Risk factors associated with preterm delivery after fetoscopic laser ablation for twin-twin transfusion syndrome

OBJECTIVE

Despite improved perinatal survival following fetoscopic laser ablation (FLA) for twin-twin transfusion syndrome (TTTS), prematurity remains an important contributor to perinatal mortality and morbidity. The objective of the study was to identify risk factors for complicated preterm delivery after FLA.

METHODS

Retrospective cohort study of prospectively collected data on maternal/fetal demographics and pre-operative, operative and postoperative variables of 459 patients treated with FLA in three USA fetal centers. Multivariate linear regression was performed to identify significant risk factors associated with preterm delivery, which were cross-validated using the k-fold method. Multivariate logistic regression was performed to identify risk factors for early compared with late preterm delivery based on median gestational age at delivery of 32 weeks.

RESULTS

There were significant differences in case selection and outcomes between the centers. After controlling for the center of surgery, multivariate analysis indicated that a lower maternal age at procedure, a history of previous prematurity, shortened cervical length, use of amnioinfusion, a cannula diameter of 12 French (Fr), lack of a collagen plug placement and iatrogenic preterm premature rupture of membranes (iPPROM) were significantly associated with a lower gestational age at delivery.

CONCLUSIONS

Specific fetal/maternal and operative variables are associated with preterm delivery after FLA for the treatment of TTTS. Further studies to modify some of these variables may decrease the perinatal morbidity after laser therapy.

Identifying sickle cell disease cases using administrative claims

OBJECTIVE

To develop and test the accuracy of administrative claims method for identifying children with sickle cell disease (SCD) to enable quality of care assessments among children enrolled in Medicaid.

METHODS

All administrative claims with an SCD diagnosis were obtained from Michigan Medicaid from 2008 to 2011 for children ≤18 years, representing 1828 individuals. All Medicaid claims were obtained for these children and classified into categories on the basis of SCD care; these classifications were used to develop 37 alternative case definitions for identifying children with SCD. Children with ≥1 SCD claim in 2010 or 2011 were identified as confirmed SCD or not SCD using the gold standard of Michigan newborn screening administrative records. Measures of performance were calculated for each case definition for eligible children in 2010. Further validation of the case definitions was performed among eligible children in 2011.

RESULTS

In 2010, a total of 938 children met eligibility criteria and were linked to newborn screening records; 605 (59%) were confirmed SCD, and 333 (32%) were not SCD. Measures of performance varied among the 37 case definitions, and the 4 best case definitions on the basis of the sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve were validated among 924 children meeting eligibility criteria in 2011. The case definition of at least 3 SCD claims in any position identified children with SCD with the most accuracy, with an area under the ROC curve of 0.91 (95% confidence interval 0.89, 0.93).

CONCLUSIONS

This definition can be used to facilitate a more accurate identification of children with SCD in future studies. Further investigation is necessary to determine whether this method translates to other populations besides Michigan Medicaid-insured children.

Neurocysticercosis: relationship between the developmental stage of metacestode present and the titre of specific IgG in the cerebrospinal fluid

In double-blind, immunological assays, samples of cerebrospinal fluid (CSF) from 141 patients with neurocysticercosis (NCC) or other neurological disorders were tested for IgG reacting with the excretory/secretory (E/S) antigens of Taenia solium metacestodes. The results for the cases of NCC were then correlated with the developmental stage of the metacestodes present in each case, as assessed by computerized tomography and magnetic-resonance imaging. In the ELISA first used, the samples of CSF from most (88%) of the patients with the vesicular stage of NCC (some of whom also had the degenerate and/or calcified metacestodes) were found to contain the specific IgG. In electro-immunotransfer blot (EITB) assays, three of the E/S antigens, of 95, 49 and 29 kDA, were recognized by 86%-100% of the ELISA-positive CSF. When these three antigens were isolated and tested, as a pool, against all the CSF samples in double-blind ELISA, almost all (96.6%) of the CSF samples from patients with metacestodes at the vesicular stage were recognized. In the detection of individuals with vesicular metacestodes, the assay based on the three isolated antigens was significantly more sensitive than that based on the crude extract of E/S antigens (P < 0.05). In EITB assays based on the three antigens, the isolated proteins were again recognized by IgG in the CSF samples from those with vesicular metacestodes, but without the background 'noise' seen with the crude extract. In every assay employed, none of the CSF samples from NCC cases who only harboured degenerative and/or calcified metacestodes and none of those from patients who had other neurological disorders gave a positive result. The use in ELISA and EITB of antigens purified from crude extracts of metacestode E/S proteins could improve the immunodiagnosis of the vesicular stage of NCC, and allow better evaluation of NCC cases both pre- and post-treatment.

The early response to a novel coronavirus in the Middle East

The detection of a novel coronavirus in patients from the Arabian Peninsula in late 2012 raised serious concerns of a possible international outbreak. Ministries of health of the three affected countries invited missions from the World Health Organization to participate in a review of data and capacity to detect and respond to further cases. Recommendations were made for investigations to answer critical questions about human-to-human transmission and the geographic extent of the virus. Additional recommendations were made to improve surveillance capacity by acquiring the capacity to test for the virus and enhance syndromic surveillance. Available evidence continues to suggest an unknown animal reservoir for the virus with sporadic zoonotic transmission the primary epidemiological pattern of transmission. Human-to-human transmission, while it can occur, does not appear to be sustained in the community.

Abstract P5-18-15: Molecular effects of lapatinib in HER2 positive ductal carcinoma in situ (DCIS)

Background: HER2 amplification is frequent in DCIS and is associated with poor prognosis features. This study aimed to determine the molecular effects in Ras/Raf/MAK and PI3K/AKT signaling pathway of the HER2 inhibitor lapatinib in patients with HER2 positive DCIS as well as correlation with radiological and pathological response.

Patients and Methods: Patients (pts) with HER2 positive DCIS received 1500 mg daily of lapatinib for 4 consecutive weeks prior to surgical resection. Changes in tumor volume were evaluated by MRI. The molecular effects of lapatinib on apoptotic level (TUNEL), cell proliferation (Ki67) and HER2 signaling pathway were determined in pre and post-treatment tumor biopsies.

Results: A total of 20 pts were included. Lapatinib was well tolerated with only minor and transient side effects reported. The agent effectively modulated HER2 signaling by affecting cell cycle kinetics through decreasing cytoplasm pERK1 in 11 pts with no change or slight increase activation in 5 pts. Of those 11 pts: eight had parallel inactivation of pHER2, two pts had paradoxical activation of pAkt and three pts had an increase in apoptotic level. In addition, seven pts also presented with decrease in MRI signal intensity and tumor size.

Conclusions: Four weeks of lapatinib for patients with HER2-positive DCIS result in significant antiproliferative changes through RAS/MAPK signaling pathway together with a decrease in MRI signal.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-18-15.

(1)H NMR based profiling of spent culture media cannot predict success of implantation for day 3 human embryos

BACKGROUND

Identification of a non-invasive technique to assess embryo implantation potential in assisted reproduction would greatly increase success rates and lead more efficiently to single embryo transfer. Early studies suggested metabonomic analysis of spent culture media could improve embryo selection. The goal of this study is to assess if embryo implantation can be predicted based on proton nuclear magnetic resonance ((1)H NMR) profiles of spent embryo culture media from patients undergoing transfer of multiple embryos on cycle day 3.

METHOD

We conducted a retrospective study in an academic assisted reproduction technology (ART) program and analyzed the data in a university research center. Two hundred twenty-eight spent culture media samples originating from 108 patients were individually analyzed. Specifically, five distinct sets (1 to 5) of different types of spent media samples (volume ~14 μL) from embryos that resulted in clinical pregnancy (positive heart rate at 6 weeks gestation) (n (1) = 29; n (2) = 19; n (3) = 9; n (4) = 12; n (5) = 33; n (total) = 102) and from embryos that did not implant (n (1) = 28; n (2) = 29; n (3) = 18; n (4) = 15; n (5) = 36; n (total) = 126) were collected on day 3 of embryo growth. The media samples were profiled using (1)H NMR spectroscopy, and the NMR profiles of sets 1 to 5 were subject to standard uni- and multi-variate data analyses in order to evaluate potential correlation of profiles with implantation success.

RESULTS

For set 1 of the media samples, a borderline class separation of NMR profiles was obtained by use of principal component analysis (PCA) and logistic regression. This tentative class separation could not be repeated and validated in any of the other media sets 2 to 5.

CONCLUSIONS

Despite the rigorous technical approach, (1)H NMR based profiling of spent culture media cannot predict success of implantation for day 3 human embryos.

Allergic rhinitis and associated factors in schoolchildren from Bogota, Colombia

BACKGROUND

Allergic rhinitis is one of the most frequent chronic diseases among children. The objective of the study was to assess the prevalence of and the factors associated with self-reported allergic rhinitis symptoms in schoolchildren from Bogota, Colombia.

METHODOLOGY/PRINCIPAL

We followed the International Study of Asthma and Allergies in Childhood (ISAAC) methodology. Our sample included 3,256 children aged 6 - 7 and 3,830 adolescents aged 13 - 14 years.

RESULTS

The prevalence of self-reported allergic rhinitis symptoms was 30.8% among children and 36.6% among adolescents. Factors associated with self-reported allergic rhinitis among children included current asthma and atopic dermatitis symptoms; use of acetaminophen in the first year of life and in the last 12 months; antibiotic use in the first year of life; high- school and university maternal education; smokers at home; and caesarean delivery. Among adolescents, associated factors included current asthma and atopic dermatitis symptoms; current acetaminophen use once per month; frequent fast-food consumption; cat exposure at home; and smoking.

CONCLUSION

Further exploration of factors associated with allergic rhinitis symptoms is needed.

Cadherin switch from E- to N-cadherin in melanoma progression is regulated by the PI3K/PTEN pathway through Twist and Snail

BACKGROUND

Transition of normal melanocytic cells to malignant melanoma has characteristic features of epithelial to mesenchymal transition. This includes the disruption of the adherens junctions caused by the downregulation of E-cadherin and the upregulation of N-cadherin. The cadherins have functional importance in normal skin homeostasis and melanoma development; however, the exact mechanism(s) that regulate the 'cadherin switch' are unclear.

OBJECTIVES

To determine the mechanistic role of the PI3K/PTEN pathway in regulating the change in cadherin phenotype during melanoma progression.

METHODS

Using a panel of cell lines representative of the phases of melanoma progression, we determined cellular expressions of the components of the PI3K/PTEN pathway, E- and N-cadherin, and the transcriptional regulators Twist, Snail and Slug with Western blot and immunofluorescence analysis. Transcriptional regulation of E-cadherin, N-cadherin, Twist and Snail by the PI3K/PTEN pathway was confirmed using quantitative reverse transcription-polymerase chain reaction.

RESULTS

Loss or inactivity of PTEN correlated with the switch in cadherin phenotype during melanoma progression. PTEN-null or inactive cells exhibited high levels of phosphorylated protein kinase B (PKB)/AKT (Serine 473) (PKB-Ser473-P), undetectable levels of E-cadherin and high levels of N-cadherin. Re-introduction of PTEN or treatment with the PI3K inhibitor Wortmannin resulted in the re-expression of E-cadherin and downregulation of N-cadherin. This cadherin switch was regulated at the transcriptional level by Twist and Snail which were, in turn, transcriptionally regulated by the PI3K pathway. Although E-cadherin was re-expressed, it failed to localize to the plasma membrane.

CONCLUSIONS

The PI3K/PTEN pathway transcriptionally regulates the 'cadherin switch' via transcriptional regulation of Twist and Snail but does not regulate the localization of E-cadherin to the plasma membrane.

Influence of changes in protein binding on the central activity of antidepressants

The central effect (expressed as analgesic response), protein binding and brain uptake of mianserin were measured in mice receiving drug intraperitoneally. A significant decrease of the central effect of mianserin (30 mg kg−1) was seen in mice with experimental inflammation when compared with control animals (reaction time (s)= 12·12 ± 1·22 vs 25·56 ± 2·92; P &lt; 0·001) and the dose-analgesia response curve (10−60 mg kg−1) was significantly shifted to the right in mice with inflammation. In serum of mice with inflammation, unbound concentration of mianserin was decreased from 19·37 ± 0·73 to 17·83 ± 0·30% (P &lt; 0·05) and seromucoid levels were significantly increased (P &lt; 0·001). Following the intraperitoneal administration of 30 mg kg−1 of mianserin, brain uptake decreased in diseased mice when compared with control animals (P &lt; 0·02), suggesting that the decrease in analgesia was secondary to a decrease in drug delivery to the brain because of increased protein binding.

Diagnosis of early stage ovarian cancer by 1H NMR metabonomics of serum explored by use of a microflow NMR probe

We show that (1)H NMR based metabonomicsof serum allows the diagnosis of early stage I/II epithelial ovarian cancer (EOC) required for successful treatment. Because patient specimens are highly precious, we conducted an exploratory study using a microflow probe requiring only 20 μL of serum. By use of logistic regression on principal components (PCs) of the NMR profiles, we built a 4-variable model for early stage EOC prediction (training set: 69 EOC specimens, 84 healthy controls; test set: 40 EOC, 44 controls) with operating characteristics estimated for the test set at 80% specificity [95% confidence interval (CI): 65-90%], 63% sensitivity (95% CI: 46-77%), and an area under the Receiver Operator Characteristic Curve (AUC) of 0.796. Independent validation (50 EOC, 50 controls) of the model yielded 95% specificity (95% CI: 86-99.5%), 68% sensitivity (95% CI: 53-80%) and an AUC of 0.949. A test on cancer type specificity showed that women diseased with renal cell carcinoma were not incorrectly diagnosed with EOC, indicating that metabonomics bears significant potential for cancer type-specific diagnosis. Our model can potentially be applied for women at high risk for EOC, and our study promises to contribute to developing a screening protocol for the general population.

Abstract P3-02-11: First Analysis of the Value of Circulating Epithelial Tumor Cells and Circulating Endothelial Cells (CTCs/CECs) in Patients with HER-2 Negative Recurrent or Metastatic Breast Cancer Treated with Bevacizumab in Combination with Paclitaxel and Gemcitabine as First Line Therapy (AVALUZ Trial)

Background: Circulating epithelial tumor cells (CTCs) in peripheral blood are an ideal source for the detection of disseminated tumor cells of an easy sampling procedure. Their prognosis significance has been demonstrated in metastasic breast carcinoma and have potencial to influence the clinical management for pts. with breast cancer (Cristofanilli, NEJM 2004). The antiangiogenic agent bevacizumab (Bev.), in combination with CT, improves progression free survival (PFS) of first line treatments, may modify tumor cell intravasation and CTC count, and may change CEC levels. Aims of this study are the evaluation of the prevalence and kinetics of CTCs and CECs before and after antiangiogenic treatment with Bev in pts with metastatic breast cancer.

Methods: Eligible pts. received Bev (10mg/kg q2w) combined with paclitaxel 150 mg/m2 and gemcitabine 2000mg/m2 d 1 y 15 q28d as first line therapy, until disease progression, unacceptable toxicity or withdrawal. For pts. participating in the sub-study, CTC and CEC were measured in 7.5ml of blood at baseline and after the first cycle of treatment. Samples were subjected to imnumomagnetic enrichment with an anti-EpCAM antibody and fluorescence labelled. CTCs were defined as nucleated cells (DAPI+) expressing cytokeratin 8, 18 and 19 but CD45 negative phenotype. CECs were defined as nuclear cells (DAPI+) expressing CD105 PE and CD45 negative phenotype. A sample was considered positive when 1 or more cells were detected.

Results: Data are available for 37 pts. We found ≥1 CTCs before first cycle of treatment with bev in 73% of the patients (N=27). After first treatment, reduction of CTCs was found in 57% of the patients (N=16). The median number of CTCs was 34 cells/7.5 ml (min 0-max 845) of blood in the first determination and 4.79 cells/7.5 ml (min 0-max 99) in the second determination, p=0.0075. In 38% of the pts (N=14) we found ≥5 baseline CTCs and after treatment &lt;5 CTCs were found in 89% of the pts (N=25). In 70% of pts with baseline ≥5 CTCs count, a reduction to &lt; 5CTCs was observed in the second determination (N=10), p=0.20 (IC 34.15-93.33). In 10 pts we found CTCs=0 baseline value (35%) and in the second determination after treatment CTCs=0 cells/7.5 ml was observed in 53%, p=0.058. Baseline CECs ≥1 was observed in 100% of the pts (N=31). After first cycle of treatment with bev plus CT CECs=0 was found in 1 patient (3.4%). In 70% of pts (N=14) there was a reduction of baseline CECs count, p=0.3. The median value of baseline CECs was 123 cells/7.5 ml (min 4- max 1407) and the median value in second determination was 54 cells/7.5 ml (min 0-max 349). The median of reduction of CECs after treatment was 70 CECs, p=0.02.

Conclusions: The addiction of bev to 1st line CT was related with high reduction of the value of baseline CTCs and CECs count, statistically significant correlation. Reduction to &lt; 5 CTCs of patients with baseline ≥5 CTCs (unfavourable prognosis) was observed in 70% of patients. The results of this explorative study are preliminary and a large number of pts and follow-up is required.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-02-11.

The transient receptor potential channel antagonist SKF96365 is a potent blocker of low-voltage-activated T-type calcium channels

BACKGROUND AND PURPOSE

SKF96365 (SKF), originally identified as a blocker of receptor-mediated calcium entry, is widely used diagnostically, as a blocker of transient receptor potential canonical type (TRPC) channels. While SKF has been used as a tool to define the functional roles of TRPC channels in various cell and tissue types, there are notable overlapping physiological and pathophysiological associations between TRPC channels and low-voltage-activated (LVA) T-type calcium channels. The activity of SKF against T-type Ca channels has not been previously explored, and here we systematically investigated the effects of SKF on recombinant and native voltage-gated Ca channel-mediated currents.

EXPERIMENTAL APPROACH

Effects of SKF on recombinant Ca channels were studied under whole-cell patch clamp conditions after expression in HEK293 cells. The effect of SKF on cerebellar Purkinje cells (PCs) expressing native T-type Ca channels was also assessed.

KEY RESULTS

SKF blocked recombinant Ca channels, representative of each of the three main molecular genetic classes (Ca(V)1, Ca(V)2 and Ca(V)3) at concentrations typically utilized to assay TRPC function (10 microM). Particularly, human Ca(V)3.1 T-type Ca channels were more potently inhibited by SKF (IC(50) approximately 560 nM) in our experiments than previously reported for similarly expressed TRPC channels. SKF also inhibited native Ca(V)3.1 T-type currents in a rat cerebellar PC slice preparation.

CONCLUSIONS AND IMPLICATIONS

SKF was a potent blocker of LVA T-type Ca channels. We suggest caution in the interpretation of results using SKF alone as a diagnostic agent for TRPC activity in native tissues.

Adipose differentiation-related protein regulates lipids and insulin in pancreatic islets

The excess accumulation of lipids in islets is thought to contribute to the development of diabetes in obesity by impairing beta-cell function. However, lipids also serve a nutrient function in islets, and fatty acids acutely increase insulin secretion. A better understanding of lipid metabolism in islets will shed light on complex effects of lipids on beta-cells. Adipose differentiation-related protein (ADFP) is localized on the surface of lipid droplets in a wide range of cells and plays an important role in intracellular lipid metabolism. We found that ADFP was highly expressed in murine beta-cells. Moreover, islet ADFP was increased in mice on a high-fat diet (3.5-fold of control) and after fasting (2.5-fold of control), revealing dynamic changes in ADFP in response to metabolic cues. ADFP expression was also increased by addition of fatty acids in human islets. The downregulation of ADFP in MIN6 cells by antisense oligonucleotide (ASO) suppressed the accumulation of triglycerides upon fatty acid loading (56% of control) along with a reduction in the mRNA levels of lipogenic genes such as diacylglycerol O-acyltransferase-2 and fatty acid synthase. Fatty acid uptake, oxidation, and lipolysis were also reduced by downregulation of ADFP. Moreover, the reduction of ADFP impaired the ability of palmitate to increase insulin secretion. These findings demonstrate that ADFP is important in regulation of lipid metabolism and insulin secretion in beta-cells.

The development of generalized imitation within topographically determined boundaries

A multiple baseline technique was employed to examine the experimental development of an imitative repertoire within preselected topographical boundaries. Four severely retarded children, initially nonimitative, were individually trained to imitate a number of motor and vocal responses by shaping and fading procedures. Other untrained responses (probes) were demonstrated to the subjects systematically throughout the ongoing training. Training responses were divided into three topographical types: small motor, large motor, and short vocal responses. Probe responses were divided into four topographical types: small motor, large motor, short vocal, and long vocal responses. Following a multiple baseline format, sequential training of the first three types was begun at different temporal periods of the study; unreinforced imitative generalization was continually measured by the probes. Generalized imitation was observed in each subject (untrained responses were imitated even though unreinforced); but this generalization was restricted to the topographical type of imitation currently receiving training or having previously received training.

Improvement of retardates' mealtime behaviors by timeout procedures using multiple baseline techniques

Undesirable mealtime behaviors of a hospital cottage of retardates were reduced by contingent timeout procedures applied by ward personnel successively to one undesirable behavior after another, in a multiple baseline design. In some cases the timeout procedure was to remove the subject from the room until the meal was finished; in other cases (depending on the health of the child and the initial rate of the behavior to be reduced), timeout consisted of a 15-sec removal of the child's meal tray. Undesirable behaviors were defined as stealing, using fingers inappropriately, messy use of utensils, and pigging (eating directly with mouth or eating spilled food). Timeout was applied to these behaviors in that order, and in each case led to a marked and useful reduction in the behavior throughout the group. As these undesirable behaviors were reduced, more appropriate mealtime behaviors emerged: as inappropriate use of fingers declined (under contingent timeout), messy utensil behavior increased; later, as messy utensil behavior declined (under contingent timeout), a defined category of neat utensil behavior increased. Weights of the subjects were monitored steadily throughout the study and showed essentially no change.

Development of syntax in a retarded girl using procedures of imitation, reinforcement, and modelling

Three experiments demonstrated the development and generalized use of a singular and plural declarative sentence in a child initially lacking sentence form responses. In each experiment, an adult(s) served as a language model(s), and consequences (sweets) were provided for imitation of the model. During training trials, an item(s) was displayed first to the model(s) then to the subject; these displays were accompanied by requests to label the item(s). Generalization was assessed by a number of probe trials that were periodically interspersed among training trials. During these trials, the subject was requested to label the displayed item(s) without any preceding labelling response from the model. Using these procedures, generalized use of a singular sentence ("That is one-") resulted in Experiment I, and generalized use of a plural sentence ("These are two-") resulted in Experiment II. In Experiment III, two models (a singular and a plural sentence model) were made available to the subject but imitation of only one model was reinforced during any one condition. Results indicated the subject labelled probe (generalization) items with the same sentence form that was modelled and reinforced during training trials.

Omalizumab in children with inadequately controlled severe allergic (IgE-mediated) asthma

BACKGROUND

Many children with severe persistent allergic (IgE-mediated) asthma remain inadequately controlled despite treatment with high-dose inhaled corticosteroids (ICS) plus a long-acting beta(2)-agonist (LABA).

RESEARCH AND DESIGN METHODS

This pre-specified analysis of a randomized, double-blind, placebo-controlled trial evaluated the efficacy and safety of omalizumab in children (6-<12 years) with perennial allergen sensitivity, and history of asthma exacerbations and symptoms despite treatment with ICS (fluticasone >or=500 microg x day(-1) or equivalent) plus a LABA. Patients received omalizumab (75-375 mg once or twice a month by subcutaneous injection, as determined from dosing tables) or placebo over 52 weeks (24-week fixed-steroid then 28-week adjustable-steroid phases).

RESULTS

Out of 246 randomized patients (omalizumab, n = 166; placebo, n = 80), efficacy was analysed in 235 (omalizumab, n = 159; placebo, n = 76). Over the 24-week fixed-steroid phase, omalizumab reduced the rate of clinically significant asthma exacerbations (worsening symptoms requiring doubling of baseline ICS dose and/or systemic steroids) by 34% versus placebo (0.42 vs 0.63, rate ratio 0.662; P = 0.047). Over 52 weeks, the exacerbation rate was reduced by 50% (P < 0.001). Omalizumab had an acceptable safety profile, with no statistically significant (P < 0.05) differences in adverse events observed between omalizumab and placebo.

CONCLUSION

Add-on omalizumab is well-tolerated and reduces exacerbations in children (6-<12 years) with severe persistent allergic asthma, inadequately controlled despite high-dose ICS plus a LABA. It should be noted that the sample size was not based on providing statistical power in the severe subgroup, and no corrections were made for multiple comparisons; however, outcomes consistently favoured omalizumab.