Treatment Difficulties in Wheat Oral Immunotherapy and the Predictive Value of Wheat-Specific IgE.

BACKGROUND: Factors associated with wheat oral immunotherapy (OIT) difficulties in patients with IgE-mediated wheat allergy have not been well studied. OBJECTIVE: We aimed to assess factors associated with difficulties in wheat OIT. METHODS: We retrospectively collected data from children under 18 years of age with history of IgE-mediated wheat allergy who underwent wheat OIT. The initial specific IgE (sIgE) of wheat and omega-5-gliadin, wheat skin prick test (SPT) sizes, eliciting doses, and adverse reactions during the OIT were evaluated. RESULTS: A total of 81 children were enrolled, with a mean age of 7.0 ± 2.7 years at the initiation of wheat OIT. The median follow-up duration was 2 years (IQR 1.2 -3.0 years). Difficulties in wheat OIT included patients who experienced frequent reactions (at least grade 2 or exercise-induced reactions) or deviated from the up-dosing protocol, which we defined as 'Complicated cases.' Twenty-six patients (32.1%) were complicated cases. Initial wheat-sIgEs were significantly higher in complicated cases than in noncomplicated cases (median of 192.3 kUA/L (IQR 30.4-590.0) vs 6.9 kUA/L (IQR 1.9-100.0) (p = 0.001)). Initial omega-5-gliadin-sIgEs in the complicated group were also significantly higher, with a median of 15.0 kUA/L (IQR 6.3-69.8) vs 1.6 kUA/L (IQR 0.2-11.4) (p < 0.001). The risk factors for complicated cases include higher omega-5-gliadin-sIgEs and anaphylaxis during the oral food challenge test (aOR 1.035 and 5.684, respectively). CONCLUSION: The initial wheat and omega-5-gliadin-sIgEs were significant risk factors for complicated OIT patients and could be used to monitor these patients carefully during the OIT period.

Feasibility of a 3-step protocol of wheat oral immunotherapy in children with severe wheat allergy.

BACKGROUND: Wheat allergy is not an uncommon event among Thai children. Despite strict avoidance, some patients developed reactions after accidental exposure to minute amount of wheat and thus disturbed their quality of life. Wheat oral immunotherapy (OIT) has been reported to be an alternative treatment for such patients. OBJECTIVE: We designed a new 3-step wheat OIT protocol for treatment of severe wheat allergy in Thai patients. The feasibility of the protocol is evaluated and is reported here in this paper. METHODS: We retrospectively reviewed medical records of 26 patients who had undergone wheat OIT during a 30-month period. The 3-step protocol consisted of an initial phase of double-blind, placebo-controlled food challenge (DBPCFC) and initiation of OIT, a build-up phase, and a maintenance phase. Patient retention in the protocol was the main outcome for this feasibility study. Adverse effects during OIT were recorded. Correlation between serum specific IgE (SpIgE) to wheat and eliciting dose in phase I was determined. RESULTS: Fourteen females and 12 males with a median age of 6 years were studied. Their median age when wheat allergy began was 8 months. Median SpIgE to wheat was high (198 kUA/L). All patients developed reactions during DBPCFC with 17 of 26 patients had moderate to severe reactions required adrenaline injections. Median of eliciting dose of wheat was exceedingly low, i.e., 20 mg of wheat protein. At the end of the study, 23 of 26 patients (88%) were still in the study. Adverse reactions during the build-up phase was frequent (13 patients, 50%), with adrenaline required in 6 occasions. Six patients reached maintenance phase. CONCLUSION: The new 3-step wheat OIT protocol was feasible in these highly wheat-sensitized patients. Despite a high retention rate, a high rate of adverse effects was observed both during DBPCFC and build-up phases.

Comparison of exhaled nitric oxide levels in pediatric patients with allergic rhinitis.

OBJECTIVE: To determine whether the measurement of exhaled nitric oxide (eNO) can help distinguish children with allergic rhinitis (AR) from healthy controls and whether eNO in children with AR correlates with disease severity. METHODS: From August 2015 to 2016, children aged 5-15 years of age grouped into those with allergic rhinitis (n = 40) and those classified as healthy control subjects (n = 40) had exhaled nitric oxide (eNO) levels measured. The eNO level was additionally compared to the patient's clinical disease severity according to the ARIA (Allergic Rhinitis and its Impact on Asthma) classification. RESULTS: Mean eNO in children with AR (12.64 ±â€¯14.67 ppb) was significantly higher than that in the healthy control group (7.00 ±â€¯6.33 ppb) (p-value = 0.046). In the persistent AR group (17.11 ±â€¯18.40 ppb), eNO level was significantly higher than individuals in the intermittent AR group (8.59 ±â€¯8.88 ppb, p-value = 0.024) and the healthy control group (7.00 ±â€¯6.33 ppb, p-value = 0.008). Among children with AR, eNo was not significantly different with relationship to gender, age, weight and passive smoking exposure. CONCLUSIONS: Exhaled nitric oxide may be elevated in children with AR that do not have concomitant asthma. This suggests exhaled nitric oxide may show utility as a parameter to monitor the severity of allergic rhinitis and to monitor the efficacy of the treatment. Physicians should consider comorbid AR when utilizing exhaled nitric oxide as a monitoring parameter in the treatment of asthma.

Inhibitory effect of Phlai capsules on skin test responses among allergic rhinitis patients: a randomized, three-way crossover study.

BACKGROUND: Zingiber cassumunar Roxb., commonly known as Phlai in Thai, has been used as a traditional medicine in Thailand for the treatment of various diseases, including inflammation and chronic airway disease. OBJECTIVE: The purpose of this study was to assess the antihistaminic effect of Phlai on skin testing. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: This was a randomized, open-label, three-way crossover study. Twenty allergic rhinitis (AR) patients were enrolled. In randomized sequence, patients received a single dose of Phlai capsules (100 or 200 mg) or loratadine (10 mg) with a washout period of 1 week between each treatment. MAIN OUTCOME MEASURES: Skin prick testing for histamine and common aeroallergen (house dust mite) were performed before treatment and after 1, 2, 3, 4, 6, 8, 12 and 24 hours of treatment. The main treatment outcomes were the mean wheal and flare responses to the skin prick test after treatment. RESULTS: Both 100 mg and 200 mg Phlai doses suppressed wheal and flare responses to house dust mite allergen, but only 200 mg of Phlai capsules significantly suppressed wheal and flare responses to histamine. Repeated measures analysis of variance showed that loratadine caused more wheal and flare suppression than Phlai capsules in responses to the histamine skin prick test. However, there were no significant differences among the effects of 100 mg Phlai capsules, 200 mg Phlai capsules and loratadine in suppression of wheal and flare induced by the mite skin prick test. Both doses of Phlai were well-tolerated with no adverse events. CONCLUSION: Both 100 mg (compound D 4 mg) and 200 mg (compound D 8 mg) Phlai capsules, when taken as a single therapeutic dose, inhibited skin reactivity to histamine and mite skin prick tests in AR patients. TRIAL REGISTRATION: Thai clinical trial registry (TCTR20160510001).

MDI with DIY Spacer versus Nebulizer for Bronchodilator Therapy in Children Admitted with Asthmatic Attack.

Background: Inhaled bronchodilator treatment given via the pressurized metered-dose inhaler (pMDI) with spacer has been recommended for an acute asthma treatment. Unfortunately, most of commercially available spacers are at high cost while a do-it-yourself (DIY) spacer has lower cost as it is made from plastic bottle and siphon pump which are inexpensive and easilyfound materials. Objective: This study aims to compare treatment response in nebulizer and DIY spacer used for asthmatic children. Material and Method: A prospective, randomized control study was conducted in children aged 1-15 years old hospitalized for mild to moderate asthmatic attack at Thammasat University Hospital between June 2014 and March 2015. The patients were divided into 2 groups, receiving ß2-agonist via nebulization and via pMDI with DIY spacer. Their vital signs and oxygen saturation were monitored and asthma scores were also recorded at admission, 24 hours, 48 hours, and before discharge. The satisfaction of equipment use was evaluated employing questionnaires. Results: 40 childrens were enrolled with male at 72.5% and mean age at 3.1±1.6 years old. There was no significant difference in efficacy of ß2-agonist among 2 groups when comparing in consideration of vital signs, oximetry, asthma scores and hospital stay. However, there were significantly different on side effect in which the DIY spacer had less tachycardia and agitation. Satisfaction of parents and healthcare workers were higher in DIY spacer. Conclusion: MDI with DIY spacer was able to be used effectively when compared with nebulization to treat mild to moderate acute exacerbations of asthma in children admitted in hospital.

Outcome analysis of jaundice fast-track system implementation in Thammasat University Hospital.

BACKGROUND: Infants who were readmitted with high level of bilirubin (more than 20 mg/dl) should be treated as an acute medical emergency to prevent acute and chronic bilirubin encephalopathy. OBJECTIVE: To determine causes of severe neonatal hyperbilirubinemia, risk factors for exchange transfusion and outcomes of neonate after implementation of the jaundice fast-track system in Thammasat hospital. MATERIAL AND METHOD: The medical records of neonates presenting with clinically significant hyperbilirubinemia to the outpatient department or emergency department after implementation of the jaundice fast-track system at Thammasat university from October 1, 2010 through september 30, 2012, were retrospectively reviewed. RESULTS: There were 76 infants included in the study. One infant had neurological abnormalities consistent with acute bilirubin encephalopathy at presentation. all infants received intensive phototherapy. Eight infants (10.5%) underwent an exchange transfusion. a cause of hyperbilirubinemia was identified in 66 cases (86%). Breastfeeding jaundice was the most common cause (47%). The mean peak MB level was higher in the exchange transfusion group than the phototherapy group (25.0 +/- 2.9 mg/dl vs. 21.2 +/- 1.8 mg/dl, p < 0.001). Three infants in the exchange transfusion group had sepsis on admission compared to none in the phototherapy group, (p < 0.001). Infant diagnosed as cephalhematoma underwent an exchange transfusion. The median (range) length of stay was significantly longer in the exchange transfusion group than the phototherapy group (9 (2-15) days vs. 2 (1-12) days, p < 0.001). There were no statistical differences between the two groups in age at readmission and time to phototherapy. All infants in this study were discharged as no neurological abnormalities. Infants presented with peak MB > or = 24 mg/dl had the greatest risk of exchange transfusion (or = 26.6; 95% ci = 4.6, 153.7). CONCLUSION: Initiating phototherapy within an hour of admission in infants who were readmitted with high levels of bilirubin is effective to prevent bilirubin encephalopathy. Physicians' early recognition of the risk factors to exchange transfusion is, therefore, crucial.