KAAACI Allergic Rhinitis Guidelines: Part 2. Update in nonpharmacotherapy

Allergic rhinitis is the most common chronic disease worldwide. Various upper airway symptoms lower quality of life, and due to the recurrent symptoms, multiple treatments are usually attempted rather than one definitive treatment. There are alternatives to medical (medication-based) and nonmedical treatments. A guideline is needed to understand allergic rhinitis and develop an appropriate treatment plan. We have developed guidelines for medical treatment based on previous reports. The current guidelines herein are associated with the “KAAACI Evidence-Based Guidelines for Allergic Rhinitis in Korea, Part 1: Update in pharmacotherapy” in which we aimed to provide evidence-based recommendations for the medical treatment of allergic rhinitis. Part 2 focuses on nonpharmacological management, including allergen-specific immunotherapy, subcutaneous or sublingual immunotherapy, nasal saline irrigation, environmental management strategies, companion animal management, and nasal turbinate surgery. The evidence to support the treatment efficacy, safety, and selection has been systematically reviewed. However, larger controlled studies are needed to elevate the level of evidence to select rational non-medical therapeutic options for patients with allergic rhinitis.

Clinical Manifestations and Risk Factors of Anaphylaxis in Pollen-Food Allergy Syndrome

PURPOSE: Many studies have reported that pollen-food allergy syndrome (PFAS) can cause anaphylaxis. No comprehensive investigations into anaphylaxis in PFAS have been conducted, however. In this study, we investigated the clinical manifestations and risk factors for anaphylaxis in PFAS in Korean patients with pollinosis. MATERIALS AND METHODS: Data were obtained from a nationwide cross-sectional study that previously reported on PFAS in Korean patients with pollinosis. Data from 273 patients with PFAS were collected, including demographics, list of culprit fruits and vegetables, and clinical manifestations of food allergy. We analyzed 27 anaphylaxis patients and compared them with patients with PFAS with oropharyngeal symptoms only (n=130). RESULTS: The most common cause of anaphylaxis in PFAS was peanut (33.3%), apple (22.2%), walnut (22.2%), pine nut (18.5%), peach (14.8%), and ginseng (14.8%). Anaphylaxis was significantly associated with the strength of sensitization to alder, hazel, willow, poplar, timothy, and ragweed (p<0.05, respectively). Multivariable analysis revealed that the presence of atopic dermatitis [odds ratio (OR), 3.58; 95% confidence interval (CI), 1.25–10.23; p=0.017]; sensitization to hazel (OR, 5.27; 95% CI, 1.79–15.53; p=0.003), timothy (OR, 11.8; 95% CI, 2.70–51.64; p=0.001), or ragweed (OR, 3.18; 95% CI, 1.03–9.87; p=0.045); and the number of culprit foods (OR, 1.25; 95% CI, 1.15–1.37; p<0.001) were related to the development of anaphylaxis in PFAS. CONCLUSION: The most common culprit foods causing anaphylaxis in PFAS were peanut and apple. The presence of atopic dermatitis; sensitization to hazel, timothy, or ragweed; and a greater number of culprit foods were risk factors for anaphylaxis in PFAS.

Pollen-Food Allergy Syndrome in Korean Pollinosis Patients: A Nationwide Survey

PURPOSE: Pollen-food allergy syndrome (PFAS) is an immunoglobulin E (IgE)-mediated allergy in pollinosis patients caused by raw fruits and vegetables and is the most common food allergy in adults. However, there has been no nationwide study on PFAS in Korea. In this study, we investigated the prevalence and clinical characteristics of PFAS in Korea. METHODS: Twenty-two investigators participated in this study, in which patients with allergic rhinoconjunctivitis and/or bronchial asthma with pollen allergy were enrolled. The questionnaires included demographic characteristics, a list of fruits and vegetables, and clinical manifestations of food allergy. Pollen allergy was diagnosed by skin prick test and/or measurement of the serum level of specific IgE. RESULTS: A total of 648 pollinosis patients were enrolled. The prevalence of PFAS was 41.7% (n = 270). PFAS patients exhibited cutaneous (43.0%), respiratory (20.0%), cardiovascular (3.7%) or neurologic symptoms (4.8%) in addition to oropharyngeal symptoms. Anaphylaxis was noted in 8.9% of the PFAS patients. Seventy types of foods were linked to PFAS; e.g., peach (48.5%), apple (46.7%), kiwi (30.4%), peanut (17.4%), plum (16.3%), chestnut (14.8%), pineapple (13.7%), walnut (14.1%), Korean melon (12.6%), tomato (11.9%), melon (11.5%) and apricot (10.7%). Korean foods such as taro/taro stem (8.9%), ginseong (8.2%), perilla leaf (4.4%), bellflower root (4.4%), crown daisy (3.0%), deodeok (3.3%), kudzu root (3.0%) and lotus root (2.6%) were also linked to PFAS. CONCLUSIONS: This was the first nationwide study of PFAS in Korea. The prevalence of PFAS was 41.7%, and 8.9% of the PFAS patients had anaphylaxis. These results will provide clinically useful information to physicians.

A Pilot Study of Intralymphatic Immunotherapy for House Dust Mite, Cat, and Dog Allergies

Several recent clinical trials reported that intralymphatic immunotherapy (ILIT) for some allergens, such as cat dander and pollen, induce tolerance more rapidly than conventional subcutaneous or sublingual immunotherapy, have a comparable duration of effect after only 3 injections, and do not provoke serious local or systemic reactions. However, the efficacy and safety of ILIT are using Dermatophagoides farinae (Df), Dermatophagoides pteronyssinus (Dp), and dog, which are indoor allergens that are commonly found globally, need to be evaluated. Furthermore, use of multiple allergens in ILIT should be investigated. We assessed the clinical efficacy and adverse effects of ILIT using aqueous Df, Dp, dog, and cat allergens or mixtures thereof in patients with allergic rhinitis. A total of 11 subjects with AR sensitized to Df, Dp, cat, and/or dog allergens received 3 intralymphatic inguinal injections of sensitized allergen extract (HollisterStier, New Orleans, LA, USA). Clinical parameters were assessed before ILIT, and 4 months and 1 year after the first injection. Rhinitis symptoms were alleviated and quality of life was improved 4 months after ILIT (P=0.012 and P=0.007, respectively), and these improvements lasted for 1 year after ILIT (P=0.047 and P=0.009, respectively). However, we observed 2 cases of anaphylaxis, one case of a moderate-to-severe systemic hypersensitivity reaction and the other case of a severe local reaction at the injection site after ILIT. In conclusion, ILIT can rapidly improve allergy symptoms and quality of life, and this effect lasts for 1 year. In hypersensitized patients, however, ILIT can provoke severe systemic and/or local hypersensitivity reactions when performed using aqueous allergen extracts.

Patterns of Inhalant Allergen Sensitization and Geographical Variation in Korean Adults: A Multicenter Retrospective Study

PURPOSE: Inhalant allergen sensitization is one of the major factors involved in the pathogenesis of allergic respiratory diseases. However, the sensitization is determined by interactions between genetic and environmental factors. Thus, testing panels of inhalant allergens may differ among geographical areas. Here we aimed to determine 10 common inhalant allergens in Korean adult patients with suspected respiratory allergies and to examine the variation between different geographical locations. METHODS: A total of 28,954 patient records were retrieved for retrospective analysis, from 12 referral allergy clinics located in 9 different areas. Inclusion criteria were Korean adults (≥18 years old) who underwent the inhalant allergen skin prick test for suspected history of respiratory allergy. The primary outcome was inhalant allergen skin prick response. Demographic and clinical information were also collected. Positive skin prick responses to allergens were defined as allergen-to-histamine wheal ratio ≥1. Based on skin test results, the most prevalent aeroallergens were determined. RESULTS: The overall prevalence of allergic sensitization was 45.3%. Dermatophagoides farinae and Dermatophagoides pteronyssinus were the most commonly sensitized allergens. Other common inhalant allergens were cat epithelium (8.1%), birch (7.7%), mugwort (6.9%), alder (6.7%), hazel (6.7%), beech (6.7%), oak (6.6%), and Tyrophagus putres (6.2%), in decreasing order frequency. These 10 inhalant allergens explained 90% of inhalant allergen sensitization in the study participants. However, distinct patterns of the 10 inhalant sensitization were observed in patients living in Chungnam and Jeju. American cockroach, Gernam cockroach, and Trichophyton metagrophytes were unique in Chungnam. Orchard, Japanese cedar, and Velvet were unique in Jeju. CONCLUSIONS: The present analysis suggests a panel of 10 most common inhalant allergens in Korean adult patients with suspected respiratory allergies, which explained 90% of inhalant allergen sensitization. This panel can be utilized as a practical and convenient tool for primary practice and epidemiological surveys of respiratory allergic diseases.

Medical Thoracoscopy in Pleural Disease: Experience from a One-Center Study / 결핵및호흡기질환

BACKGROUND: Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia. MT has been performed at the Seoul National University Hospital since February 2014. This paper summarizes the findings and outcomes of MT cases at this hospital. METHODS: Patients who had undergone MT were enrolled in the study. MT was performed by pulmonologists, using both rigid and semi-rigid thoracoscopes. During the procedure, patients were under conscious sedation with fentanyl and midazolam. Medical records were reviewed for clinical data. RESULTS: From February 2014 to January 2016, 50 procedures (47 cases) were performed (diagnostic MT, 26 cases; therapeutic MT, 24 cases). The median age of patients was 66 years (59–73 years), and 38 patients (80.9%) were male. The median procedure duration from initial incision to insertion of the chest tube was 37 minutes. The median doses of fentanyl and midazolam were 50 µg and 5 mg, respectively. All procedures were performed without unexpected events. Of the 26 cases of pleural disease with an unknown cause, 19 were successfully diagnosed using MT. Additionally, diagnostic MT provided clinically useful information in the other six patients. Therapeutic MT was very effective for treatment of malignant pleural effusion or empyema. The median number of days with chest tube drainage was 6 (3 days for diagnostic MT and 8 days for therapeutic MT). CONCLUSION: MT is a useful and necessary procedure for both diagnosis and treatment of pleural diseases.

Classification and Epidemiology of Allergic Rhinitis / 대한내과학회지

Allergic rhinitis is chronic disorder of nose which is evoked by IgE-mediated inflammation mostly triggered by contact between nasal mucosa and inhalant allergen. Allergic rhinitis can be classified according to seasonality (seasonal or perennial), continuity (intermittent or persistent), and severity (mild, moderate, or severe). Allergic rhinitis is relatively common, and the prevalence of allergic rhinitis has increased in Korea like other countries. As well as the prevalence of allergic rhinitis, the indoor and outdoor concentration of inhalant allergens and the sensitization to inhalant allergens were systematically investigated in Korea. As a result, house dust mite, pollens, fungal spores, cockroach, and animal hairs were found to be common inhalant allergens. Moreover, the concentration of tree pollens and grass pollens and sensitization to those pollens increased because of global warming, which may consequently increase the prevalence of pollen-induced allergic rhinitis. With regard to socioeconomic burden of allergic rhinitis, the direct medical cost including herbal and alternative medicine was as high as 1.78 million Korean won per year. Direct nonmedical cost as well as indirect cost including unproductivity, absenteeism, and medical cost for associated diseases such as asthma worsened the socioeconomic burden of allergic rhinitis.

Classification and Epidemiology of Allergic Rhinitis / 대한내과학회지

Allergic rhinitis is chronic disorder of nose which is evoked by IgE-mediated inflammation mostly triggered by contact between nasal mucosa and inhalant allergen. Allergic rhinitis can be classified according to seasonality (seasonal or perennial), continuity (intermittent or persistent), and severity (mild, moderate, or severe). Allergic rhinitis is relatively common, and the prevalence of allergic rhinitis has increased in Korea like other countries. As well as the prevalence of allergic rhinitis, the indoor and outdoor concentration of inhalant allergens and the sensitization to inhalant allergens were systematically investigated in Korea. As a result, house dust mite, pollens, fungal spores, cockroach, and animal hairs were found to be common inhalant allergens. Moreover, the concentration of tree pollens and grass pollens and sensitization to those pollens increased because of global warming, which may consequently increase the prevalence of pollen-induced allergic rhinitis. With regard to socioeconomic burden of allergic rhinitis, the direct medical cost including herbal and alternative medicine was as high as 1.78 million Korean won per year. Direct nonmedical cost as well as indirect cost including unproductivity, absenteeism, and medical cost for associated diseases such as asthma worsened the socioeconomic burden of allergic rhinitis.

Bacterial Yield from Quantitative Cultures of Bronchoalveolar Lavage Fluid in Patients with Pneumonia on Antimicrobial Therapy

BACKGROUND/AIMS: Early diagnosis and appropriate antimicrobial choice are crucial when managing pneumonia patients, and quantitative culture of bronchoalveolar lavage (BAL) fluid is considered a useful method for identifying pneumonia pathogens. We evaluated the quantitative yield of BAL fluid bacterial cultures in patients being treated with antimicrobials and attempted to identify factors predictive of positive BAL cultures. METHODS: Patients over 18 years old and whose BAL fluid was subjected to quantitative culture to identify the organism causative of pneumonia between January 1, 2005, and December 31, 2009, were included. We reviewed the results of BAL fluid bacterial cultures and the clinical records, laboratory tests, and radiographic findings of the patients. RESULTS: BAL was performed on 340 patients with pneumonia. A positive BAL culture, defined as isolation of more than 10(4) colony forming units/mL bacteria, was documented in 18 (5.29%) patients. Of these, 9 bacteria isolated from 10 patients were classified as probable pathogens. The most frequently isolated bacteria were methicillin-resistant Staphylococcus aureus, Acinetobacter baumannii, and Pseudomonas aeruginosa. No independent predictive factor for positive BAL cultures was identified. CONCLUSIONS: The yield of quantitative BAL fluid bacterial culture in patients already on antimicrobials was low. Clinicians should be cautious when performing a BAL culture in patients with pneumonia who are already on antimicrobials.

Antiallodynic Effects of Electroacupuncture Combined with MK-801 Treatment through the Regulation of p35/p25 in Experimental Diabetic Neuropathy

The anti-allodynic effect of NMDA receptor antagonist and acupuncture treatments were explored through spinal p35 regulation of diabetic neuropathic rat. We evaluated the change over time of p35/p25 protein levels in the spinal cord compared with behavioral responses to thermal and mechanical stimulation in streptozotocin (STZ)-induced diabetic rats. Additionally, we studied p35 expression when electroacupuncture (EA) and a sub-effective dose of NMDA (N-methyl-D-aspartate) receptor antagonist (MK-801) were used to treat hyperalgesia in the diabetic neuropathic pain (DNP). Thermal paw withdrawal latency (PWL) and mechanical paw withdrawal threshold (PWT) were significantly decreased in the early stage of diabetes in rats. p35 expression after STZ injection gradually decreased from 1 week to 4 weeks compared to normal controls. p25 expression in 4-week diabetic rats was significantly higher than that of 2-week diabetic rats, and thermal PWL in 4-week diabetic rats showed delayed responses to painful thermal stimulation compared with those at 2 weeks. EA applied to the SP-9 point (2 Hz frequency) significantly prevented the thermal and mechanical hyperalgesia in the DNP rat. Additionally, EA combined with MK-801 prolonged anti-hyperalgesia, increased p35 expression, and decreased the cleavage of p35 to p25 during diabetic neuropathic pain. In this study we show EA combined with a sub-effective dose of MK-801 treatment in DNP induced by STZ that is related to p35/p25 expression in spinal cord.

Chinese Bellflower Root Anaphylaxis: IgE-Binding Components and Cross-Reactivity With Mugwort and Birch

A 56-year-old man who had suffered from seasonal rhinitis in spring and autumn experienced recurrent generalized urticaria and an oral burning sensation after eating several cooked herbs for 3 months. A skin-prick test showed positive responses to various pollens, celery, Chinese bellflower, and arrowroot. The Chinese bellflower-specific IgE ELISA OD value was 1.547. Oral challenge with unprocessed raw Chinese bellflower root provoked oral burning sensation, eyelid swelling, generalized urticaria, and hypotension. In an ELISA inhibition test, IgE binding to Chinese bellflower was significantly inhibited by Chinese bellflower, mugwort, and birch pollen extract. SDS-PAGE and immunoblot assay revealed nine IgE-binding components, and common protein bands were detected in the range of 40~55 kDa (Chinese bellflower-mugwort-birch) and 14 kDa (Chinese bellflower-birch). Chinese bellflower root can cause anaphylaxis and may have cross-reactivity with mugwort and birch.

Preliminary Study on The Effect of Multicomponent Cognitive-behavioral Group Treatment Program for Fear of Flying / 항공우주의학회지

BACKGROUND: The multicomponent cognitive-behavioral group treatment program is an effective treatment for fear of flying (FOF). In Korea, the effect of this treatment has not yet been studied. This is a preliminary study to assess the program's effect for Koreans with FOF. METHODS: Among 11 patients who participated in the treatment program, 10 completed the program, and data of 9 patients were obtained. Patients participated in individual treatment phase by diagnosis and symptoms, and in the group treatment phase for 2 days, composed of education on flight and anxiety, relaxation technique, cognitive reconstruction, imaginary exposure, mock-up treatment, real flight, etc. Flying history, Visual Analogue Flight Anxiety Scale (VAFAS), Flight Anxiety Situation Questionnaire (FAS) with 3 subscales (generalized, anticipatory, in-flight), Flight anxiety Modality Questionnaire (FAM) with 2 subscale (somatic, cognitive) were assessed before treatment and at 3 months after completion of the program. RESULTS: 8 patients made flights within 3 months after treatment. VAFAS, FAS total, 3 FAS subscales, FAM, and 2 FAM subscales were all decreased significantly after treatment. CONCLUSION: This results suggest that the multicomponent cognitive-behavioral group treatment program is effective for Koreans with FOF.

Overview of Treatment Program for Fear of Flying

With the growing number of international exchange and airline travel, fear of flying has become a rising new anxiety disorder that obstructs occupational and social functioning of an individual. Fear of flying which is a clinical manifestation of diverse anxiety disorders has treatment programs based on cognitive-behavioral therapy already actively practiced in many industrialized countries. These treatment programs are composed of education on flight and anxiety, cognitive reconstruction, relaxation technique, in vitro exposure using a simulator, real flight, etc. The treatment program for Korean should be made within the range of international standard and reflect the korean cognitive and emotional characteristics.

Intracardiac Electrogram at Successful Site of Radiofrequency Catheter Ablation in Patients with Atrioventricular Nodal Reentrant Tachycardia

BACKGROUND AND OBJECTIVES: Ablation of the slow pathway in patients with atrioventricular nodal reentrant tachycardia (AVNRT) can be performed by using a specific intracardiac electrogram findings predicting a successful radiofrequency catheter ablation. The purpose of the present study is to recognize a specific intracardiac electrogram findings predicting a successful sites of radiofrequency catheter ablation in patients with AVNRT. MATERIALS AND METHODS: The study population consisted of the 18 patients (7 males, mean age:46 yr) to undergo successful catheter ablation using radiofrequency current in order to eliminate AVNRT from January 1993 to september 1994. We have analyzed local intracardiac electrogram at successful and unsuccessful sites of radiofrequency catheter ablation before the radiofrequency application: Atrial electrogram amplitude, duration, number of peaks in atrial electrogram, atrial/ventricular (A/V) electrogram amplitude ratio, and presence of His potential and/or slow potential. RESULTS: Of 18 patients, 16 patients underwent a slow pathway ablation, the other 2 patients a fast pathway ablation. The mean A/V electrogram amplitude ratio at successful and unsuccessful sites was 0.69+/-0.91 and 1.86+/-2.03, respectively. The mean atrial electrogram duration and number of peaks at successful and unsuccessful sites was 57+/-16 msec vs 69+/-16 msec and 1.7+/-0.5 vs 2.2+/-0.7, respectively. His bundle electrogram was seen in one slow pathway ablated and one fast pathway ablated patient. No slow potential could be identified in any of these 18 patients. CONCLUSION: We think that A/V electrocardiogram amplitude ratio below 0.5 at posterior interatrial septum along tricuspid annulus is important marker indicating a successful ablation sites.

The Effect of Midazolam as Premedication for Laser-Assisted Uvulopalatoplasty / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Snoring generated at the level of the velopharynx is usually treated with laser-assisted uvulopalatoplasty (LAUP), which is mostly performed under local anesthesia and on an out-patient basis. However, if adequate sedation is not achieved during this procedure, patients may suffer from anxiety, disgusting smell of tissue vaporization, and doctors may even be disturbed by the patients gagging or repetitive swallowing. A relatively new sedative drug, midazolam, is known for its improved safety, effectiveness, more rapid onset of action and shorter life in comparison to the classical sedative agent, diazepam. The authors tried to evaluate the efficacy and safety of intravenous midazolam as a sedative premedication for LAUP surgery. MATERIALS AND METHODS: Thirty-two patients designated for LAUP were divided into three groups by random double-blinded sampling. Each group received an intravenous injection of midazolam (0.05 mg/kg), diazepam (0.1 mg/kg), and normal saline (0.01 ml/kg) 5 minutes before the laser procedure. Vital signs were monitored before, during and after the procedure. Questionnaires about the effectiveness were given to the operator and the patients, and the scores of the three groups were compared statistically. RESULTS: Vital signs were stable in all three groups throughout the entire procedure. Midazolam showed better sedative effect than placebo and diazepam. It also showed stronger analgesic and anti-anxiety, and more potent antegrade amnesic effects than placebo. CONCLUSION: Intravenous injection of midazolam is one of the effective and safe ways of premedication for patients receiving LAUP.

The Effects of the Small Doses of Nondepolarzing Muscle Relaxants Administered Just Prior to Succinylcholine on Intragastric and Intraocular Pressures / 대한마취과학회지

Succinylcho1ine(Sch) may provoke regurgitation of gastric contents by producing fasciculations of abdominal musculatrue, which in turn may increase intragastric pressure. And it has been also believed that Sch increases intraocular pressure in part by contracture of the extraocular muscles. The purpose of this study was to determine whether these increases and the degree of fasciculation could be reduced by prior administration of a nondepolarizing muscle relaxant. Simultaneous administration of pancuronium or vecuronium with Sch significantly reduced the degree of fasciculation and also decreased the elevation of the intragastric pressure, but did not show any remarkable effect on the intraocular pressure, We might say that wed better use the small amount of nondepolarizing muscle relaxant with Sch to prevent the increase of intragastric pressure, thereby decrease the chance of regurgitation and aspiration during induction period.