Cross-sectional analysis of financial relationships between board certified allergists and the pharmaceutical industry in Japan.

BACKGROUND: Financial interactions between pharmaceutical companies and physicians lead to conflicts of interest. This study examines the extent and trends of non-research payments made by pharmaceutical companies to board-certified allergists in Japan between 2016 and 2020. METHODS: A retrospective analysis of disclosed payment data from pharmaceutical companies affiliated with the Japanese Pharmaceutical Manufacturers Association was conducted. The study focused on non-research payments for lecturing, consulting, and manuscript drafting made to board-certified allergists from 2016 to 2020. We performed descriptive analyses on payment data. Trends were analyzed using generalized estimating equation models. RESULTS: Of the 3,943 board-certified allergists, 2,398 (60.8%) received non-research payments totaling $43.4 million over five years. Lecturing fees comprised 85.7% ($37.2 million) of the total payment amounts. For allergists who received at least one payment, the median amount per allergist was $3,106 (interquartile range: $966 - $12,124), in contrast to a mean of $18,092 (standard deviation: $49,233) over the five-year span. The top 1% and 10% of these allergists accounted for 20.8% and 68.8% of all non-research payments, respectively. The annual payment amounts significantly increased by 7.2% annual increase (95% CI: 4.4 - 10.0%, p < 0.001) each year until 2019, but saw a significant decrease in 2020 amid the COVID-19 pandemic. CONCLUSION: The majority of allergists received non-research payments, with a notable concentration among a small group. Payments increased annually until the pandemic's onset, which coincided with a substantial decrease. Further research is needed to explore the implications of these financial interactions on clinical practice and patient care in Japan.

An Ethical Framework for Allergy and Immunology.

Ethical dilemmas routinely occur in the clinical practice of allergy and immunology. These ethical questions stem from the range of conditions and the different populations cared for by Allergists/Immunologists. Hence, medical ethics is not an esoteric concept, but a practical skill physicians exercise regularly. Moreover, an ethics-centered approach may improve patient safety and outcomes. This article describes key principles of bioethics and illustrates an ethical framework that physicians can use in their conversations with patients. Utilization of this ethical framework is demonstrated through applying it to 4 unique clinical scenarios encountered by Allergists/Immunologists from different practice settings. The ethical framework for allergy and immunology is a technique to navigate ethically complex decisions that arise in routine clinical practice.

Is Adrenaline Always the First Choice Therapy of Anaphylaxis? An Allergist-cardiologist Interdisciplinary Point of View.

Worldwide, adrenaline is considered the first choice therapy in the international guidelines for the management of anaphylaxis. However, the heart and cardiovascular apparatus are strongly involved in anaphylaxis; for that reason, there are some cardiac conditions and certain anaphylaxis patterns that make epinephrine use problematic without adequate heart monitoring. The onset of Kounis syndrome, takotsubo cardiopathy, or the paradoxical anaphylaxis require great attention in the management of anaphylaxis and adrenaline administration by clinicians, who should be aware of the undervalued evolution of anaphylaxis and the potential cardiologic complications of epinephrine administration. Numerous case reports and studies describe the unexpected onset of cardiac diseases following epinephrine treatment, despite the latter being the recommended therapy for anaphylaxis. Our review suggests that future anaphylaxis guidelines should incorporate cardiovascular specialists since the treatment of Kounis syndrome or takotsubo cardiopathy requires cardiologist skills.

The Long Road of Long COVID: Specific Considerations for the Allergist/Immunologist.

Long COVID (coronavirus disease 2019) syndrome, also known as post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is a new disorder that can develop after an acute infection with the SARS-CoV-2 virus. The condition is characterized by multiorgan system involvement with a wide range of symptoms that can vary in severity from mild to debilitating. Some of the common symptoms associated with long COVID syndrome include cardiovascular issues such as heart palpitations and chest pain; thrombotic events (eg, blood clotting disorders); metabolic problems (eg, type 2 diabetes); dysautonomia; paroxysmal orthostatic tachycardia syndrome; myalgic encephalomyelitis/chronic fatigue syndrome; reactivation of the Epstein-Barr virus; the presence of autoantibodies; chronic spontaneous urticaria (hives); and connective tissue diseases. Whereas long COVID syndrome can affect individuals from various backgrounds, certain populations may be at higher risk such as individuals of Hispanic and Latino heritage, as well as those with low socioeconomic status, although approximately one-third of affected patients have no known risk factors or preexisting conditions. Many survivors of COVID-19 struggle with multiple symptoms, increased disability, reduced function, and poor quality of life. Whereas vaccination has been the most significant intervention able to decrease the severity of acute SARS-Cov2 infection and curtail deaths, limited data are available related to its modulating effect on long COVID necessitating the need for further investigation. Furthermore, several inflammatory pathways have been proposed for the pathogenesis of long COVID that are the targets for ongoing clinical studies evaluating novel pharmacological agents. The purpose of the present report is to review the many factors associated with long COVID with a focus on those aspects that have relevance to the allergist-immunologist.

Quality, reliability, and popularity of YouTube videos on urticaria: a cross-sectional analysis.

BACKGROUND: Recently, YouTube has been frequently used by non-physicians and physicians to share information and experiences about diseases. This study aims to compare videos uploaded to YouTube about urticaria in terms of quality, reliability, usefulness, and popularity based on the uploaded source. METHODS: YouTube was searched using the keyword "urticaria". From the search returns, we selected the first 60 videos created by physicians and the first 60 videos created by non-physicians. We compared the two sets of videos in terms of reliability, usefulness, quality, and popularity using the Video Power Index (VPI) score, DISCERN score, global quality score (GQS) and usefulness score. RESULTS: The mean DISCERN score, GQS, and usefulness score were statistically significantly higher (P<0.001) for videos uploaded by physicians than those uploaded by non-physicians. Although not statistically significant, the median number of likes and comments, the rate of views, and the VPI scores were higher for videos uploaded by the non-physician group. The mean DISCERN scores, GQS, and usefulness scores were statistically significantly higher (P<0.001) for videos uploaded by specialist physicians (dermatologists and allergists) than for those uploaded by non-specialists. Specialist physicians mentioned medical treatment for the condition more than non-specialists, which was statistically significant (P<0.001). CONCLUSIONS: YouTube videos about urticaria uploaded by physicians, especially specialists, are of higher quality, reliable and useful, but videos uploaded by non-physicians are more popular and have higher viewing rates.

Preparing the Allergist/Immunologist for the Next Pandemic.

The COVID-19 pandemic had a profound impact on society in general and allergists' practices in particular. The adverse effects included a loss of practice productivity and income, staffing, and in-office procedures due to concerns about the spread of infection and the need for social/physical distancing as well as isolation. Allergy training programs and research activities also suffered. Federal financial assistance, rapid adoption of telehealth with Medicare waivers, and adaptation of practice sites, training programs, and research activities allowed for some return to normal, although still with significant restrictions in staffing and in-office procedures. There were positive aspects to the pandemic in the form of telehealth initiatives, pathways for rapid development and approval of tests and treatments, opportunities for new collaborations, and expertise in vaccines. Preparation for the next pandemic needs to be considered now to avoid the mistakes and missteps that occurred with the COVID-19 pandemic. On a national level, a strategy to overcome the societal divisions, misinformation/disinformation, and distrust of science needs to be developed based on better communication, as well as advocacy for continued improvement in our public health system. Practices and training programs as well as research centers need to institutionalize changes made during the pandemic so they can quickly be reinitiated when necessary.

An updated review of pediatric autoimmune neuropsychiatric disorders associated with Streptococcus/pediatric acute-onset neuropsychiatric syndrome, also known as idiopathic autoimmune encephalitis: What the allergist should know.

BACKGROUND: Pediatric acute-onset neuropsychiatric syndrome, further subcategorized as pediatric autoimmune neuropsychiatric disorders associated with streptococcus, is a form of idiopathic autoimmune encephalitis (IAE). Poststreptococcal autoimmunity seen in Idiopathic autoimmune encephalitis manifests as various neuropsychiatric symptoms such as obsessive rituals, tics, anxiety, depression, and many others. Idiopathic autoimmune encephalitis has clinically heterogeneous phenotypes that make accurate diagnosing difficult, although diagnostic testing such as the Cunningham Panel increases the likelihood of finding effective treatments. Current recommended treatments include psychiatric medication, behavioral intervention, antibiotics, anti-inflammatory therapy, and immunomodulating therapy. OBJECTIVE: To provide an updated review on the diagnosis, management, and treatment of pediatric autoimmune neuropsychiatric disorder associated with streptococcus and pediatric autoimmune neuropsychiatric syndrome, also referred to as IAE. RESULTS: Information from 47 sources was used to outline current knowledge of IAE pathophysiology, clinical manifestations, and epidemiology, and to outline diagnostic recommendations and current treatment guidelines. Gaps in knowledge, in addition to current controversy, were also outlined to provide a thorough background of this condition and future needs for IAE research. CONCLUSION: Owing to the complexity and variability in ways patients with IAE may present to the allergist/immunologist office, an interdisciplinary approach is imperative to provide patients with the best medical care. Still, more research is needed to further elucidate the mechanism(s) and optimal treatment algorithm for IAE to facilitate broader recognition and acceptance of this condition by the medical community.

New insights in the optimal diagnosis and management of food allergy.

Background: In recent years, food allergy has become a rising global epidemic, more so in Western countries. Although genetics may play a role in this increase, there are many other factors that have contributed to the upsurge. Recent research has shown that introducing allergenic foods to infants at an early age can reduce the risk of developing allergies to those foods. This is a substantial departure from traditional advice, which had recommended delaying the introduction of potential allergenic foods until a child was at least 1 year old and, in some cases, until the child was much older. Objective: The purpose of the present report is to review the epidemiology, mechanisms, and new prevention strategies for food allergies, and to discuss new treatment modalities associated with immune tolerance, which include the use of biologics as well as new forms of allergen immunotherapy (AIT) such as oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and epicutaneous immunotherapy (EPIT), which have particular relevance for the allergist/immunologist. Results: Innovative developments in the treatment of food allergies have emerged through improved comprehension of immune tolerance and the induction of regulatory T (Treg) cells, the understanding of T-helper type 2 (Th2) cell-driven responses and their associated proinflammatory cytokine production, epitope mapping techniques, and the utilization of drugs such as monoclonal antibodies that target interleukin (IL) 4, IL-5, and IL-13 to disrupt Th2 cell-related pathways. In addition, there have been significant advancements in new forms AIT methods, which include OIT, SLIT, and EPIT. Conclusion: The present report reviews several of the many aspects of food allergy that have been impacted by this new knowledge and which have led to new insights for the optimal diagnosis and management of food allergy, and has had important implications for the diagnosis, treatment, prevention, and management of these conditions. The improved understanding of Treg-related mechanisms of immune tolerance and Th2 cell-driven responses associated with the production of proinflammatory cytokines associated with these responses, together with epitope mapping techniques, have played a crucial role in enhancing the diagnosis and management of food allergies. By identifying these variables, the allergist/immunologist is better equipped to tailor new diagnostic approaches and develop targeted therapies to significantly impact the lives of individuals affected by food allergies.

The PANDAS/PANS disorders. Is it time for more allergist-immunologists to get involved?

Background: The pediatric autoimmune neurologic disorders associated with streptococcal infections (PANDAS) comprise a group of patients who, after infection with group A ß-hemolytic streptococci (GAS), exhibit a spectrum of neuropsychiatric symptoms that include obsessive thoughts, compulsive behaviors, tics, hyperactivity, inattention, and mild choreiform movements. More recently, a group of patients with a symptom complex similar to PANDAS without evidence of streptococcal etiology was given the acronym pediatric acute-onset neuropsychiatric syndrome (PANS). Despite more than several decades of study and increasing numbers of patients being identified with PANDAS and PANS, there are ongoing controversies, which range from disagreements about specific pathogenetic mechanisms to whether these entities actually exist. Objective: The purpose of this report was to examine the current body of evidence that deals with the relationship(s) of immunologic host responses to infection and putative immunologic mechanisms involved in the pathogenesis of these disorders, to evaluate the effectiveness of anti-inflammatory and immunomodulatory therapies with intravenous immunoglobulin (IVIG), and to consider the extent to which allergist/immunologists might be involved in their management. Methods: An extensive literature review was conducted in medical literature data bases by applying terms such as PANDAS, PAN, autoimmune encephalitis, neuroinflammation, and autoimmune obsessive-compulsive disorders. Results: PANDAS and its later iterative form, PANS, continue to challenge clinicians, patients, and their families. Although the precise reason why these disorders develop remains unknown, both are considered to have an autoimmune basis related to the production of antibodies directed at antigens of the putative causative infectious disease agents that are cross-reactive with antigenic epitopes on selected brain nuclei, which lead to the neuroinflammatory sequelae responsible for the neuropsychiatric symptoms of these conditions, a phenomenon referred to as molecular mimicry. Conclusion: The PANDAS/PANS disorders are a continuing burden for growing numbers of patients, health-care providers, and the global health-care systems, and are a particular challenge for the allergist/immunologist who is increasingly being called upon for their management. Because of the importance of immunologic factors in the pathogenesis and treatment of these conditions with anti-inflammatory and immune-modulating treatments, the allergist/immunologist is well poised to offer consultative care.