with the evaluations of specialists (i.e., using both guide base rating together with specialist's rating), and items with the greatest discriminating validity were identified. Stepwise regression methods were used to select items. KACT scale scores showed significant differences between the asthma control ratings generated by integrating ratings (r=0.77, P<0.001), by specialist's evaluations (r=0.54, P<0.001), or by FEV1 percent predicted (r=0.39, P<0.001). Specialist's and guideline ratings detected 56% and 48.6% of patients with well-controlled asthma, respectively. However, the integrated ratings indicated that only 34.3% of the patients in the test sample were well controlled. The overall agreement between KACT and the integrated rating ranged from 45% to 78%, depending on the cut-off points used. It is possible to formulate a valid, useful country-specific diagnostic tool for the assessment of asthma patients based on the original ACT that reflect differences in sociocultural context.

The causes of chronic cough: Chronic cough due to extrapulmonary etiologies / 대한내과학회지

Cough is one of the most common symptoms leading to referral to medical institutions, and can be triggered by various causes. Since chronic cough does not respond well to antitussives that are generally prescribed in outpatient clinics, it is most important to seek the underlying cause and provide appropriate treatment rather than to just simply relieve symptoms. Although chronic cough is induced by various causes, it is one of difficult symptoms to deal with in clinical settings, having no specific symptom for diagnosis or definitive diagnostic tool. While taking patient's history, however, physicians can take a step closer to the treatment of chronic cough by asking more details about the character, frequency, onset, duration, and aggravating factor of cough, if any; the type of medication and time of its application; the response to previous treatment, etc. Underlying causes of chronic cough often require a long term treatment. Therefore, when treating patients, the physician must inform and discuss with the patient about the duration of treatment and what specifically he or she needs to do at home to maintain satisfactory compliance and expect good outcomes.

Morganella Morganii Sepsis with Massive Hemolysis

Morganella morganii is a facultative gram-negative and anaerobic rod. It may be a cause of devastating infections in neonates and immunocompromised hosts. Some bacterial infections such as Clostridium and Vibrio are associated with hemolysis. However, massive hemolysis caused by M. morganii sepsis has not yet been reported. We observed a 59-yr-old man who had chemotherapy-induced neutropenia and was found to have massive hemolysis and metabolic acidosis due to sepsis. He died 6 hr after admission in spite of aggressive treatment. Two sets of blood cultures revealed the growth of M. morganii. We report here that M. morganii sepsis can cause fatal massive hemolysis leading to death.

Easy Diagnosis of Asthma: Computer-Assisted, Symptom-Based Diagnosis

Diagnosis of asthma is often challenging in primary-care physicians due to lack of tools measuring airway obstruction and variability. Symptom-based diagnosis of asthma utilizing objective diagnostic parameters and appropriate software would be useful in clinical practice. A total of 302 adult patients with respiratory symptoms responded to a questionnaire regarding asthma symptoms and provoking factors. Questions were asked and recorded by physicians into a computer program. A definite diagnosis of asthma was made based on a positive response to methacholine bronchial provocation or bronchodilator response (BDR) testing. Multivariate logistic regression analysis was used to evaluate the significance of questionnaire responses in terms of discriminating asthmatics. Asthmatic patients showed higher total symptom scores than non-asthmatics (mean 5.93 vs. 4.93; p<0.01). Multivariate logistic regression analysis identified that response to questions concerning the following significantly discriminated asthmatics; wheezing with dyspnea, which is aggravated at night, and by exercise, cold air, and upper respiratory infection. Moreover, the presence of these symptoms was found to agree significantly with definite diagnosis of asthma (by kappa statistics). Receiver-operating characteristic curve analysis revealed that the diagnostic accuracy of symptom-based diagnosis was high with an area under the curve of 0.647+/-0.033. Using a computer-assisted symptom-based diagnosis program, it is possible to increase the accuracy of diagnosing asthma in general practice, when the facilities required to evaluate airway hyperresponsiveness or BDR are unavailable.

Two Cases of Vivax Malaria Recurred at 38 and 40 Days after Hydoxychloroquine Therapy / 대한임상미생물학회지

There are two stages in the life circle of Plasmodium spp in humans: exoerythrocytic and erythrocytic stages. Hydroxychloroquine is the major chemotherapeutic agent against malarial parasites in their erythrocytic stage. The recurrence of Plasmodium vivax malaria, which is usually caused by an inadequate treatment or the presence of drug resistant parasites, has been reported frequently in the world, but rarely in Korea. We experienced two patients who recurred with P. vivax malaria after hydroxychloroquine therapy, and treating with insufficient doses of the drug was suspected as the cause of the recurrence.

Effects of Basic Hospital Infection Control Methods on the Isolation Rate of Methicillin: Resistant Staphylococcus aureus / 병원감염관리

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in hospitals in Korea. The overall rate of MRSA in hospitals in Korea was estimated over 60%. Recently hospital infections caused by MRSA are getting increased and problematic in Korea, Our hospital Seoul Paik Hospital, has been trying to solve this problem. We had not applied exact methods for hospital infection control. Therefore, we adapted strict methods under the control of hospital infection control committee (HICC) and assessed the effectiveness of these methods. METHODS: Every month, the number of MRSA isolates was collected and analyzed; the results of the analysis were reported to every ward. All wards were supplied with Microshild(R) (Johnson & Johnson, Australia), Clean N' Fresh(R) (Carroll, USA), and standard paper towels. Health care workers were regularly educated for hospital infection control. The use of antibiotics was controlled by the HICC. We compared MRSA isolation rate between before and after applying the strict infection control methods under the regulation of HICC. Mann-Whitney U test, one-way ANOVA, and Chi-square test were used for statistical analysis of the results. RESULTS: After restricting the uses of antibiotics, glycopeptides and carbapenems were prescribed 15% less (20.3 vs 17.3 DDD /1000 patient-days) and 35% less (9.3 vs 6.0 DDD /1000 patient-days) respectively, compared to before restricting antibiotics. Methicillin resistance rate was decreased from 78% to 69% compared to before the methods(p=0.02). The isolation rate of MRSA was reduced by 31-42% from 2.33 to 1.35-1.60/1000 patient-days compared to before adapting strict infection control methods (p=0.04-0.07). CONCLUSION: This study showed that applying the strict infection control methods in the hospital can be effective to reduce the isolation rate of MRSA.

A case of eosinophilic panniculitis diagnosed in the lower extremity skin lesions with tenderness / 천식및알레르기

Eosinophilic panniculitis is characterized by prominent infiltration of eosinophils in the subcutaneous fat. Clinically it may be considered as a reactive process because most patients have an associated systemic condition. We report a case of tender subcutaneous nodules and plaques with erythema on the lower legs in a 30-year-old man with blood eosinophilia. The histologic features were characterized by massive eosinophilic infiltration in the septae and lobule in the parenchymal area of subcutaneous tissues. Despite exhaustive investigation, no obvious trigger of the panniculitis could be identified. The cutaneous lesions regressed and the eosinophil count became normal during the seven days course of treatment with intravenous corticosteroid. Another flare-up occurred about one month after treatment. The patient is presently being treated with prolonged use of alternate-day steroid without recurrence.

Measurement of nasal airway conductance in the diagnosis of allergic rhinitis by allergen nasal provocation test / 천식및알레르기

BACKGROUND AND OBJECTIVES: Allergic rhinitis is one of the most common allergic diseases. Diagnosis and therapeutic improvement of allergic rhinitis have been evaluated using only subjective symptoms. However, it is important to assess nasal obstruction using objective parameters for the diagnosis and evaluation of therapeutic responses. The aim of this study was to evaluate the usefulness of the objective parameter for nasal obstruction: nasal airway conductance using rhinomanometry to diagnose allergic rhinitis by allergen specific nasal challenge test. SUBJECTS AND METHODS: A total of 56 individuals were included in this study. They were categorized into a patient group sensitized to house dust mite (n=32) and a control group (n=24). They responded to the questionnaire concerned on rhinitis symptoms, and underwent skin prick tests to 11 common inhalant allergens and Dermatophagoides pteronyssinus(D.P.)- specific nasal provocation tests with varying degrees of concentrations. Symptom scores based on subjective nasal symptoms such as runny nose, sneezing, nasal obstruction, and visual analogue scale (VAS) were recorded. Objective parameter i.e. nasal airway conductance using rhinomanometry was also measured before and after the inhalation of D.P. aerosol. RESULTS: Nine subjects of the patient group (28.1%) experienced sneezing, 12 (37.5%) rhinorrhea, 17 (53.1%) nasal obstruction, and 9 (32%) nasal or ocular itching. There were no significant differences between the patient and the control groups in baseline nasal conductance measured by anterior rhinomanometry (p>0.05). In the patient group, however, nasal conductance was significantly decreased after inhalation of the low D.P. concentration (250 B.E.U. of D.P. extract) compared to baseline value (p0.05). Symptom scores were more significantly increased in the high D.P. concentration (1000 B.E.U. of D.P. extract) than in the baseline concentration of the patient group (p0.05). As for VAS, the patient group showed significant differences after the high D.P.(5000 B.E.U. of D.P. extract) inhalation (p<0.05), while the control group showed no difference. CONCLUSION: Although nasal symptoms such as obstruction, itching, sneezing, and rhinorrhea should be considered in diagnosing allergic rhinitis, nasal conductance using rhinomanometry can be a more valuable objective index since it can discriminate the patient group from the control group more sensitively in lower allergen concentrations.