Incidence, predictors, and treatment outcomes of biphasic anaphylaxis in the emergency department of a tertiary hospital:A 5-year retrospective study.

BACKGROUND: Biphasic anaphylaxis despite successful treatment has an incidence of 4-5% based on NIAID/FAAN criteria. Our study aimed to investigate the frequency and predictive factors associated with biphasic reactions within the emergency department (ED) at Siriraj Hospital. METHODS: This observational study assessed medical records of anaphylaxis and anaphylactic shock patients at Siriraj Hospital's ED from January 2015 to December 2019. Of these, a random sample was reviewed and validated by allergists. Telephone interviews were performed to collect more data. Uni- or biphasic response were analyzed descriptively. Prediction modeling was performed. RESULTS: Among 1888 ED anaphylaxis cases, 601 were randomly sampled; 239 patients completing interviews were analyzed. The incidence of biphasic reactions was 7.1% (17/239) of cases. Common triggers of biphasic responses were foods (57.7%), drugs (31%), other known allergens (5.9%). Shellfish, edible insects, and wheat were the leading food triggers. Biphasic responses were significantly associated with history of drug allergy, any allergic disease, allergic rhinitis, number of prior anaphylactic reactions, angioedema, less generalized erythema, less reaction to shellfish, reaction to NSAIDs, and no epinephrine giving at ED visit (all p < 0.1). From a 3-predictor prognostic model including drug/idiopathic reaction, duration from onset to first epinephrine > 60 minutes, and any cutaneous edema/angioedema with an area under the curve of 0.72 (95%CI 0.54, 0.90). CONCLUSION: The incidence of biphasic response was 7.1%. Predictors of biphasic response were drug/idiopathic reac- tion, any cutaneous edema/angioedema, and time from onset to first epinephrine > 60 minutes.

Validity and reliability of the Thai version of Food Allergy Quality of Life Questionnaire - Adult Form (FAQLQ-AF) and Food Allergy Independent Measure - Adult Form (FAIM-AF).

BACKGROUND: Food allergy affects the patient's quality of life (QoL) and leads to anxiety and depression. In addition to routine treatment, QoL evaluation should also be performed in patients with food allergies. The validated Food Allergy Quality of Life Questionnaire - Adult Form (FAQLQ-AF) and Food Allergy Independent Measure - Adult Form (FAIM-AF) have been well accepted and available in many languages. OBJECTIVE: Translate FAQLQ-AF and FAIM-AF into Thai and perform reliability and validity tests in Thai adult patients with food allergies. METHODS: The translation process was performed according to the ISPOR Task Force for Translation and Cultural Adaptation. Participants 18 years or older and with physician-diagnosed food allergies were included in the study. Thai versions of FAQLQ-AF and FAIM-AF were administered to participants at baseline and after two weeks. The intraclass correlation coefficient and Cronbach's α coefficient were evaluated to demonstrate both questionnaires' test-retest reliability and internal consistency. RESULTS: The study included 104 participants. The Thai version of FAQLQ-AF and FAIM-AF demonstrated good reliability, with intraclass correlation coefficients of 0.83 (95%CI 0.76, 0.88) and 0.85 (95%CI 0.79, 0.90), respectively. The validity was excellent, with Cronbach's α coefficient of 0.91 and 0.92, respectively. Both questionnaires were moderately correlated (r = 0.69, P < 0.001), but poorly correlated with the 36-Item Short Form Survey, which is usually used to evaluate general health status. CONCLUSIONS: To evaluate the QoL in adult patients with food allergies, the Thai versions of FAQLQ-AF and FAIM-AF are valid, reliable, and more suitable than the general questionnaire.

Children with wheat anaphylaxis and with low wheat specific IgE have a different IgE immunoblot pattern than those with high wheat specific IgE.

BACKGROUND: Children with wheat anaphylaxis can present with a wide range of wheat-specific IgE (sIgE). OBJECTIVE: To identify differences in clinical features and predominant wheat allergens sensitized by these patients. METHODS: Children with history of wheat anaphylaxis were recruited. Skin prick test (SPT) to wheat, sIgE to wheat, omega-5 gliadin (ω5G), lipid transfer protein (LTP) were investigated. Profiles of IgE-bound wheat allergens were studied to identify predominant wheat allergens. RESULTS: Twenty-nine children (17 males) aged 1-18 years were enrolled. Sixteen patients (55.2%) had wheat-sIgE > 100 kUA/L (WAhi) and 13 patients (44.8%) had wheat-sIgE < 34 kUA/L (WAlo). The median of peak wheat-sIgE in WAhi and WAlo were 340.5 kUA/L (IQR 184.3, 564.5) and 12.2 kUA/L (IQR 1.4, 41.3), respectively. Oral food challenge test (OFC) was carried out in 12 of 13 patients in the WAlo group, all of which had positive results. Eight of these 12 patients developed anaphylaxis during OFC despite having wheat-sIgE less than 10 kUA/L. There were no differences in clinical characteristics and atopic history between WAhi vs. WAlo. Medium to low molecular weight gliadin (< 40 kDa) and glutenin (< 60 kDa) were commonly recognized by patients with WAhi. IgE immunoblot pattern among the WAlo group was more widely dispersed than those with WAhi. CONCLUSIONS: Wheat anaphylaxis can occur in patients with low wheat-sIgE. Predominant wheat allergens recognized by patients with WAlo were different than those with WAhi. Such difference could be responsible for anaphylaxis at even low levels of wheat-sIgE.

Perioperative immediate hypersensitivity incidence, clinical characteristics, and outcomes after allergological evaluation: A multi-disciplinary protocol from tertiary hospital, Thailand.

BACKGROUND: Perioperative immediate hypersensitivity reaction (POH) is an immediate hypersensitivity reaction during an anesthesiologist monitored procedure. We report data of clinically-suspected POH (csPOH) patients undergoing an allergist-performed unified diagnostic workup algorithm for POH. OBJECTIVE: To describe the characteristics of patients with csPOH, POH events, and the POH outcomes of procedures after the unified diagnostic workup algorithm for POH. METHODS: A prospective cohort was conducted in adult patients with csPOH at Siriraj Hospital, a tertiary hospital, in Thailand from January 2018 to August 2022. Diagnostic workup for POH by the allergist included an initial assessment, followed by comprehensive allergological evaluation. Patients were then follow-up for POH outcomes during subsequent anesthesia procedures. RESULTS: Of 68 patients were csPOH, only 52 patients were diagnosed with POH by allergists. The incidence was 1:4,304 anesthetic procedures for POH, and 1:11,900 anesthetic procedures for at least grade III POH. Most patients had a grade III (51.2%) or II (46.4%) reaction. The leading identified causative agents were antibiotics (36.8%), antiseptics (21%), latex (13.1%), and morphine (13.1%). Cefazolin and chlorhexidine were the most common antibiotic and antiseptic, respectively. During a median follow-up time of 2.1 years, all 14 patients completing comprehensive allergological evaluation underwent subsequent anesthesia without recurrence of POH. CONCLUSIONS: The incidence of POH at our hospital was comparable to the global incidence. Antibiotics were the most common causative agent. Complete records, collaboration among the multidisciplinary team, and comprehensive evaluation of POH allow for safe subsequent procedures.

Prevalence and characteristics of adult patients with adult-onset and childhood-onset food allergy.

BACKGROUND: IgE-mediated food allergy (FA) affects health-related quality of life, and may cause life-threatening reactions. Few studies characterizing adult FA patients have been reported, especially first ever reaction (FER) in adult-onset. OBJECTIVE: We describe the characteristics of adult FA patients, especially FER and compare these characteristics between childhood- and adult-onset FA. METHODS: A cross-sectional study of all adult patients visiting the Allergy Clinic, Siriraj Hospital at the outpatient department between January 2009 to December 2019 was conducted. Demographic, clinical data, and first reaction in life data were collected. Adult-onset was defined as ≥ 18 years old. RESULTS: Of 711 patients visiting the clinic, 174 (24.4%) were FA with a median age of 31.0 years (interquartile range 24.0, 44.0 years); 29.3% were male. FA patients had significantly higher prevalence of sensitization to cockroach compared with non-FA patients (67.4% vs. 56.3%); p = 0.016). The three most common food triggers were shellfish (68.0%), wheat (28.7%), and fruit and vegetables (10.0%). Before diagnosis, 56.7% (97/171) experienced at least 1 food-related anaphylaxis. Of the 166 patients compared on age of onset, 127 (76.5%) were adult-onset. In FER, patients with adult-onset had significantly more reactions to fruit and vegetables, more respiratory system involvement, and more other systems involvement [OR 8.95 (1.13, 1157); p = 0.034; OR 3.15 (95%CI 1.30, 8.25), p = 0.011; OR 10.8 (1.35, 1404), p = 0.019, respectively]. In sensitivity analysis, the cardiovascular system involvement was also significantly more common [OR 2.78 (1.05, 9.15); p = 0.038]. CONCLUSIONS: Shellfish was the most common trigger foods in adult FA patients. In FER, anaphylaxis was common for adult-onset. Adult-onset FA patients also had more respiratory, cardiovascular, and other systems involvements than childhood-onset ones. FA awareness, early diagnosis, and proper management are encouraged. Further studies on the adult-onset food allergic patients are required.

As-needed versus regular intranasal corticosteroid for allergic rhinitis: A systematic review and meta-analysis.

BACKGROUND: Daily intranasal corticosteroid (INCS) is recommended for treating allergic rhinitis (AR). Nevertheless, patients are generally not adherent and use it on-demand. The data on the efficacy of as-needed INCS was insufficient. OBJECTIVE: We conducted a systematic review and meta-analysis to assess the efficacy of as-needed INCS compared with regular use for AR. METHODS: We searched PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) until May 2021. A pairwise meta-analysis used a random-effects model to estimate the pooled standardized mean difference (SMD). The primary outcome was the total nasal symptom score (TNSS) changes from baseline at 4 and 6 weeks. Secondary outcomes were the changes of individual nasal symptom score and quality-of-life (QoL) score. RESULTS: We identified five eligible RCTs with a total of 436 patients with AR. Only four studies had adequate data for quantitative synthesis. The TNSS changes of as-needed INCS were not significantly different from the regular use at both 4 (SMD 0.23 [95%CI: -0.14 to 0.60], p = 0.230) and 6 weeks (SMD 0.21 [95%CI: -0.02 to 0.44], p = 0.080). Most of the changes of individual nasal symptom scores and QoL scores were not significantly different between the two regimens. At 50% or more INCS dose of regular use, as-needed and regular INCS provided a similar efficacy. The treatment effect was, however, less sustained with as-needed INCS. CONCLUSIONS: The efficacy of as-needed use of INCS at 50% of corticosteroid exposure was comparable to regular use in improving nasal symptoms and QoL.

Clinical characteristics and aspirin desensitization in Thai patients with a suggestive history of NSAID-exacerbated respiratory disease.

BACKGROUND: Non-steroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD) is characterized by the triad of chronic rhinosinusitis with nasal polyp, asthma, and aspirin (ASA) or NSAID hypersensitivity. Previous study of NERD has rarely been reported in Asian population. OBJECTIVE: To investigate the clinical characteristics and outcomes of aspirin desensitization (ASAD) in Thai NERD. METHODS: This retrospective chart review included patients with a suggestive history of NERD with or without ASAD from the Adult Allergy Clinic of Siriraj Hospital (Bangkok, Thailand) during January 2008 to December 2018. RESULTS: Ten NERD patients were recruited. The median age of onset was 30 years. Comorbid atopic diseases were found in 4 patients. Asthma control level was step 3 of the Global Initiative for Asthma (GINA) guideline or greater in all patients. Five patients had reactions to more than one NSAIDs. Ibuprofen was the most common culprit agent. Reactions frequently involved the respiratory and cutaneous systems. Four patients underwent ASAD followed by ingestion of ASA 300-600 mg daily. One patient discontinued ASA after taking ASA 600 mg daily for 3 months due to severe gastrointestinal side effect. The remaining three patients successfully continued ASA 300 mg daily as maintenance to control sino-nasal inflammation and to prevent recurrence of nasal polyp. None of the 4 patients required sinus surgery revision. CONCLUSIONS: NERD is a difficult-to-treat disease with unique clinical characteristics. ASAD followed by a maintenance dose of ASA 300 mg daily was found to be effective and well-tolerated in most patients.

House dust mite allergen immunotherapy for monosensitized versus polysensitized patients with allergic rhinitis: A systematic review and meta-analysis.

BACKGROUND: Most patients with allergic rhinitis are polysensitized. The efficacy of house dust mite (HDM) allergen immunotherapy (AIT) compared between monosensitized and polysensitized patients remains limited. OBJECTIVE: To systematically review the efficacy and safety of HDM AIT compared between monosensitized and polysensitized patients with allergic rhinitis. METHODS: We searched PubMed/MEDLINE, Scopus, EMBASE, and the Cochrane central register of Controlled Trials (CENTRAL) until June 2022. The primary outcome was the changes from baseline in total nasal symptom score (TNSS). Secondary outcomes were changes from baseline in total medication score (TMS), combined symptom medication score (CSMS), visual analog scale (VAS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score, immunological parameters, and adverse events (AEs). RESULTS: Of 13 eligible studies, 10 prospective cohorts, 2 retrospective cohorts, and 1 matched cohort, we identified 10 studies for quantitative synthesis. There were 1,113 patients with allergic rhinitis, 566 with HDM monosensitization and 547 with polysensitization to HDM and other allergens. There was no significant difference in the pooled mean changes of the 2 groups in TNSS (SMD -0.05, 95%CI: -0.22 to 0.11, p = 0.532) and VAS (SMD -0.20, 95%CI: -0.42 to 0.01, p = 0.060) with moderate certainty of evidence. The changes in TMS, CSMS, and RQLQ were similar between the 2 groups with very low certainty of evidence. The AEs were mild and comparable between the 2 groups. The immunological indices remained inconsistent and were not predictive of clinical responses. CONCLUSIONS: A single HDM AIT similarly improved clinical outcomes in monosensitized and polysensitized patients with allergic rhinitis.

Effect of gene polymorphisms in ADAM33, TGFß1, VEGFA, and PLAUR on asthma in Thai population.

BACKGROUND: Most of the asthma susceptibility genes have demonstrated moderate effect. Gene-gene interaction may play a role in asthma. OBJECTIVE: To investigate the genetic and gene-gene interaction effects of single nucleotide polymorphisms (SNPs) in the ADAM33, TGFß1, VEGFA, and PLAUR genes on asthma in Thai population. METHODS: Two hundred and fifty control and 250 asthmatic Thai subjects were recruited. Asthma was diagnosed based on symptoms and spirometry assessments using criteria outlined by the American Thoracic Society. Degrees of asthma severity were determined according to guidelines provided by the Global Initiative for Asthma. Asthmatic subjects were subcategorized into the low-severity (n = 106) and high-severity (n = 144) groups. Eleven SNPs in four genes were genotyped, including ADAM33 SNPs (rs528557/S2, rs598418, rs44707/ST+4), TGFß1 SNPs (rs2241715, rs11466345), VEGFA SNPs (rs833069, rs3025010), and PLAUR SNPs (rs344781, rs344787, rs2239374, rs2239372). Association analyses between SNPs and asthma, and tests for gene-gene interaction were performed. RESULTS: The ADAM33 rs528557/S2 SNP was found to be associated with asthma according to the additive and dominant models. Comparison between the low-severity group and controls showed the VEGFA rs833069 SNP to be significantly associated with the low-severity group. No gene-gene interactions were observed in this study. CONCLUSIONS: The ADAM33 rs528557/S2 and the VEGFA rs833069 SNPs were associated with Thai asthmatics, as well as with other populations worldwide. Further studies are warranted to investigate the use these SNPs as biomarkers for establishing early diagnosis or for predicting future risk of asthma.

Natural resolution of non-anaphylactic shrimp allergy in patients diagnosed 10 years earlier by oral food challenge.

BACKGROUND: Shrimp allergy is considered a lifelong condition. The natural resolution of shrimp allergy is not well studied. OBJECTIVE: To investigate the natural resolution of shrimp allergy among a cohort of patients diagnosed with shrimp allergy 10 years earlier by oral shrimp challenge. METHODS: A prospective study recruited patients diagnosed with shrimp allergy to Penaeus monodon (Pm), Macrobrachium rosenbergii (Mr), or both from a study conducted during 2005-2006. The current oral shrimp challenges were conducted during 2015-2016. The negative oral shrimp challenge was designated 'resolved shrimp allergy' (RSA), with a positive challenge designated 'persistent shrimp allergy' (PSA). Skin prick and prick-to-prick testing to shrimp were used to determine sensitization. RESULTS: Sixty patients who had positive shrimp challenge from the previous cohort were contacted. Patients who had previous anaphylactic reaction (8 subjects) or allergic reaction after shrimp ingestion within 6 months (6 subjects), were not included. Nine patients refused to participate and 20 patients could not be contacted. Seventeen patients were included. Three were previously diagnosed with allergy to Pm, 3 to Mr, and 11 to both species. RSA was observed in 1 patient with isolated Pm allergy, and in 3 patients with isolated Mr allergy. Three of 9 patients with dual allergy had RSA to both species. RSA patients had significantly smaller size of shrimp skin test than PSA patients at both diagnosis and follow-up. CONCLUSIONS: At ten years after diagnosis, 46% of patients had RSA. These patients had significantly smaller size of shrimp skin test than PSA patients.

Concomitant chronic spontaneous urticaria treatment might hinder the diagnosis of occupational latex-induced anaphylaxis: A case report.

BACKGROUND: Cutaneous manifestations of chronic spontaneous urticaria (CSU) are identical to type 1 hypersensitivity reactions. The daily occurrence of rash from occupational allergy could be misinterpreted as CSU exacerbation. OBJECTIVE: We aim to report a nurse with concomitant CSU suffering from latex-induced anaphylaxis. METHODS: Skin tests, specific IgE using ImmunoCAP, and gloves challenge were performed. RESULTS: A 27-year-old nurse with CSU suffered from several episodes of severe urticarial flare. H1-antihistamine up-dosing and oral corticosteroid burst were given. Unfortunately, she developed 3 episodes of anaphylaxis during her routine nursing care work on a medical ward, leading to allergist consultation. She had positive latex-specific IgE (6.86 kUA/L) and positive gloves challenge test. CONCLUSIONS: Concomitant CSU treatment might hinder the recognition of latex allergy by masking or delaying skin manifestations. IgE-mediated allergy should be suspected if there was a change in severity or frequency of previously controlled CSU or the presence of systemic symptoms.

Clinical practice guidelines for the diagnosis and management of atopic dermatitis.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.

The contribution of particulate matter to respiratory allergy.

BACKGROUND: Air pollution contributes to an estimated six million deaths per year. Epidemiological and experimental studies show an association between air pollutant exposure and respiratory allergy. OBJECTIVE: We aimed to write a narrative review of the epidemiology of air pollution-related respiratory-related allergic disorders (including asthma and allergic rhinitis) and the effects of air pollutants - with an emphasis on the particulate matter - on respiratory allergy-related health. METHODS: PubMed Medline was searched, and representative epidemiologic and controlled-exposure studies were selected by using terms for air pollutants, particulate matter, and respiratory allergy including asthma and allergic rhinitis. RESULTS: Epidemiological studies showed methodologic heterogeneity, including variability in study populations, geographical regions, types and sources of pollutants, methods for exposure estimation, approaches to controlling for confounding, and case definitions. This heterogeneity affected measures of association between studies. There is strong evidence to support an association between exposure to particulate matter and asthmatic exacerbations. Although data are inconclusive, several studies suggest exposure to particulate matter contributes to the development of asthma, allergic sensitization, and allergic rhinitis. Experimental studies, such as controlled-exposure studies, support a causal association between particulate matter and adverse health effects. CONCLUSIONS: Particulate matter exposure can exacerbate pre-existing asthma and may contribute to developing asthma, allergic rhinitis, and aeroallergen sensitization. Short-term and long-term strategies are needed to reduce disease severity and prevent new-onset disease development. Additional research is needed to identify effective avoidance strategies and therapeutic approaches.

Features and outcomes of immunoglobulin therapy in patients with Good syndrome at Thailand's largest tertiary referral hospital.

BACKGROUND: Good syndrome (GS) is an adult-onset immunodeficiency characterized by coexisting thymoma and hypogammaglobulinemia. Clinical course after treatment with intravenous immunoglobulin (IVIg) has rarely been reported. OBJECTIVE: To investigate and report the clinical course and outcomes of GS patients after treatment with IVIg at Thailand's largest national tertiary referral hospital METHODS: This retrospective chart review included patients diagnosed with GS and treated with IVIg during the 1 January 2005 to 31 December 2015 study period. RESULTS: Nine GS patients with a median age at diagnosis of 53 years were included. Pneumonia and sepsis were the most common clinical manifestations. Six infectious organisms suggestive of cell-mediated immunity defect occurred in six patients, including cytomegalovirus (CMV), Mycobacterium tuberculosis, Mycobacterium abscessus, Herpes simplex virus (HSV), Pneumocystis jirovecii, and Aspergillus. Mean serum IgG level was 317 mg/dL. Eight patients had very low to undetectable B-cells. Five patients had either low CD4 number or impaired T-cell function, and one patient had both. All patients received IVIg replacement therapy monthly at a dose of 0.4 g/kg. The mean trough IgG level was 881 mg/dL. After treatment with IVIg replacement, seven patients had favorable clinical outcomes. However, two patients expired due to septicemia. CONCLUSION: Clinical outcomes of patients with GS are more dependent on the severity of infections and associated hematologic and autoimmune diseases than on the severity of thymoma itself. Therefore, early recognition and prompt IVIg replacement may change the natural course of this condition and may be successful in keeping the patient infections free.

Beta-Expansin of Bermuda, Johnson, and Para grass pollens, is a major cross-reactive allergen for Allergic Rhinitis patients in subtropical climate.

BACKGROUND: Subtropical grass pollens of Bermuda (BGP), Johnson (JGP), and Para or buffalo grass (PGP), are common causes of pollen allergies in warm climate area. Allergic rhinitis (AR) patients had positive skin prick test (SPT) to extract of these 3 grass pollens. However, no allergenic proteins of 3 grass pollens have never been studied. OBJECTIVE: To identify major allergens of BGP, JGP, and PGP in Thai grass pollen-allergic patients and to examine their sIgE cross-reactivity. METHODS: Serum of nine AR patients with positive SPT to at least 2 of 3 studied pollens were collected. Based on availability, only ImmunoCAP of BGP and JGP were available to determine a level of sIgE. Profiles of sIgE bound proteins from BGP, JGP, and PGP, were obtained by immunoblot. Major IgE bound protein was identified by liquid chromatography-tandem mass spectrophotometry (LC-MS/MS). Cross-reactivity of purified major allergen of the 3 grass pollens was determined by inhibition of sIgE in both ELISA and immunoblot. RESULTS: AR patients who have positive SPT to extract of BGP, JGP, and PGP, were 9, 8, and 6, respectively. Positive sIgE (> 0.35 kUA/L) to BGP and JGP were found in 9 and 8 patients, respectively. Eight profiles of IgE bound proteins of the 3 grass pollens showed 29-30 kDa pollen protein as major allergen and was identified as beta-expansin (ExpB). Moreover, purified ExpB of the 3 grass pollens cross-inhibited serum sIgE. CONCLUSION: ~30 kDa ExpB of BGP, JGP, and PGP, is major cross-reactive allergen for AR Thai patients.

The effectiveness of oxymetazoline plus intranasal steroid in the treatment of chronic rhinitis: A randomised controlled trial.

BACKGROUND: The recommended drug for moderate to severe chronic rhinitis is intranasal steroids (INS). However, nasal congestion could be refractory and need additional treatments. OBJECTIVE: We sought to explore the benefit of oxymetazoline (Oxymet) plus INS on nasal congestion without inducing rhinitis medicamentosa. METHODS: We performed a 60-week, randomised, double-blind clinical trial in 50 patients, 18 years of age or greater, with chronic rhinitis who had used INS and cetirizine and still had nasal congestion. Subjects were randomised to receive 2 sprays of 0.05% Oxymet in each nostril twice daily or placebo for 4 weeks. All patients received 2 sprays of budesonide (100 µg/spray) in each nostril twice daily and 10 mg cetirizine once daily from entry throughout the study. Nasal symptom scores, nasal peak inspiratory flow (NPIF) and Rhinoconjunctivitis Quality of Life (Rcq) scores were measured. RESULTS: Oxymet significantly reduced nasal congestion in subjects with chronic rhinitis compared with placebo on the day of 15-28 and 29-42. In subjects with allergic rhinitis, nasal congestion scores in the Oxymet group were significantly reduced compared with those in the placebo group on days 4-7, days 8-14, days 15-28 and days 29-42. In the Oxymet group, post hoc analysis showed that subjects with allergic rhinitis significantly improved their nasal congestion scores compared to non-allergic individuals (N, allergic/non-allergic = 18/7, p < 0.05). The combination of INS and Oxymet was not associated with rhinitis medicamentosa. CONCLUSIONS: The combination of INS and Oxymet provides additional benefit compared to INS monotherapy in relieving nasal congestion in subjects with chronic rhinitis and allergic rhinitis without developing rhinitis medicamentosa.

The Effect of English Language on Multiple Choice Question Scores of Thai Medical Students.

BACKGROUND: Universities in Thailand are preparing for Thailand's integration into the ASEAN Economic Community (AEC) by increasing the number of tests in English language. English language is not the native language of Thailand Differences in English language proficiency may affect scores among test-takers, even when subject knowledge among test-takers is comparable and may falsely represent the knowledge level of the test-taker. OBJECTIVE: To study the impact of English language multiple choice test questions on test scores of medical students. MATERIAL AND METHOD: The final examination of fourth-year medical students completing internal medicine rotation contains 120 multiple choice questions (MCQ). The languages used on the test are Thai and English at a ratio of 3:1. Individual scores of tests taken in both languages were collected and the effect of English language on MCQ was analyzed Individual MCQ scores were then compared with individual student English language proficiency and student grade point average (GPA). RESULTS: Two hundred ninety five fourth-year medical students were enrolled. The mean percentage of MCQ scores in Thai and English were significantly different (65.0 ± 8.4 and 56.5 ± 12.4, respectively, p < 0.001). The correlation between MCQ scores in Thai and English was fair (Spearman's correlation coefficient = 0.41, p < 0.001). Of 295 students, only 73 (24.7%) students scored higher when being tested in English than in Thai language. Students were classified into six grade categories (A, B+, B, C+, C, and D+), which cumulatively measured total internal medicine rotation performance score plus final examination score. MCQ scores from Thai language examination were more closely correlated with total course grades than were the scores from English language examination (Spearman's correlation coefficient = 0.73 (p < 0.001) and 0.53 (p < 0.001), respectively). The gap difference between MCQ scores in both languages was higher in borderline students than in the excellent student group (11.2 ± 11.2 and 7.1 ± 8.2, respectively, p < 0.001). Overall, average student English proficiency score was very high, at 3.71 ± 0.35 from a total of 4.00. Mean student GPA was 3.40 ± 0.33 from a possible 4.00. English language MCQ examination scores were more highly associated with GPA than with English language proficiency. CONCLUSION: The use of English language multiple choice question test may decrease scores of the fourth-year internal medicine post-rotation final examination, especially those of borderline students.

Efficacy and Safety of Biologics for Oral Corticosteroid-Dependent Asthma: A Systematic Review and Network Meta-Analysis.

BACKGROUND: A maintenance oral corticosteroid (OCS) in addition to high-dose inhaled corticosteroids plus long-acting ß2-agonists in patients with severe asthma leads to long-term adverse events. Oral corticosteroid-sparing agents are of high priority. OBJECTIVE: This network meta-analysis assessed biologics' comparative efficacy and safety in OCS-dependent patients with asthma. METHODS: We performed a systematic search through PubMed, Scopus, Embase, the Cochrane Center of Controlled Trials, and Google Scholar for randomized controlled trials that addressed the efficacy and safety of biologics compared with placebo in OCS-dependent patients with asthma from inception to July 2023. The primary outcome was an overall reduction in the OCS dose while asthma control was maintained. RESULTS: We included seven randomized controlled trials involving 1,052 OCS-dependent patients with asthma. Compared with placebo, benralizumab every 8 weeks, benralizumab every 4 weeks, dupilumab, and mepolizumab were efficacious in achieving a reduction in the OCS dose with low to moderate confidence (odds ratio [95% CI]: 4.12 [2.22-7.64]; 4.09 [2.22-7.55]; 3.25 [1.90-5.55]; and 2.39 [1.25-4.57], respectively) whereas tralokinumab, tezepelumab, and subcutaneous reslizumab were ineffective. An indirect comparison found no significant differences among benralizumab, dupilumab, and mepolizumab. Efficacy in reducing exacerbations was consistent with the primary analysis. High baseline blood eosinophil counts benefit from anti-IL-5 therapies, whereas high FeNO levels favor dupilumab regardless of blood eosinophil counts. Adverse events between biologics and placebo were comparable, except for eosinophilia with dupilumab. CONCLUSIONS: In OCS-dependent patients with asthma, benralizumab, dupilumab, and mepolizumab were superior to placebo in reducing the OCS dose. Evaluating baseline biomarkers helps in choosing the proper biologics to maximize treatment effects.

HLA variants and their association with IgE-Mediated banana allergy: A cross-sectional study.

Background: Banana allergy is on the rise in tropical regions. Advances in genomics and candidate gene identification have increased interest in genetic factors in food allergies. However, the genetic basis of IgE-mediated banana allergy is underexplored. Objective: To characterize HLA variants and their association with IgE-mediated banana allergy. Methods: This cross-sectional study recruited banana-allergic adults, confirmed by allergology tests, with non-allergic individuals as controls. Genomic DNA extraction and sequencing BAM files for HLA typing were conducted. Allele frequency was calculated using the direct counting method, and odds ratio (OR) with 95 % confidence interval (CI) were determined. Fisher's exact or chi-square tests were used to assess associations with Bonferroni's correction for multiple tests. The allele frequency of the Thai population from The Allele Frequency Net Database was used to compute the allele enrichment ratio (ER). Results: A total of 59 cases and 64 controls were recruited. HLA genotyping indicated potential associations of HLA-B*15:25 (OR 11.872; p-value 0.027), HLA-C*04:03 (OR 7.636; p-value 0.033), and HLA-DQB1*06:09 (OR 11.558; p-value 0.039) with banana allergy. However, after Bonferroni correction, none of these associations reached statistical significance. Comparing allele frequency with the general population from The Allele Frequency Net Database, our ER analysis revealed a higher prevalence in the banana allergy group for B*15:25 (ER 1.849), C*04:03 (ER 1.332), and DQB1*06:09 (ER 6.602) alleles. Conclusions: This study provides initial genetic insights into banana allergy, suggesting potential links with specific HLA alleles. Despite 12 initially identifying alleles, none were statistically significant after multiple testing correction. Larger studies are needed to detect possible significant correlations.

Adverse reactions to iodinated contrast media: prevalence, risk factors and outcome-the results of a 3-year period.

BACKGROUND: Iodinated contrast media (CM) are commonly used. Hypersensitivity reactions to CM occasionally result in morbidity. Risk factors and the role of premedication remain to be investigated. OBJECTIVE: We sought to explore the prevalence, risk factors and outcome of CM reactions. METHODS: The retrospective case-control study was conducted between 2008 and 2010. In total, 55,286 subjects who were exposed to iodinated CM were enrolled to determine the prevalence of CM reactions. The case-control statistical method was applied to determine the risk factors of CM reactions. 579 subjects who had CM reactions were categorised in the case group and 1,175 of the 55,286 subjects who had tolerated CM exposure were randomised for the control group. RESULTS: The overall prevalence of CM reactions was 1.05%. In a multivariate analysis, the history of previous CM reactions, female gender and the history of seafood allergy were significant risk factors for CM reactions. The significant risk factors for the first episode of CM reactions were female gender, the history of seafood allergy and asthma. We found sixteen serious reactions in the immediate reaction group: ten fully recovered after hospitalisation, five fully recovered after out-patient treatment and one died after the administration of CM via an intra-arterial route during coronary angiogram. The most significant risk factor associated with serious reactions was asthma, whereas comorbid cardiovascular disease, male gender, history of seafood allergy and history of previous CM reactions were significant risk factors for mild reactions. CONCLUSIONS: The prevalence of CM adverse reactions was as low as 1.05%. Risk factors consist of a history of previous CM reactions, female gender and seafood allergy. Nevertheless, serious immediate reactions could occur particularly in patients with asthma.