Stepwise Approach in Asthma Revisited 2023: Expert Panel Opinion of Turkish Guideline of Asthma Diagnosis and Management Group.

Introduction of inhaled corticosteroids (ICS) has been the cornerstone of the long-term management of asthma. ICSs either alone or in combination with long-acting beta-2 agonists have been shown to be associated with favorable asthma outcomes. However, asthma control is still reported to be below expectations all around the world. Research in the last decades focusing on the use of ICS/formoterol both as maintenance and as needed (maintenance and reliever therapy approach) showed improved asthma outcomes. As a result of recent developments, Turkish Asthma Guidelines group aimed to revise asthma treatment recommendations. In general, we recommend physicians to consider the risk factors for poor asthma outcomes, patients' compliance and expectations and then to determine "a personalized treatment plan." Importantly, the use of short-acting beta-2 agonists alone as a symptom reliever in asthma patients not using regular ICS is no longer recommended. In stepwise treatment approach, we primarily recommend to use ICS-based controllers and initiate ICS as soon as possible. We define 2 different treatment tracks in stepwise approaches as maintenance and reliever therapy or fixed-dose therapy and equally recommend each track depending on the patient's risks as well as decision of physicians in a personalized manner. For both tracks, a strong recommendation was made in favor of using add-on treatments before initiating phenotype-specific treatment in step 5. A strong recommendation was also made in favor of using biologic agents and/or aspirin treatment after desensitization in severe asthma when indicated.

Adverse effect of VEGFR-2 (rs1870377) polymorphism on the clinical course of COVID-19 in females and males in an age-dependent manner.

The COVID-19 pandemic has affected people worldwide with varying clinical presentations ranging from mild to severe or fatal, and studies have found that age, gender, and some comorbidities can influence the severity of the disease. It would be valuable to have genetic markers that might help predict the likely outcome of infection. For this objective, genes encoding VEGFR-2 (rs1870377), CCR5Δ32 (rs333), and TLR3 (rs5743313) were analyzed for polymorphisms in the peripheral blood of 160 COVID-19 patients before COVID-19 vaccine was available in Türkiye. We observed that possession of the VEGFR-2 rs1870377 mutant allele increased the risk of severe/moderate disease in females and subjects ≥65 years of age, but was protective in males <65 years of age. Other significant results were that the CCR5Δ32 allele was protective against severe disease in subjects ≥65 years of age, while TLR3 rs5743313 polymorphism was found to be protective against severe/moderate illness in males <65 years of age. The VEGFR-2 rs1870377 mutant allele was a risk factor for severe/moderate disease, particularly in females over the age of 65. These findings suggest that genetic polymorphisms have an age- and sex-dependent influence on the severity of COVID-19, and the VEGFR-2 rs1870377 mutant allele could be a potential predictor of disease severity.

Picturing asthma in Turkey: results from the Turkish adult asthma registry.

INTRODUCTION: National data on asthma characteristics and the factors associated with uncontrolled asthma seem to be necessary for every country. For this purpose, we developed the Turkish Adult Asthma Registry for patients with asthma aiming to take a snapshot of our patients, thereby assigning the unmet needs and niche areas of intervention. METHODS: Case entries were performed between March 2018 and March 2022. A web-based application was used to record data. Study outcomes were demographic features, disease characteristics, asthma control levels, and phenotypes. RESULTS: The registry included 2053 patients from 36 study centers in Turkey. Female subjects dominated the group (n = 1535, 74.8%). The majority of the patients had allergic (n = 1158, 65.3%) and eosinophilic (n = 1174, 57.2%) asthma. Six hundred nineteen (32.2%) of the patients had obese asthma. Severe asthma existed in 670 (32.6%) patients. Majority of cases were on step 3-5 treatment (n: 1525; 88.1%). Uncontrolled asthma was associated with low educational level, severe asthma attacks in the last year, low FEV1, existence of chronic rhinosinusitis and living in particular regions. CONCLUSION: The picture of this registry showed a dominancy of middle-aged obese women with moderate-to-severe asthma. We also determined particular strategic targets such as low educational level, severe asthma attacks, low FEV1, and chronic rhinosinusitis to decrease uncontrolled asthma in our country. Moreover, some regional strategies may also be needed as uncontrolled asthma is higher in certain regions. We believe that these data will guide authorities to reestablish national asthma programs to improve asthma service delivery.

Amoxicillin/Clavulanic Acid-Induced Symmetric Drug-Related Intertrigious and Flexural Exanthema.

ß-Lactams, particularly penicillins, may cause several allergic reactions. We described symmetric drug-related intertriginous and flexural exanthema (SDRIFE) illness in this case, a rare instance of systemic contact dermatitis caused by amoxicillin/clavulanic acid that needs to be considered in the differential diagnosis. A 65-year-old male patient was admitted to our Allergy Outpatient Clinic because of increased blue-purple pigmentation on the flexural surfaces of the hip, forearm, axilla, and posterior face of the neck. The patient was receiving a combination of angiotensin receptor blocker (ARB) and hydrochlorothiazide diuretic medication for hypertension. The patient used an antibiotic containing amoxicillin three months ago; As a result, there was localized redness, itching, and black spotting without any systemic symptoms. Similarly, the patient reported that when he used amoxicillin for an upper respiratory tract infection eight months ago, he experienced similar side effects within 20 days and recovered when he applied corticosteroid ointment. Due to the symmetrical site involvement following the consumption of penicillin group antibiotics with a five-month gap and subsequent comparable reactions in our patient, SDRIFE was taken into consideration. The results of the skin punch biopsy identified Baboon Syndrome (SDRIFE). Treatment with topical corticosteroids and antihistamines began. Clinically speaking, SDRIFE is distinguished by significant erythema of the gluteal/perianal area and/or V-shaped erythema of the inguinal/perigenital area, symmetric involvement of at least one other intertriginous or flexural area, and the absence of systemic signs or symptoms. The possibility that the medication may have contributed to the patient's erythematous eruption in the flexural regions should be taken into account, and the patient should be advised to stop taking the medication and not use it again.

Does serum leptin levels differ between patients with rhinitis of allergic versus nonallergic aetiology?

BACKGROUND: Leptin may play a critical role in airway inflammation. However, it has rarely been evaluated in rhinitis with different aetiology. This study aimed to compare the serum leptin levels between allergic rhinitis (AR) and nonallergic rhinitis (NAR). METHODS: Patients with chronic rhinitis were classified due to skin prick (ALK-Abello/Madrid) and/or serum-specific immunoglobulin E tests (UniCAP 100-Pharmacia), against to aeroallergens if concordant with symptoms. RESULTS: A total of 398 patients with a mean age of 29.03 years were recruited and grouped as AR and NAR. Mean serum leptin levels were similar in patients with NAR and AR, as well as in patients with and without asthma, but were significantly higher in females than males in both groups. Also, leptin levels were significantly higher in obese than nonobese patients in AR. In correlation analysis, leptin levels were found to be correlated with female gender, older age, and high body mass index (BMI) in the whole group. Despite the higher total nasal symptom score (TNSS) in patients with AR compared with NAR, there was no association of leptin levels with TNSS, severity and seasonality of symptoms, and allergen sensitization. In logistic regression analysis, younger age and high serum leptin levels were found to be independent predictors for the diagnosis of AR. CONCLUSIONS: We conclude that female patients with high BMI are more prone to AR probably due to immunological effects of adipose tissue, in addition to hormonal factors. This study showed that leptin measurement has limited value as a sole diagnostic tool to differentiate AR and NAR.

Erratum to "IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper" [World Allergy Organ J 13/2 (2020) 100080].

[This corrects the article DOI: 10.1016/j.waojou.2019.100080.].

IgE allergy diagnostics and other relevant tests in allergy, a World Allergy Organization position paper.

Currently, testing for immunoglobulin E (IgE) sensitization is the cornerstone of diagnostic evaluation in suspected allergic conditions. This review provides a thorough and updated critical appraisal of the most frequently used diagnostic tests, both in vivo and in vitro. It discusses skin tests, challenges, and serological and cellular in vitro tests, and provides an overview of indications, advantages and disadvantages of each in conditions such as respiratory, food, venom, drug, and occupational allergy. Skin prick testing remains the first line approach in most instances; the added value of serum specific IgE to whole allergen extracts or components, as well as the role of basophil activation tests, is evaluated. Unproven, non-validated, diagnostic tests are also discussed. Throughout the review, the reader must bear in mind the relevance of differentiating between sensitization and allergy; the latter entails not only allergic sensitization, but also clinically relevant symptoms triggered by the culprit allergen.

Comparison of azelastine versus triamcinolone nasal spray in allergic and nonallergic rhinitis.

BACKGROUND: Intranasal antihistamine has not been thoroughly studied in the treatment of rhinitis of different etiologies. This study was designed to show the comparative efficacy of nasal antihistamine and nasal corticosteroid in patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). METHODS: A comparison of the efficacy of azelastine nasal spray (AZENS) versus triamcinolone acetonide nasal spray (TANS) on total nasal symptom scores (TNSS), nasal peak inspiratory flow rate (nPIFR), and nasal cytology was studied in a 2-week randomized parallel-group trial. The Epworth Sleepiness Scale (ESS) and health-related quality of life (HRQoL) were also analyzed. RESULTS: The study group consisted of 132 patients (100 women and 32 men) with a mean age of 33.14 +/- 12.52 years. Sixty-nine patients had AR and 63 had NAR. Although TNSS including sneezing, itching, rhinorrhea, congestion-but not anosmia-significantly improved in both groups, intranasal azelastine reduced ocular symptoms greatly compared with intranasal triamcinolone (p = 0.05). Patients with NAR seemed to respond more to TANS, whereas AZENS was more useful in AR. The nPIFR improved in AR and NAR, with no significant difference between the treatment groups. Neither intranasal azelastine nor intranasal triamcinolone changed cytology in nasal lavage. Both medications were well tolerated, but AZENS led to more adverse events than TANS (56.9 and 19%, respectively; p = 0.001), mainly because of bitter taste. Scores on each domain of generic HRQoL (36-Item Short-Form Health Survey) and mini-rhinitis QoL questionnaires, as well as ESS score, significantly improved in both groups, irrespective of rhinitis etiology. CONCLUSION: In this first comparative demonstration, AZENS appears to be as effective as triamcinolone in symptom scores, nPIFR, ESS, and HRQoL, equally in AR and NAR.

An unusual form of formaldehyde-induced lung disease.

A case report of an unusual formaldehyde exposure that had happened accidentally is described. A 54-year-old male ingested 10% formaldehyde and inhaled while vomiting and he developed cough, dyspnea and wheezing with prevalent ronci and bilateral infiltrates on chest x-ray (cxr). His pulmonary symptoms and FEV1 responded well to systemic corticosteroids and nebulised salbutamol given for the possible diagnosis of hypersensitivity and/or chemical pneumonitis, and infiltrates were cleared. Two weeks after the incident, he had massive haemoptysis, fever, leucocytes, prevalent crackles, bronchospasm, and new infiltrates on CXR. After an antibiotic and steroid therapy, his symptoms and crackles relieved, radiographic infiltrates were regressed. Delayed type hypersensitivity to formaldehyde patch test was appropriate with late-onset symptoms. This is a first case of pneumonitis as well as asthma different from the occupational exposure to formaldehyde. This data suggests direct and indirect effects of formaldehyde in healthy human airways.

An unusual form of formaldehyde induced lung disease / Una forma inusual de enfermedad pulmonar inducida por formaldehido

A case report of an unusual formaldehyde exposure that had happened accidentally is described. A 54-year-old male ingested 10 % formaldehyde and inhaled while vomiting and he developed cough, dyspnea and wheezing with prevalent ronci and bilateral infiltrates on chest x-ray (cxr). His pulmonary symptoms and FEV1 responded well to systemic corticosteroids and nebulised salbutamol given for the possible diagnosis of hypersensitivity and/or chemical pneumonitis, and infiltrates were cleared. Two weeks after the incident, he had massive haemoptysis, fever, leucocytes, prevalent crackles, bronchospasm, and new infiltrates on CXR. After an antibiotic and steroid therapy, his symptoms and crackles relieved, radiographic infiltrates were regressed. Delayed type hypersensitivity to formaldehyde patch test was appropriate with late-onset symptoms. This is a first case of pneumonitis as well as asthma different from the occupational exposure to formaldehyde. This data suggests direct and indirect effects of formaldehyde in healthy human airways

Se presenta un caso inusual de exposición a formaldehído que ocurrió accidentalmente. Varón de 54 años que ingirió accidentalmente unos 200 cc de formaldehído al 10%, que también inhaló, siguiéndose de vómitos, tos, disnea, con prevalencia de roncus y la radiografía mostró infiltrados en ambos pulmones. Los síntomas pulmonares y el FEV1 respondieron bien con corticosteroides sistémicos y salbutamol nebulizado, por el posible diagnóstico de hipersensibilidad y neumonitis química. También los infiltrados pulmonares se aclararon. Dos semanas después del incidente, el paciente tuvo una hemoptisis masiva, fiebre, crepitantes, broncoespasmo y nuevos infiltrados (RX), leucocitosis. Después de ser tratado con antibióticos y corticoides, los síntomas y los infiltrados regresaron. Se comprobó la existencia de hipersensibilidad retardada mediante prueba del parche con formaldehído, lo que correlacionó con la aparición tardía de los síntomas. Este es el primer caso de neumonitis así como de asma, diferente de la exposición ocupacional a formaldehído. Estos datos sugieren los efectos directos e indirectos del formaldehído en las vías aéreas de individuos sanos

Evaluation and impact of chronic cough: comparison of specific vs generic quality-of-life questionnaires.

BACKGROUND: Chronic cough is a common condition that has a significant impact on health-related quality of life (HRQoL). OBJECTIVE: To investigate whether chronic cough is associated with adverse psychological and physical effects on quality of life (QoL) using different HRQoL questionnaires. METHODS: Forty patients were recruited for the study. The diagnostic workup was mainly based on the pathogenic triad in chronic cough: postnasal drip syndrome, asthma, and gastroesophageal reflux disease. The HRQoL was evaluated with the cough-specific quality-of-life questionnaire (CQLQ), Leicester Cough Questionnaire (LCQ), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Hospital Anxiety and Depression Scale. RESULTS: Symptom scores were significantly correlated with the CQLQ and LCQ (beta = .415 and beta = -.272, respectively) but not with the SF-36. A statistically significant difference was found in all questionnaires, except the physical component summary domain of the SF-36, after specific therapy. Correlation between the 2 specific HRQoL questionnaires was moderate to high when pretreatment and posttreatment scores were compared (r = -0.42 and r = -0.60). Concurrent validity of the LCQ was higher than the CQLQ when compared with the SF-36 domains. The effect size of each specific QoL questionnaire was 1 or higher after treatment, whereas it was much less in the SF-36. There was no change in depression with treatment despite anxiety. Posttreatment symptom scores were related with anxiety (r > 0.40) CONCLUSIONS: Because HRQoL is important to patients, a cough-specific HRQoL instrument, either the CQLQ or LCQ, should be routinely used to optimally evaluate the impact of cough on patients and to evaluate the efficacy of cough-modifying agents.

Possible association between cockroach allergy and HLA class II antigens.

BACKGROUND: Susceptibility to the development of allergic diseases is known to be associated with genetic components, as well as environmental factors. Although the genetics of immunoglobulin E, atopy, and asthma are complex, genetic markers are needed to identify populations at risk and to plan intervention studies. OBJECTIVE: Human leukocyte antigen (HLA) class II genes play a major role in the control of immune response. We investigated the association between HLA class II alleles of DRB1 and DQB1 and the expression of atopy in cockroach-sensitive patients. METHODS: Levels of total and specific immunoglobulin E were determined. Skin prick tests were performed. HLA class II typing was performed by the Polymerase chain reaction with sequence-specific primers. Distribution of the HLA genotypes of 32 cockroach-positive atopic patients from the inner city were compared with those of 32 healthy, nonatopic controls of Turkish Caucasian origin. RESULTS: HLA class II gene analysis showed an increase of the HLA-DRB1*0701 and HLA-DQB1*02 alleles in atopic patients compared with nonatopic controls (31.3% vs 3.1% and 50% vs 15.6%, Pc < 0.036 and Pc < 0.021, respectively). Conversely, HLA-DRB1*15 allele was encountered more frequently in the control subjects. An association between cockroach sensitivity and cutaneous reactivity to other aeroallergens was observed (P < 0.001). CONCLUSIONS: It is suggested that the higher frequencies of HLA-DRB1*0701 and HLA-DQB1*02 alleles are probably related to atopy rather than an association between class II antigens and cockroach allergy in this group of polysensitized, atopic individuals. Further studies may lead to a better understanding of the genetically determined susceptibility, and evaluate the individual effects of each locus (or allele) on sensitivity to specific allergens in the Turkish population.