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Brunetto S, Gammeri L, Buta F, Gangemi S, Ricciardi L. Hymenoptera venom immunotherapy: Safety and efficacy of an accelerated induction regimen with depot aluminum adsorbed extracts. Allergy Asthma Proc 2024; 45:195-200. [PMID: 38755779 DOI: 10.2500/aap.2024.45.240011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Introduction: Hymenoptera venom immunotherapy (VIT) is the only therapy that protects patients with Hymenoptera venom allergy by preventing systemic reactions after a new sting. Various extracts for VIT are available and used. VIT administration consists of an induction phase and a maintenance phase. Depot preparations of Hymenoptera VIT extracts are typically used for cluster and conventional protocols, and the maintenance phase. Many patients with Hymenoptera allergy need to achieve tolerance quickly because of the high risk of re-sting and possible anaphylaxis. Objective: Our study aimed to show the safety and efficacy of an accelerated regimen with depot preparations on aluminum hydroxide by using relatively high starting doses in a heterogeneous group of patients. Methods: The research focused on a group of patients with a history of severe systemic reactions to Hymenoptera stings, with the necessity of swift immunization due to high occupational risks. Aluminum hydroxide depot extracts either of Vepula species or Apis mellifera extracts were used. Results: The induction protocol was started with the highest concentration of depot venom extract of 100,000 standard quality unit and was well tolerated by 19 of 20 patients. Onne patient presented with a mild systemic reaction during the accelerated induction schedule, which was promptly treated with intravenous steroids and intramuscular H1 antihistamine; when switched to a conventional induction protocol, he had a similar reaction but finally reached maintenance with an H1-antagonist premedication. Conclusion: If validated, the accelerated induction protocol by using depot aluminum adsorbed extracts with the highest concentration of venom from the beginning could offer a streamlined and accessible treatment modality for patients diagnosed with anaphylaxis from bee and wasp venoms in need of rapid desensitization.
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Bournonville L, Askri D, Arafah K, Voisin SN, Bocquet M, Bulet P. Unraveling the Bombus terrestris Hemolymph, an Indicator of the Immune Response to Microbial Infections, through Complementary Mass Spectrometry Approaches. Int J Mol Sci 2023; 24:ijms24054658. [PMID: 36902086 PMCID: PMC10003634 DOI: 10.3390/ijms24054658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023] Open
Abstract
Pollinators, including Bombus terrestris, are crucial for maintaining biodiversity in ecosystems and for agriculture. Deciphering their immune response under stress conditions is a key issue for protecting these populations. To assess this metric, we analyzed the B. terrestris hemolymph as an indicator of their immune status. Hemolymph analysis was carried out using mass spectrometry, MALDI molecular mass fingerprinting was used for its effectiveness in assessing the immune status, and high-resolution mass spectrometry was used to measure the impact of experimental bacterial infections on the "hemoproteome". By infecting with three different types of bacteria, we observed that B. terrestris reacts in a specific way to bacterial attacks. Indeed, bacteria impact survival and stimulate an immune response in infected individuals, visible through changes in the molecular composition of their hemolymph. The characterization and label-free quantification of proteins involved in specific signaling pathways in bumble bees by bottom-up proteomics revealed differences in protein expression between the non-experimentally infected and the infected bees. Our results highlight the alteration of pathways involved in immune and defense reactions, stress, and energetic metabolism. Lastly, we developed molecular signatures reflecting the health status of B. terrestris to pave the way for diagnosis/prognosis tools in response to environmental stress.
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Affiliation(s)
- Lorène Bournonville
- Platform BioPark Archamps, 218 Avenue Marie Curie ArchParc, 74160 Archamps, France
- Department of Molecular and Cellular Biology, University of Geneva, Sciences III, 30 Quai Ernest-Ansermet, 1211 Geneva, Switzerland
| | - Dalel Askri
- Platform BioPark Archamps, 218 Avenue Marie Curie ArchParc, 74160 Archamps, France
| | - Karim Arafah
- Platform BioPark Archamps, 218 Avenue Marie Curie ArchParc, 74160 Archamps, France
| | - Sébastien N. Voisin
- Platform BioPark Archamps, 218 Avenue Marie Curie ArchParc, 74160 Archamps, France
- Phylogene S.A. 62 RN113, 30620 Bernis, France
| | - Michel Bocquet
- Michel Bocquet, Apimedia, 82 Route de Proméry, Pringy, 74370 Annecy, France
| | - Philippe Bulet
- Platform BioPark Archamps, 218 Avenue Marie Curie ArchParc, 74160 Archamps, France
- Institute for Advanced Biosciences, Inserm U 1209, CNRS UMR 5309, University Grenoble Alpes, 38000 Grenoble, France
- Correspondence: ; Tel.: +33-4-50-43-25-21
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Chu DK, Freitag T, Marrin A, Walker TD, Avilla E, Freitag A, Spill P, Foster GA, Thabane L, Jordana M, Waserman S. Peanut Oral Immunotherapy With or Without H 1 and H 2 Antihistamine Premedication for Peanut Allergy (PISCES): A Placebo-Controlled Randomized Clinical Trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2386-2394. [PMID: 35643280 DOI: 10.1016/j.jaip.2022.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/02/2022] [Accepted: 05/09/2022] [Indexed: 05/15/2023]
Abstract
BACKGROUND Current forms of peanut oral immunotherapy (OIT) are associated with side effects, and there is a lack of evidence addressing how to mitigate them. OBJECTIVE To determine whether premedication with desloratadine and ranitidine results in fewer side effects during peanut OIT/desensitization. METHODS A total of 43 patients with peanut allergy (mean age, 7.6 ± 2.1 years, 37% females, 63% males, baseline eliciting dose, 33 ± 26 mg) were randomized to OIT with or without concomitant H1 and H2 antihistamine blockade, or double-placebo. Patients, study staff/investigators, and statisticians were blinded. The primary outcomes were the frequency and severity of OIT-induced adverse events. The secondary outcomes were quality of life and eliciting doses to blinded food challenge. RESULTS Adverse reactions occurred more in the OIT groups compared with the double-placebo group (OIT with antihistamines vs double-placebo hazard ratio, 3.75 [95% CI, 2.79-4.72]; OIT with placebo antihistamines vs double-placebo, hazard ratio, 4.62 [95% CI, 3.61-5.62]). Patients given antihistamines cotreatment with OIT had a similar risk of adverse events compared with those who did not use antihistamines with OIT (hazard ratio, 1.23 [95% CI, 0.49-1.97]). OIT with and without antihistamines accelerated the incidence rate of adverse events compared with double-placebo (4.8 and 6.4 events per patient vs 3.5 per patient, incidence rate ratio, 2.49 [95% CI, 1.36-4.56] and 2.04 [95% CI, 1.01-4.15], respectively). Antihistamines pretreatment modestly reduced the frequency of moderate to severe adverse reactions among OIT-treated groups (1.9 per patient vs 4.2 per patient, incidence rate ratio, 0.46 [95% CI, 0.24-0.89]), primarily urticaria (0.6 vs 2.1 per patient) followed by abdominal pain (2.6 vs 4.2 per patient), but increased neuropsychiatric adverse events (primarily tiredness and sedation, 2.3 vs 0.7 per patient). Eliciting doses after treatment were similar in all groups. Quality of life improved similarly regardless of treatment with peanut OIT or placebo OIT. CONCLUSIONS Peanut OIT with antihistamines modestly reduce the skin and gastrointestinal components of the high incidence of adverse reactions during OIT, and there are no clear differences in improvement in quality of life whether treated with OIT, OIT with antihistamines, or placebo OIT despite OIT being effective in inducing desensitization. Safer food allergy treatment approaches that importantly improve quality of life need to be proved in future robust randomized trials.
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Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada.
| | - Tosha Freitag
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrea Marrin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tina D Walker
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ernie Avilla
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andeas Freitag
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul Spill
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gary A Foster
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada; The Research Institute of St Joe's Hamilton, Hamilton, ON, Canada
| | - Manel Jordana
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Susan Waserman
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Abstract
Accelerated allergy shot schedules for inhalant and venom allergens provide individuals with allergy symptom relief but in a shorter time frame than conventional therapy. Accelerated immunotherapy (IT) protocols allow patients to reach therapeutic doses in a shorter time frame while improving adherence and reducing direct costs (e.g., fewer office visits and medications) and indirect costs (e.g., less travel time, missed work or school). Rush IT and cluster IT are believed to work through mechanisms similar to conventional subcutaneous IT (SCIT). The risk for severe systemic reactions during accelerated IT is low when appropriately administered; however, life-threatening and fatal reactions do occur. To reduce the incidence of systemic allergic reactions during cluster and rush IT protocols, premedication is recommended. It is important to exclude individuals at high risk such as those with poorly controlled asthma or those who are on β-blockers to mitigate the risk for developing systemic allergic reactions. However, accelerated SCIT regimens offer increased convenience, faster improvement in allergy symptoms, and the potential to reduce health-care costs while providing equivalent safety outcomes compared with conventional IT protocols.
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Affiliation(s)
- Justin Greiwe
- From the Bernstein Allergy Group Inc, Cincinnati, Ohio; and
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Duman Senol H, Topyildiz E, Ulusoy Severcan E, Eren Akercan S, Cigerci Gunaydin N, Gulen F, Demir E. Could Age and Oral Challenge Outcomes Identify High-Risk Patients During Cow's Milk Oral Immunotherapy? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:95-101. [PMID: 35675663 DOI: 10.1089/ped.2022.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: Severe immunglobuline E (IgE)-mediated reactions during oral immunotherapy (OIT) are major obstacles to treatment. The present study aimed to evaluate and identify clinical and laboratory biomarkers of adverse events during OIT among children with cow's milk (CM) allergy. Study Design: Eighty-six children older than 36 months who had undergone OIT with milk were enrolled. Clinical data, oral food challenge (OFC) test results, and laboratory data were recorded retrospectively. Results: The median duration of the build-up phase of OIT was 19 weeks (min 10-max 40) and the duration of the maintenance phase was 86.5 (min 1-max 132) months. A total of 11,767 CM doses were administered during the build-up phase and adverse reactions were seen in 62 (73.8%) patients with reactions registered for 157 doses among 11,767 (1/75 doses). The number of reactions during the maintenance phase was 41 (47.6%) in 24 (27.9%) patients. There was a significant reduction in the number of reactions (P = 0.000) between the build-up phase and maintenance phase. Adverse reactions and anaphylaxis were higher for patients who had cough during OFC (P = 0.003, P = 0.002, respectively) during the build-up phase and also during the maintenance phase too (P = 0.000). Evaluation for all reactions and anaphylaxis (during build-up and maintenance) with Kaplan-Meier and Cox regression analysis showed class IV-VI of CM-specific immunoglobulin E (sIgE), casein-sIgE and cough during OFC were significantly associated with increased probability of reaction and anaphylaxis. Younger age at onset of OIT was associated with risk reduction (0.017). Conclusion: Laboratory data and reactions during the OFC (especially cough) can help to identify high-risk patients during OIT.
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Affiliation(s)
- Handan Duman Senol
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Topyildiz
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ezgi Ulusoy Severcan
- Department of Pediatric Allergy, Health Sciences University Dr. Sami Ulus Gynecology, Obstetrics and Gynecology Education and Research Hospital, Ankara, Turkey
| | - Sanem Eren Akercan
- Department of Pediatric Allergy, Health Sciences University Tepecik Education and Research Hospital, Izmir, Turkey
| | - Nursen Cigerci Gunaydin
- Department of Pediatric Allergy, Namik Kemal University Faculty of Medicine, Tekirdağ, Turkey
| | - Figen Gulen
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
| | - Esen Demir
- Department of Pediatric Allergy, Ege University Faculty of Medicine, Izmir, Turkey
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Time-dependent effect of desensitization with wasp venom on selected parameters of the immune system. Sci Rep 2022; 12:7206. [PMID: 35504938 PMCID: PMC9064979 DOI: 10.1038/s41598-022-11155-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/12/2022] [Indexed: 11/08/2022] Open
Abstract
The emergence of tolerance during Hymenoptera venom immunotherapy (VIT) is a complex process. The main goal of VIT is to induce a change from proinflammatory Th2 response to the Th1 response. However, the immune mechanism of acquiring rapid tolerance during VIT has not yet been fully understood. Therefore, we have analyzed (in 4-time points: 0, 2, 6, and 24 weeks after the initiation phase of VIT) the concentration of complement C3, C4, and C5 components, lymphocyte subpopulations (flow cytometry), as well as histamine and tryptase serum concentrations of 43 patients with wasp venom allergy (III and IV Müller grade) classified to ultra-rush treatment and 18 volunteers as the control group (CG). We observed that VIT affected the immune system by inducing changes in the complement system (decreased C3 and C4 compartment protein concentrations) and "normalized" the percentage of lymphocytes and neutrophils in the peripheral blood. Moreover, a significant increase in the percentage of nTreg in the blood of patients treated with VIT was observed. On the other hand, there were no changes in histamine or tryptase concentrations in the blood. Increased percentage of nTreg cells is a well-known mechanism by which VIT affects the immune system. Finally, VIT also modulated the concentrations of the complement components, which may be a previously unknown VIT mechanism of action.
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Sturm GJ, Arzt‐Gradwohl L, Čerpes U, Koch L, Bokanovic D, Laipold K, Vollmann J, Binder B. Prospective studies are needed to elucidate the clinical impact of predominant Api m 10 sensitization. Allergy 2022; 77:687-689. [PMID: 34695255 DOI: 10.1111/all.15151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Gunter J. Sturm
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
- Allergy Outpatient Clinic Reumannplatz Vienna Austria
| | - Lisa Arzt‐Gradwohl
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - Urban Čerpes
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - Lukas Koch
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - Danijela Bokanovic
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - Karin Laipold
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | | | - Barbara Binder
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
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Wang L, Wang C, Lou H, Zhang L. Antihistamine premedication improves safety and efficacy of allergen immunotherapy. Ann Allergy Asthma Immunol 2021; 127:363-371.e1. [PMID: 34052425 DOI: 10.1016/j.anai.2021.05.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Allergen immunotherapy (AIT)-associated adverse events are a major concern for safety and efficacy of AIT. Presently, there is no consensus to whether antihistamine premedication could improve such conditions. OBJECTIVE To identify the superiority of antihistamine pretreatment in AIT. METHODS A comprehensive literature search for randomized controlled trials reporting the effects of antihistamine premedication on safety and efficacy of AIT was performed in MEDLINE, Embase, and Cochrane Library databases. Safety was evaluated according to the number of patients reporting systemic adverse reactions (SARs, the primary outcome) and efficacy according to the number of patients achieving target maintenance dose (TMD) and sustained unresponsiveness to allergen. RESULTS A total of 11 randomized controlled trials (including 609 patients) satisfied the inclusion criteria for the meta-analysis. All premedication protocols were temporary. Pooled analysis revealed that compared with control patients, significantly fewer antihistamine-pretreated patients reported total and moderate-to-severe SARs (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.23-0.56; P < .05 and OR, 0.20; 95% CI, 0.06-0.74; P < .05, respectively) and total and moderate-to-severe SAR episodes (OR, 0.42; 95% CI, 0.34-0.53; P < .05 and OR, 0.09; 95% CI, 0.01-0.50; P < .05, respectively). Similarly, antihistamine pretreatment significantly increased the number of patients achieving TMD (OR, 2.94; 95% CI, 1.72-5.03; P < .05), but not sustained unresponsiveness (OR, 1.65; 95% CI, 0.77-3.54; P = 0.2), compared with the control group. Subgroup analysis according to different allergens and dose-escalating approaches also displayed superiority of antihistamine pretreatment than control. CONCLUSION Antihistamine premedication can markedly improve safety and efficacy of AIT by reducing frequency and severity of SAR and increasing TMD.
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Affiliation(s)
- Li Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, People's Republic of China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, People's Republic of China
| | - Chengshuo Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, People's Republic of China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, People's Republic of China
| | - Hongfei Lou
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, People's Republic of China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, People's Republic of China.
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, People's Republic of China; Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, People's Republic of China; Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, People's Republic of China.
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9
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Stock R, Fischer T, Aẞmus K, Zoeller N, Ackermann H, Kaufmann R, Meissner M, Valesky E. Safety and tolerability of venom immunotherapy: Evaluation of 581 rush- and ultra-rush induction protocols (safety of rush and ultra-rush venom immunotherapy). World Allergy Organ J 2020; 14:100496. [PMID: 33376576 PMCID: PMC7750415 DOI: 10.1016/j.waojou.2020.100496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/05/2020] [Accepted: 11/20/2020] [Indexed: 12/26/2022] Open
Abstract
Background Current literature is inconsistent regarding the risk of severe side effects using accelerated induction protocols in Hymenoptera venom immunotherapy (VIT). In addition, several data indicate the influence of purity grade of venom preparation on tolerability. We evaluated the safety and tolerability of ultra-rush and rush build-up protocols using purified and non-purified venom preparations. Methods Retrospective single-center study of 581 VIT inductions (325 ultra-rush and 256 rush protocols) from 2005 to 2018 in 559 patients with bee and vespid venom allergy using aqueous purified (ALK SQ®) for ultra-rush protocol and aqueous non-purified (ALK Reless®) venom preparations for rush protocol. Results Urticaria (8% vs. 3.1%, p = 0,013) and dose reductions (4.3% vs. 1.2%, p = 0,026) were significantly more frequent in the ultra-rush group. Overall rate of moderate-to-severe side effects (anaphylaxis ≥grade 2 according to Ring and Meβmer) was low and did not differ significantly between protocols (p = 0.105). Severe events (grade 4 anaphylaxis) were not reported. Discontinuation rate was very low in both cohorts (0.6% vs 1.2%). The higher purity grade of venom preparations in the ultra-rush cohort did not improve tolerability. The bee venom group showed a non-significant trend towards higher incidence of mild reactions (urticaria), resulting in more frequent dose reductions and antiallergic therapy. Conclusion Rush and ultra-rush protocols show an excellent safety profile with only infrequent and mild anaphylactic reactions in bee and vespid venom allergy. Ultra-rush immunotherapy reduces the duration of the inpatient build-up phase setting and thus is viewed by the authors as preferred treatment in Hymenoptera venom allergic patients.
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Key Words
- BTC, basal tryptase concentration
- BV, bee venom
- Bee venom allergy
- Hymenoptera venom immunotherapy
- IgE, Immunoglobulin E
- R, rush
- Rush protocol
- UR, ultra-rush
- Ultra-rush protocol
- VIT, venom immunotherapy
- VV, vespid venom
- Vespid venom allergy
- f, female
- m, male
- ml, millilitres
- n, number of patients
- y, years
- μL, microlitres
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Affiliation(s)
- Richard Stock
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Tatjana Fischer
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Katharina Aẞmus
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Nadja Zoeller
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Hanns Ackermann
- Institute for Biostatistics, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt, Germany
| | - Roland Kaufmann
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Markus Meissner
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
| | - Eva Valesky
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University of Frankfurt, Theodor Stern Kai 7, D-60590, Frankfurt am Main, Germany
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Shaker MS, Wallace DV, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, Lang DM, Lang ES, Lieberman JA, Portnoy J, Rank MA, Stukus DR, Wang J, Riblet N, Bobrownicki AMP, Bontrager T, Dusin J, Foley J, Frederick B, Fregene E, Hellerstedt S, Hassan F, Hess K, Horner C, Huntington K, Kasireddy P, Keeler D, Kim B, Lieberman P, Lindhorst E, McEnany F, Milbank J, Murphy H, Pando O, Patel AK, Ratliff N, Rhodes R, Robertson K, Scott H, Snell A, Sullivan R, Trivedi V, Wickham A, Shaker MS, Wallace DV, Shaker MS, Wallace DV, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Golden DBK, Greenhawt M, Lieberman JA, Rank MA, Stukus DR, Wang J, Shaker MS, Wallace DV, Golden DBK, Bernstein JA, Dinakar C, Ellis A, Greenhawt M, Horner C, Khan DA, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol 2020; 145:1082-1123. [PMID: 32001253 DOI: 10.1016/j.jaci.2020.01.017] [Citation(s) in RCA: 369] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.
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Affiliation(s)
- Marcus S Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Dana V Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David B K Golden
- Division of Allergy-Clinical Immunology, Johns Hopkins University, Baltimore, Md
| | - John Oppenheimer
- Department of Internal Medicine, Pulmonary and Allergy, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School and Pulmonary and Allergy Associates, Morristown, NJ
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Chitra Dinakar
- Allergy, Asthma, and Immunodeficiency, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Anne Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, Colo
| | - David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Jay Portnoy
- Pediatric Allergy and Immunology, Children's Mercy Hospital, Kansas City School of Medicine, Kansas City, Mo
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Natalie Riblet
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | | | - Teresa Bontrager
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Jarrod Dusin
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Jennifer Foley
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Becky Frederick
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Eyitemi Fregene
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Sage Hellerstedt
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Ferdaus Hassan
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Kori Hess
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Caroline Horner
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Kelly Huntington
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Poojita Kasireddy
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - David Keeler
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Bertha Kim
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Phil Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Erin Lindhorst
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Fiona McEnany
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Jennifer Milbank
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Helen Murphy
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Oriana Pando
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Ami K Patel
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Nicole Ratliff
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Robert Rhodes
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Kim Robertson
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Hope Scott
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Audrey Snell
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Rhonda Sullivan
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Varahi Trivedi
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Azadeh Wickham
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
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11
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Abstract
Stinging insect allergy is uncommon but can be life threatening. Diagnosis requires clinical history and confirmative skin or blood testing by an allergist. Baseline serum tryptase level can be used to stratify risk. Treatment is supportive for all reactions except for anaphylaxis, which is treated with intramuscular epinephrine, recumbent posture, and adjunct measures such as IV fluids, and oxygen. Venom immunotherapy is most effective for long-term management in patients with a history of anaphylaxis. Venom immunotherapy rapidly reduces the risk of sting anaphylaxis by up to 98% and maintenance treatment can be stopped after 5 years in most cases.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, Manitoba R2A 5L9, Canada
| | - David B K Golden
- Department of Medicine, Johns Hopkins University School of Medicine, 20 Crossroads Drive Suite 16, Owings Mills, MD 21117, USA.
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12
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Abstract
Questions and controversies regarding venom immunotherapy (VIT) remain. It is important to recognize risk factors for severe sting anaphylaxis that guide the recommendation for testing, epinephrine injectors, and VIT. Premedication, rush VIT, and omalizumab are successful in overcoming recurrent systemic reactions to VIT. A maintenance dose is adequate in children, but higher doses are needed in high-risk patients. The consensus on risk of β-blockers and angiotensin-converting enzyme inhibitors in patients on VIT has shifted to the belief that risk is small. The decision to stop VIT after 5 years rests on known risk factors rather than any diagnostic tests.
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13
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Mastocytosis presenting as insect anaphylaxis: gender differences and natural history. Curr Opin Allergy Clin Immunol 2019; 19:468-474. [DOI: 10.1097/aci.0000000000000567] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Allergenspezifische Immuntherapie bei IgE-vermittelten Erkrankungen im Kindes- und Jugendalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-018-0448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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15
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Chang G, Wang L, Ma N, Zhang W, Zhang H, Dai H, Shen X. Histamine activates inflammatory response and depresses casein synthesis in mammary gland of dairy cows during SARA. BMC Vet Res 2018; 14:168. [PMID: 29792195 PMCID: PMC5966854 DOI: 10.1186/s12917-018-1491-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/10/2018] [Indexed: 11/25/2022] Open
Abstract
Background Mounting evidences observed that subacute ruminal acidosis (SARA) induced by high concentration (HC) diet increases the translocation of histamine from digestive tract into circulation causing a diverse of diseases in dairy cows. However, it is largely unknown how it does affect the function of mammary gland and milk quality. Hence, this study aims to observe the effects of histamine derived from the digestive tract on the inflammatory response and casein synthesis in the mammary glands during SARA. Twelve cows fitted rumen fistula were randomly divided into either control group administrated low concentration (LC) diet (60% forage, n = 6) or treatment group administrated HC diet (40% forage, n = 6) for 18 weeks. Results Our data showed that HC diet resulted in significant declines in rumen pH value, milk yield and milk quality, as well as longer duration of averaged pH value below 5.6 per day (more than 180 min) compared to LC diet, these findings confirmed SARA occurence. Our study also observed that SARA increased the content of histamine in rumen fluid, plasma, liver and mammary gland, and enhanced the mRNA expression of histamine specific receptor in the mammary gland. Additionally, we found that the mRNA expression of inflammatory response genes in mammary glands was increased, which was consistent with the protein expression results, showing that the protein kinase C(PKC) / nuclear factor kappa B (NF-κB) or protein kinase A (PKA) / NF-κB signalling pathways of the inflammatory response were activated. The mRNA expression of mTOR, P70S6K and αS1 in mammary glands were significantly decreased with the protein expression of mTOR, P70S6K and αS1-casein, and the phosphorylation levels of the mTOR and P70S6K proteins were also decreased. Conclusions Our study showed that the milk protein of lactating cows is depressed after long-term feeding of HC at the individual level, which was paralleled at the gene and protein levels. The inflammatory response in mammary gland caused by histamine derived from the digestive tract is related to the decline of casein synthesis. Our findings point to a new link between the inflammatory response and casein synthesis, but the understanding of the molecular mechanisms involved in this process will require further research. Electronic supplementary material The online version of this article (10.1186/s12917-018-1491-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guangjun Chang
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Lailai Wang
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Nana Ma
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Wenwen Zhang
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Huanmin Zhang
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Hongyu Dai
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China
| | - Xiangzhen Shen
- College of Veterinary Medicine, Nanjing Agricultural University, Nanjing, Jiangsu, China.
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16
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Sturm GJ, Varga EM, Roberts G, Mosbech H, Bilò MB, Akdis CA, Antolín-Amérigo D, Cichocka-Jarosz E, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Ollert M, Oude Elberink JNG, Pfaar O, Pitsios C, Pravettoni V, Ruëff F, Sin BA, Agache I, Angier E, Arasi S, Calderón MA, Fernandez-Rivas M, Halken S, Jutel M, Lau S, Pajno GB, van Ree R, Ryan D, Spranger O, van Wijk RG, Dhami S, Zaman H, Sheikh A, Muraro A. EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy 2018; 73:744-764. [PMID: 28748641 DOI: 10.1111/all.13262] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 01/27/2023]
Abstract
Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H1 -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.
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17
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Golden DBK, Demain J, Freeman T, Graft D, Tankersley M, Tracy J, Blessing-Moore J, Bernstein D, Dinakar C, Greenhawt M, Khan D, Lang D, Nicklas R, Oppenheimer J, Portnoy J, Randolph C, Schuller D, Wallace D. Stinging insect hypersensitivity: A practice parameter update 2016. Ann Allergy Asthma Immunol 2017; 118:28-54. [PMID: 28007086 DOI: 10.1016/j.anai.2016.10.031] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
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18
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Schiener M, Graessel A, Ollert M, Schmidt-Weber CB, Blank S. Allergen-specific immunotherapy of Hymenoptera venom allergy - also a matter of diagnosis. Hum Vaccin Immunother 2017; 13:2467-2481. [PMID: 28604163 PMCID: PMC5647953 DOI: 10.1080/21645515.2017.1334745] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/03/2017] [Accepted: 05/21/2017] [Indexed: 12/16/2022] Open
Abstract
Stings of hymenoptera can induce IgE-mediated hypersensitivity reactions in venom-allergic patients, ranging from local up to severe systemic reactions and even fatal anaphylaxis. Allergic patients' quality of life can be mainly improved by altering their immune response to tolerate the venoms by injecting increasing venom doses over years. This venom-specific immunotherapy is highly effective and well tolerated. However, component-resolved information about the venoms has increased in the last years. This knowledge is not only able to improve diagnostics as basis for an accurate therapy, but was additionally used to create tools which enable the analysis of therapeutic venom extracts on a molecular level. Therefore, during the last decade the detailed knowledge of the allergen composition of hymenoptera venoms has substantially improved diagnosis and therapy of venom allergy. This review focuses on state of the art diagnostic and therapeutic options as well as on novel directions trying to improve therapy.
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Affiliation(s)
- Maximilian Schiener
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Anke Graessel
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense C, Denmark
| | - Carsten B. Schmidt-Weber
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Member of the German Center of Lung Research (DZL), Munich, Germany
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19
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Boonpiyathad T, Meyer N, Moniuszko M, Sokolowska M, Eljaszewicz A, Wirz OF, Tomasiak-Lozowska MM, Bodzenta-Lukaszyk A, Ruxrungtham K, van de Veen W. High-dose bee venom exposure induces similar tolerogenic B-cell responses in allergic patients and healthy beekeepers. Allergy 2017; 72:407-415. [PMID: 27341567 DOI: 10.1111/all.12966] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The involvement of B cells in allergen tolerance induction remains largely unexplored. This study investigates the role of B cells in this process, by comparing B-cell responses in allergic patients before and during allergen immunotherapy (AIT) and naturally exposed healthy beekeepers before and during the beekeeping season. METHODS Circulating B cells were characterized by flow cytometry. Phospholipase A2 (PLA)-specific B cells were identified using dual-color staining with fluorescently labeled PLA. Expression of regulatory B-cell-associated surface markers, interleukin-10, chemokine receptors, and immunoglobulin heavy-chain isotypes, was measured. Specific and total IgG1, IgG4, IgA, and IgE from plasma as well as culture supernatants of PLA-specific cells were measured by ELISA. RESULTS Strikingly, similar responses were observed in allergic patients and beekeepers after venom exposure. Both groups showed increased frequencies of plasmablasts, PLA-specific memory B cells, and IL-10-secreting CD73- CD25+ CD71+ BR 1 cells. Phospholipase A2-specific IgG4-switched memory B cells expanded after bee venom exposure. Interestingly, PLA-specific B cells showed increased CCR5 expression after high-dose allergen exposure while CXCR4, CXCR5, CCR6, and CCR7 expression remained unaffected. CONCLUSIONS This study provides the first detailed characterization of allergen-specific B cells before and after bee venom tolerance induction. The observed B-cell responses in both venom immunotherapy-treated patients and naturally exposed beekeepers suggest a similar functional immunoregulatory role for B cells in allergen tolerance in both groups. These findings can be investigated in other AIT models to determine their potential as biomarkers of early and successful AIT responses.
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Affiliation(s)
- T. Boonpiyathad
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
- Department of Medicine; Phramongkutklao Hospital; Bangkok Thailand
- Faculty of Medicine; Chulalongkorn University; Bangkok Thailand
- Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - N. Meyer
- Department of Rheumatology, Clinical Immunology and Allergology; University Hospital; Bern Switzerland
| | - M. Moniuszko
- Department of Regenerative Medicine and Immune Regulation; Medical University of Bialystok; Bialystok Poland
- Department of Allergology and Internal Medicine; Medical University of Bialystok; Bialystok Poland
| | - M. Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
| | - A. Eljaszewicz
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
- Department of Regenerative Medicine and Immune Regulation; Medical University of Bialystok; Bialystok Poland
| | - O. F. Wirz
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
| | - M. M. Tomasiak-Lozowska
- Department of Allergology and Internal Medicine; Medical University of Bialystok; Bialystok Poland
| | - A. Bodzenta-Lukaszyk
- Department of Allergology and Internal Medicine; Medical University of Bialystok; Bialystok Poland
| | - K. Ruxrungtham
- Faculty of Medicine; Chulalongkorn University; Bangkok Thailand
| | - W. van de Veen
- Swiss Institute of Allergy and Asthma Research (SIAF); University of Zürich; Davos Switzerland
- Christine Kühne-Center for Allergy Research and Education (CK-CARE); Davos Switzerland
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20
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Kowalski ML, Ansotegui I, Aberer W, Al-Ahmad M, Akdis M, Ballmer-Weber BK, Beyer K, Blanca M, Brown S, Bunnag C, Hulett AC, Castells M, Chng HH, De Blay F, Ebisawa M, Fineman S, Golden DBK, Haahtela T, Kaliner M, Katelaris C, Lee BW, Makowska J, Muller U, Mullol J, Oppenheimer J, Park HS, Parkerson J, Passalacqua G, Pawankar R, Renz H, Rueff F, Sanchez-Borges M, Sastre J, Scadding G, Sicherer S, Tantilipikorn P, Tracy J, van Kempen V, Bohle B, Canonica GW, Caraballo L, Gomez M, Ito K, Jensen-Jarolim E, Larche M, Melioli G, Poulsen LK, Valenta R, Zuberbier T. Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement. World Allergy Organ J 2016; 9:33. [PMID: 27777642 PMCID: PMC5062928 DOI: 10.1186/s40413-016-0122-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 08/19/2016] [Indexed: 01/14/2023] Open
Abstract
One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.
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Affiliation(s)
- Marek L. Kowalski
- Department of Immunology, Rheumatology & Allergy, Medical University of Lodz, 251 Pomorska Str, 92-213 Lodz, Poland
| | - Ignacio Ansotegui
- Department of Allergy and Immunology, Hospital Quiron Bizkaia, Bilbao, Spain
| | - Werner Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Mona Al-Ahmad
- Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Mubeccel Akdis
- Swiss institute of Allergy & Asthma research, Davos, Switzerland
| | - Barbara K. Ballmer-Weber
- Allergy Unit, Dermatology Clinic, University Hospital Zürich, University Zürich, Zürich, Switzerland
| | - Kirsten Beyer
- Kirsten Beyer, Charité Universitätsmedizin Berlin, Klinik für Pädiatrie m.S. Pneumologie und Immunologie, Berlin, Germany
| | - Miguel Blanca
- Hospital Reg. Univ. Carlos Haya, Allergy Serv, Malaga, Spain
| | - Simon Brown
- Royal Perth Hospital, Department of Emergency Medicine, Perth, WA Australia
| | - Chaweewan Bunnag
- Department of Otolaryngology, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Mariana Castells
- Brigham & Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Hiok Hee Chng
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Frederic De Blay
- Hôpitaux Universitaires de Strasbourg, Chest Diseases Department, Strasbourg, France
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergology and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Stanley Fineman
- Emory University School of Medicine, Atlanta Allergy & Asthma, Atlanta, Georgia
| | | | - Tari Haahtela
- Helsinki University Central Hospital, Helsinki, Finland
| | | | | | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joanna Makowska
- CSK, Department of Allergy & Clinical Immunology, Lodz, Poland
| | | | - Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department, Hospital Clínic, Clinical & Experimental Respiratory Immunoallergy, IDIBAPS, and CIBERES, Barcelona, Spain
| | - John Oppenheimer
- UMDNJ – Rutgers Medical School, c/o Pulmonary and Allergy Associates, Summit, New Jersey, USA
| | - Hae-Sim Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, South Korea
| | | | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS San Martino Hospital IST, University of Genoa, Genoa, Italy
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Harald Renz
- Universitatsklinikum GI & MR GmbH, Institut fur Laboratoriumsmedizin & Path, Standort Marburg, Marburg, Germany
| | - Franziska Rueff
- Klinikum der Ludwig-Maximilians-Universitat, Klinik & Poliklinik fur Dermatologie & Allergologie, Munchen, Germany
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidadad, Caracas, Venezuela
| | - Joaquin Sastre
- Allergy Department, Fundacion Jimenez Diaz, Universidad Autonoma de Madrid, CIBER de Enfermedades Respiratorias (CIBERES), Institute Carlos III, Madrid, Spain
| | | | - Scott Sicherer
- Division of Allergy and Immunology, Department of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | | | | | - Vera van Kempen
- Institute for Prevention and Occupational Medicine, German Social Accident Insurance, Ruhr-University Bochum (IPA), Bochum, Germany
| | - Barbara Bohle
- Division of Experimental Allergology, Department of Pathophysiology, Allergy Research Center of Pathophysiology, Infectiology & Immunology, Medical University of Vienna, Vienna, Austria
| | - G Walter Canonica
- Allergy & Respiratory Disease Clinic, DIMI – Department Int Med, University of Genoa, IRCCS AOU, San Martino – IST, Genoa, Italy
| | - Luis Caraballo
- Immunology Department, Universidad De Cartagena, Cartagena, Colombia
| | | | - Komei Ito
- Department of Allergy, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Erika Jensen-Jarolim
- Messerli Research Institute, Medical University Vienna, University Vienna, Vienna, Austria
| | - Mark Larche
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | | | - Lars K. Poulsen
- Gentofte University Hospital, Lab for Allergology, Allergy Clinic, Hellerup, Denmark
| | | | - Torsten Zuberbier
- Campus Charite Mitte, Klinik fur Dermatologie & Allergologie, Berlin, Germany
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21
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Jutel M, Kosowska A, Smolinska S. Allergen Immunotherapy: Past, Present, and Future. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2016; 8:191-7. [PMID: 26922928 PMCID: PMC4773206 DOI: 10.4168/aair.2016.8.3.191] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/03/2015] [Indexed: 01/01/2023]
Abstract
Allergen-specific immunotherapy (AIT), although in clinical use for more than a century, is still the only causal treatment of allergic diseases. The safety and efficacy of AIT has been demonstrated in a large number of clinical trials. In addition to allergy symptom reduction AIT plays an essential role in preventing new allergies and asthma and shows long-term effects after discontinuation of treatment. Ideally, it is capable of curing allergy. However, AIT is not effective in all allergic individuals and is not equally effective in the treatment of various hypersensitivities to different allergens. For many years, the route of administration and the vaccine compositions have been evolving. Still there is a strong need for research in the field of new AIT modalities to increase its effectiveness and safety. Growing evidence on immunological effects of AIT, especially new T cell subsets involved in antigen/allergen tolerance, provides novel concepts for safer and more effective vaccination. Pharmacoeconomic studies have demonstrated a clear advantage of AIT over pharmacologic therapies.
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Affiliation(s)
- Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland.,"ALL-MED" Medical Research Institute, Wroclaw, Poland.
| | - Anna Kosowska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland.,"ALL-MED" Medical Research Institute, Wroclaw, Poland
| | - Sylwia Smolinska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland.,"ALL-MED" Medical Research Institute, Wroclaw, Poland
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22
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Nittner-Marszalska M, Liebhart J, Dor-Wojnarowska A. Sex-related clinical aspects in insect venom anaphylaxis. Int J Immunopathol Pharmacol 2015; 28:187-93. [PMID: 26078379 DOI: 10.1177/0394632015586143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/10/2015] [Indexed: 11/16/2022] Open
Abstract
Experimental studies, epidemiological data, and clinical observations suggest that the gender factor is involved in the development and manifestation of IgE-dependent allergic diseases. We intend to answer the question if sex-related factors may play a role in Hymenoptera venom allergy (HVA). In the majority of recent studies the frequency of HVA symptoms with respect to both LL and SYS reactions is similar for men and women, while proven sensitization to insect venom is less frequent in women. Studies assessing clinical reactivity in HVA indicate that male sex and vespid venom allergy are factors increasing the risk of severe allergic reactions. Regarding the risk of adverse events associated with gender in the course of venom immunotherapy (VIT), the results of two large EAACI multicenter studies are discordant. In the first study, women showed increased risk of VIT adverse events. In the latter, systemic allergic side effects were not associated with gender. Despite theoretical premises and certain clinical observations indicating an important role of estrogens in allergic diseases, their influence on stinging insects' venom hypersensitivity is not unequivocal and remains still open. Further studies on the safety of VIT in females seem to be advisable.
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Affiliation(s)
| | - Jerzy Liebhart
- Department of Internal Diseases, Geriatrics and Allergology Medical University, Wroclaw, Poland
| | - Anna Dor-Wojnarowska
- Department of Internal Diseases, Geriatrics and Allergology Medical University, Wroclaw, Poland
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Akdis CA, Akdis M. Mechanisms of allergen-specific immunotherapy and immune tolerance to allergens. World Allergy Organ J 2015; 8:17. [PMID: 26023323 PMCID: PMC4430874 DOI: 10.1186/s40413-015-0063-2] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 02/06/2015] [Indexed: 12/25/2022] Open
Abstract
Substantial progress in understanding mechanisms of immune regulation in allergy, asthma, autoimmune diseases, tumors, organ transplantation and chronic infections has led to a variety of targeted therapeutic approaches. Allergen-specific immunotherapy (AIT) has been used for 100 years as a desensitizing therapy for allergic diseases and represents the potentially curative and specific way of treatment. The mechanisms by which allergen-AIT has its mechanisms of action include the very early desensitization effects, modulation of T- and B-cell responses and related antibody isotypes as well as inhibition of migration of eosinophils, basophils and mast cells to tissues and release of their mediators. Regulatory T cells (Treg) have been identified as key regulators of immunological processes in peripheral tolerance to allergens. Skewing of allergen-specific effector T cells to a regulatory phenotype appears as a key event in the development of healthy immune response to allergens and successful outcome in AIT. Naturally occurring FoxP3+ CD4+CD25+ Treg cells and inducible type 1 Treg (Tr1) cells contribute to the control of allergen-specific immune responses in several major ways, which can be summarized as suppression of dendritic cells that support the generation of effector T cells; suppression of effector Th1, Th2 and Th17 cells; suppression of allergen-specific IgE, and induction of IgG4; suppression of mast cells, basophils and eosinophils and suppression of effector T cell migration to tissues. New strategies for immune intervention will likely include targeting of the molecular mechanisms of allergen tolerance and reciprocal regulation of effector and regulatory T cell subsets.
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Affiliation(s)
- Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), Obere Strasse 22, CH7270 Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), Obere Strasse 22, CH7270 Davos, Switzerland
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Ciebiada M, Kasztalska K, Gorska-Ciebiada M, Górski P. Histamine type 2 receptor expression on peripheral blood regulatory lymphocytes in patients with allergic rhinitis treated with specific immunotherapy. Am J Rhinol Allergy 2015; 28:e130-5. [PMID: 24980224 DOI: 10.2500/ajra.2014.28.4048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Both histamine H1- and H2-receptors (H2R) were found on regulatory T (Treg) cells; however, there is a paucity of information regarding the role of H2R in Treg function. This study aimed to investigate the effects of natural allergen stimulation and specific immunotherapy (SIT) on H2R expression in Treg cells in patients with allergic rhinitis (AR). METHODS In this prospective, double-blind, placebo-controlled study 41 patients with AR were screened for 1 year and treated with SIT (n = 21) or placebo (n = 20) for the next 2 years. Fifteen healthy subjects were included as a control. Subsets of Treg cells that expressed H2R were assessed annually in the blood by flow cytometry: before, at the height of the pollen season, and after, at the end of the pollen season. In addition, total nasal symptom score, the use of rescue medication, and nasal eosinophilia were evaluated. RESULTS Treg cells of AR patients slightly up-regulate H2R out of the pollen season. Natural allergen stimulation results in prompt up-regulation of H2R within these cells. SIT significantly decreased the number of Treg cells with increased expression of H2R in the blood exclusively at the height of pollen season, which, however, had no impact on the expression of H2R in Treg cells. SIT improved significantly the symptom score, rescue medication use, and decreased nasal eosinophilia. CONCLUSION Natural pollen exposure results in up-regulation of H2R in Treg cells. Immunotherapy might transiently decrease the number of Treg-H2R(+) cells in the blood, which may be associated with their migration to the peripheral tissues. This study was part of the clinical trial registered in www.clinicaltrials.gov.
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Affiliation(s)
- Maciej Ciebiada
- Department of General and Oncological Pneumonology, Medical University of Lodz, Lodz, Poland
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Chliva C, Aggelides X, Makris M, Katoulis A, Rigopoulos D, Tiligada E. Comparable profiles of serum histamine and IgG4 levels in allergic beekeepers. Allergy 2015; 70:457-60. [PMID: 25639973 DOI: 10.1111/all.12568] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2014] [Indexed: 11/30/2022]
Abstract
Growing evidence identifies histamine as a key player in allergic responses, but the reports relating serum histamine to tolerance are scarce and inconclusive. This study investigated the relationship of circulating histamine to the tolerant phenotype in allergic beekeepers. The results showed a positive correlation between the serum levels of histamine and specific immunoglobulin G4 (sIgG4) to honeybee venom, but not with total IgE or sIgE. Interestingly, both sIgG4 and histamine levels were negatively correlated with the time since the last bee sting. In contrast to total IgE and sIgE, serum sIgG4 and histamine levels followed comparable patterns, being higher in tolerant/recently stung individuals and lower in the least frequently stung subgroup. The data obtained in this pilot study associated, for the first time, serum histamine levels with allergen tolerance in allergic individuals and provided the lead for further considering the putative immunomodulatory properties of histamine in allergic responses.
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Affiliation(s)
- C. Chliva
- Allergy Unit ‘D. Kalogeromitros’; 2nd Department of Dermatology and Venereology; ‘Attikon’ General University Hospital; Medical School; University of Athens; Athens Greece
| | - X. Aggelides
- Allergy Unit ‘D. Kalogeromitros’; 2nd Department of Dermatology and Venereology; ‘Attikon’ General University Hospital; Medical School; University of Athens; Athens Greece
| | - M. Makris
- Allergy Unit ‘D. Kalogeromitros’; 2nd Department of Dermatology and Venereology; ‘Attikon’ General University Hospital; Medical School; University of Athens; Athens Greece
| | - A. Katoulis
- 2nd Department of Dermatology and Venereology; ‘Attikon’ General University Hospital; Medical School; University of Athens; Athens Greece
| | - D. Rigopoulos
- 2nd Department of Dermatology and Venereology; ‘Attikon’ General University Hospital; Medical School; University of Athens; Athens Greece
| | - E. Tiligada
- Allergy Unit ‘D. Kalogeromitros’; 2nd Department of Dermatology and Venereology; ‘Attikon’ General University Hospital; Medical School; University of Athens; Athens Greece
- Department of Pharmacology; Medical School; University of Athens; Athens Greece
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Zaleska A, Eiwegger T, Soyer Ö, van de Veen W, Rhyner C, Soyka MB, Bekpen C, Demiröz D, Treis A, Söllner S, Palomares O, Kwok WW, Rose H, Senti G, Kündig TM, Ozoren N, Jutel M, Akdis CA, Crameri R, Akdis M. Immune regulation by intralymphatic immunotherapy with modular allergen translocation MAT vaccine. Allergy 2014; 69:1162-70. [PMID: 24934402 DOI: 10.1111/all.12461] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Allergen-specific immunotherapy (SIT) faces problems related to side effects and limited efficacy. Direct administration of allergen extracts into lymph nodes induces increased specific IgG production and T-cell responses using significantly lower allergen doses. METHODS In this study, mechanisms of immune regulation by MAT vaccines in vitro and in allergen-SIT of cat-allergic rhinitis patients, who received 3 inguinal intra-lymph node injections of MAT-Fel d 1 vaccine, were investigated in PBMC and cell cultures for specific T-cell proliferation, Fel d 1-tetramer-specific responses, and multiple immune regulatory molecules. RESULTS MAT-Fel d 1 vaccine was efficiently internalized by antigen-presenting cells. This was followed by precaspase 1 cleavage to caspase 1 and secretion of IL-1β, indicating inflammasome activation. Mat-Fel d 1 induced specific T-cell proliferation and an IL-10- and IFN-γ-dominated T-cell responses with decreased Th2 cytokines at 100 times lower doses than Fel d 1. Induction of immune tolerance by MAT-Fel d 1-ILIT involved multiple mechanisms of immune suppression. Early Fel d 1-specific T-cell activation was followed by full T-cell unresponsiveness to allergen after 1 year in the MAT-Fel d 1 group, characterized by increased allergen-specific T regulatory cells, decreased circulating Fel d 1 tetramer-positive cells, increased IL-10 and FOXP3 expression, and change in the HR2/HR1 ratio toward HR2. CONCLUSIONS This study demonstrates the induction of allergen tolerance after 3 intra-lymph node injections of MAT-Fel d 1 vaccine, mediated by increased cellular internalization of the allergen, activation of inflammasome, and generation of allergen-specific peripheral T-cell tolerance.
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Affiliation(s)
- A. Zaleska
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
- Department and Clinic of Internal Diseases, Geriatry and Allergology; Wroclaw Medical University; Wroclaw Poland
| | - T. Eiwegger
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
- Department of Pediatrics; Medical University of Vienna; Vienna Austria
| | - Ö. Soyer
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - W. van de Veen
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - C. Rhyner
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - M. B. Soyka
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - C. Bekpen
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
- Department of Molecular Biology and Genetics; Center for Life Sciences and Technology Research; Bogazici University; Istanbul Turkey
| | - D. Demiröz
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
- Department of Molecular Biology and Genetics; Center for Life Sciences and Technology Research; Bogazici University; Istanbul Turkey
| | - A. Treis
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - S. Söllner
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - O. Palomares
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
- Department of Biochemistry and Molecular Biology; School of Chemistry; Complutense University of Madrid; Madrid Spain
| | - W. W. Kwok
- Benaroya Research Institute at Virginia Mason; Seattle WA USA
| | - H. Rose
- ImVisioN GmbH; Hannover Germany
| | - G. Senti
- Clinical Trials Center; University Hospital Zurich; Zurich Switzerland
| | - T. M. Kündig
- Department of Dermatology; University Hospital Zurich; Zurich Switzerland
| | - N. Ozoren
- Department of Molecular Biology and Genetics; Center for Life Sciences and Technology Research; Bogazici University; Istanbul Turkey
| | - M. Jutel
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
- Department of Clinical Immunology; Wroclaw Medical University; Wroclaw Poland
| | - C. A. Akdis
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - R. Crameri
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
| | - M. Akdis
- Swiss Institute for Allergy and Asthma Research (SIAF); Davos Switzerland
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Jagdis A, Berlin N, Barron C, Giruparajah M, Leader N, Maclachlan S, Sussman GL. Effect of ketotifen premedication on adverse reactions during peanut oral immunotherapy. Allergy Asthma Clin Immunol 2014; 10:36. [PMID: 25031584 PMCID: PMC4099498 DOI: 10.1186/1710-1492-10-36] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/27/2014] [Indexed: 11/21/2022] Open
Abstract
Background Oral immunotherapy (OIT) has shown promise in inducing desensitization for food allergy. However, there are safety concerns regarding the frequency and severity of adverse events during food OIT. Objective To evaluate the effect of Ketotifen premedication on adverse reactions during peanut OIT. Methods A randomized single blind placebo controlled pilot study was performed. Peanut OIT was performed using a previously published protocol. Ketotifen was up-titrated to 2 mg twice daily over two weeks (week -2 to 0), followed by a peanut OIT initial escalation day (day 1). Ketotifen was administered from week 0–4 of peanut OIT; reactions to peanut OIT doses were recorded by clinic staff and subject diary. Results Six subjects (median age 10 years, peanut IgE >100kUA/L) were enrolled, 4 randomized to Ketotifen, 2 to placebo. The most common side effect of Ketotifen was fatigue (9% during up-titration). The rate of reaction per peanut OIT dose was lower for subjects on ketotifen (K) compared to placebo (P) during initial escalation on day 1 (K: 22% (8/36) vs. P: 67% (12/18)); week 0–4 build-up doses (K: 75% (3/4) vs. P: 100% (2/2)); and week 0–4 home doses (K: 50% (54/108) vs. P: 82% (27/33)). The rate of gastrointestinal symptoms per peanut OIT dose was also lower for subjects on ketotifen during initial escalation on day 1 (K: 17% (6/36) vs. P: 61% (11/18)); week 0–4 build-up doses (K: 75% (3/4) vs P: 100% (2/2)); and week 0–4 home doses (K: 46% (50/108) vs. P: 82% (27/33)). Conclusions Ketotifen premedication is well tolerated and reduces the rate of gastrointestinal symptoms during peanut OIT. These findings require confirmation in a larger study of Ketotifen premedication used throughout peanut OIT. Trial registration Clinical Trials number: NCT0162515
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Affiliation(s)
- Amanda Jagdis
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, 202 St Clair Ave W, Toronto, ON M4V 1R2, Canada
| | - Noam Berlin
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Carly Barron
- Gordon Sussman Clinical Research Inc., Toronto, ON, Canada
| | | | - Nathan Leader
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Sean Maclachlan
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gordon L Sussman
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, 202 St Clair Ave W, Toronto, ON M4V 1R2, Canada
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Simons FER, Ardusso LRF, Bilò MB, Cardona V, Ebisawa M, El-Gamal YM, Lieberman P, Lockey RF, Muraro A, Roberts G, Sanchez-Borges M, Sheikh A, Shek LP, Wallace DV, Worm M. International consensus on (ICON) anaphylaxis. World Allergy Organ J 2014; 7:9. [PMID: 24920969 PMCID: PMC4038846 DOI: 10.1186/1939-4551-7-9] [Citation(s) in RCA: 270] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 11/21/2022] Open
Abstract
ICON: Anaphylaxis provides a unique perspective on the principal evidence-based anaphylaxis guidelines developed and published independently from 2010 through 2014 by four allergy/immunology organizations. These guidelines concur with regard to the clinical features that indicate a likely diagnosis of anaphylaxis -- a life-threatening generalized or systemic allergic or hypersensitivity reaction. They also concur about prompt initial treatment with intramuscular injection of epinephrine (adrenaline) in the mid-outer thigh, positioning the patient supine (semi-reclining if dyspneic or vomiting), calling for help, and when indicated, providing supplemental oxygen, intravenous fluid resuscitation and cardiopulmonary resuscitation, along with concomitant monitoring of vital signs and oxygenation. Additionally, they concur that H1-antihistamines, H2-antihistamines, and glucocorticoids are not initial medications of choice. For self-management of patients at risk of anaphylaxis in community settings, they recommend carrying epinephrine auto-injectors and personalized emergency action plans, as well as follow-up with a physician (ideally an allergy/immunology specialist) to help prevent anaphylaxis recurrences. ICON: Anaphylaxis describes unmet needs in anaphylaxis, noting that although epinephrine in 1 mg/mL ampules is available worldwide, other essentials, including supplemental oxygen, intravenous fluid resuscitation, and epinephrine auto-injectors are not universally available. ICON: Anaphylaxis proposes a comprehensive international research agenda that calls for additional prospective studies of anaphylaxis epidemiology, patient risk factors and co-factors, triggers, clinical criteria for diagnosis, randomized controlled trials of therapeutic interventions, and measures to prevent anaphylaxis recurrences. It also calls for facilitation of global collaborations in anaphylaxis research. IN ADDITION TO CONFIRMING THE ALIGNMENT OF MAJOR ANAPHYLAXIS GUIDELINES, ICON: Anaphylaxis adds value by including summary tables and citing 130 key references. It is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public.
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Affiliation(s)
- F Estelle R Simons
- Department of Pediatrics & Child Health and Department of Immunology, Faculty of Medicine, University of Manitoba, Room FE125, 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A 1R9
| | - Ledit RF Ardusso
- Cátedra Neumonología, Alergia e Inmunología, Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
| | - M Beatrice Bilò
- Allergy Unit, Department of Internal Medicine, University Hospital, Ancona, Italy
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Motohiro Ebisawa
- Department of Allergy, National Hospital Organization, Sagamihara National Hospital, Clinical Research Center for Allergy & Rheumatology, Kanagawa, Japan
| | - Yehia M El-Gamal
- Pediatric Allergy and Immunology Unit, Ain Shams University, Cairo, Egypt
| | | | - Richard F Lockey
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Antonella Muraro
- Department of Women and Child Health, Food Allergy Referral Centre, University of Padua, Padua, Italy
| | - Graham Roberts
- University of Southampton Faculty of Medicine, Southampton, United Kingdom, David Hide Asthma and Allergy Research Centre, St. Mary’s Hospital, Isle of Wight, United Kingdom
| | - Mario Sanchez-Borges
- Centro Medico Docente La Trinidad, Caracas, Clinica El Avila, Caracas, Venezuela
| | - Aziz Sheikh
- Center for Population Health Sciences, The University of Edinburgh, Edinburgh, United Kingdom and Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, USA
| | - Lynette P Shek
- Department of Pediatrics, National University of Singapore, Singapore
| | | | - Margitta Worm
- Allergie-Centrum-Charité, Klinik fur Dermatologie und Allergologie, Charité, Universitatsmedizin, Berlin, Germany
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Golden DBK. Advances in diagnosis and management of insect sting allergy. Ann Allergy Asthma Immunol 2013; 111:84-9. [PMID: 23886224 DOI: 10.1016/j.anai.2013.05.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/22/2013] [Accepted: 05/24/2013] [Indexed: 11/30/2022]
Affiliation(s)
- David B K Golden
- Johns Hopkins Asthma and Allergy Center, Baltimore, Maryland, USA.
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Abstract
Rush and cluster immunotherapy schedules are accelerated immunotherapy build-up schedules. A cluster immunotherapy schedule involves the patient receiving several allergen injections (generally 2-4) sequentially in a single day of treatment on nonconsecutive days. The maintenance dose is generally reached in 4-8 weeks. In rush immunotherapy protocols, higher doses are administered at 15- to 60-min intervals over a 1- to 3-day period until the maintenance dose is achieved. This review will serve as an update for accelerated immunotherapy schedules. The review will include recent investigations demonstrating the safety of cluster schedules in atopic dermatitis, pediatric patients, and inhalant allergen mixtures and an accelerated protocol utilizing an infusion pump for allergen delivery. There has also been further elucidation on the immunological changes which occur during accelerated immunotherapy. Finally, new studies analyzing systemic reaction risk factors are discussed.
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Bilò MB, Antonicelli L, Bonifazi F. Honeybee venom immunotherapy: certainties and pitfalls. Immunotherapy 2013. [PMID: 23194365 DOI: 10.2217/imt.12.113] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The honeybee is an interesting insect because of the fundamental agricultural role it plays, together with the composition of its venom, which presents new diagnostic and immunotherapeutic challenges. This article examines various aspects of honeybee venom allergy from epidemiology to diagnosis and treatment, with special emphasis on venom immunotherapy (VIT). Honeybee venom allergy represents a risk factor for severe systemic reaction in challenged allergic patients, for the diminished effectiveness of VIT, for more frequent side effects during VIT and relapse after cessation of treatment. Some strategies are available for reducing the risk of honeybee VIT-induced side effects; however, there is considerable room for further improvement in these all-important areas. At the same time, sensitized and allergic beekeepers represent unique populations for epidemiological, venom allergy immunopathogenesis and VIT mechanism studies.
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Affiliation(s)
- M Beatrice Bilò
- Allergy Unit, Department of Immunology, Allergy & Respiratory Diseases, University Hospital Ospedali Riuniti di Ancona, Ancona, Italy.
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van de Veen W, Stanic B, Yaman G, Wawrzyniak M, Söllner S, Akdis DG, Rückert B, Akdis CA, Akdis M. IgG4 production is confined to human IL-10-producing regulatory B cells that suppress antigen-specific immune responses. J Allergy Clin Immunol 2013; 131:1204-12. [PMID: 23453135 DOI: 10.1016/j.jaci.2013.01.014] [Citation(s) in RCA: 447] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 01/11/2013] [Accepted: 01/11/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND IL-10-producing regulatory B cells suppress immune responses, and lack of these cells leads to exacerbated symptoms in mouse models of chronic inflammation, transplantation, and chronic infection. IgG4 is a blocking antibody isotype with anti-inflammatory potential that is induced in human high-dose antigen tolerance models. OBJECTIVE We sought to characterize human inducible IL-10-secreting B regulatory 1 (BR1) cells and to investigate their immunoregulatory capacity through suppression of cellular immune responses and production of anti-inflammatory immunoglobulins. METHODS Highly purified IL-10-secreting B cells were phenotypically and functionally characterized by means of whole-genome expression analysis, flow cytometry, suppression assay, and antibody production. B cells specific for the major bee venom allergen phospholipase A2 (PLA) were isolated from beekeepers who displayed tolerance to bee venom antigens and allergic patients before and after specific immunotherapy. RESULTS Human IL-10+ BR1 cells expressed high surface CD25 and CD71 and low CD73 levels. Sorting of CD73-CD25+CD71+ B cells allowed enrichment of human BR1 cells, which produced high levels of IL-10 and potently suppressed antigen-specific CD4+ T-cell proliferation. IgG4 was selectively confined to human BR1 cells. B cells specific for the major bee venom allergen PLA isolated from nonallergic beekeepers show increased expression of IL-10 and IgG4. Furthermore, the frequency of IL-10+ PLA-specific B cells increased in allergic patients receiving allergen-specific immunotherapy. CONCLUSION Our data show the characterization of IL-10+ BR1 cells and in vivo evidence for 2 essential features of allergen tolerance: the suppressive B cells and IgG4-expressing B cells that are confined to IL-10+ BR1 cells in human subjects.
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Affiliation(s)
- Willem van de Veen
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zürich, Davos, Switzerland
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Boyle RJ, Elremeli M, Hockenhull J, Cherry MG, Bulsara MK, Daniels M, Oude Elberink JNG. Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev 2012; 10:CD008838. [PMID: 23076950 PMCID: PMC8734599 DOI: 10.1002/14651858.cd008838.pub2] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Venom immunotherapy (VIT) is commonly used for preventing further allergic reactions to insect stings in people who have had a sting reaction. The efficacy and safety of this treatment has not previously been assessed by a high-quality systematic review. OBJECTIVES To assess the effects of immunotherapy using extracted insect venom for preventing further allergic reactions to insect stings in people who have had an allergic reaction to a sting. SEARCH METHODS We searched the following databases up to February 2012: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library, MEDLINE (from 1946), EMBASE (from 1974), PsycINFO (from 1806), AMED (from 1985), LILACS (from 1982), the Armed Forces Pest Management Board Literature Retrieval System, and OpenGrey. There were no language or publication status restrictions to our searches. We searched trials databases, abstracts from recent European and North American allergy meetings, and the references of identified review articles in order to identify further relevant trials. SELECTION CRITERIA Randomised controlled trials of venom immunotherapy using standardised venom extract in insect sting allergy. DATA COLLECTION AND ANALYSIS Two authors independently undertook study selection, data extraction, and assessment of risk of bias. We identified adverse events from included controlled trials and from a separate analysis of observational studies identified as part of a National Institute for Health and Clinical Excellence Health Technology Assessment. MAIN RESULTS We identified 6 randomised controlled trials and 1 quasi-randomised controlled trial for inclusion in the review; the total number of participants was 392. The trials had some risk of bias because five of the trials did not blind outcome assessors to treatment allocation. The interventions included ant, bee, and wasp immunotherapy in children or adults with previous systemic or large local reactions to a sting, using sublingual (one trial) or subcutaneous (six trials) VIT. We found that VIT is effective for preventing systemic allergic reaction to an insect sting, which was our primary outcome measure. This applies whether the sting occurs accidentally or is given intentionally as part of a trial procedure.In the trials, 3/113 (2.7%) participants treated with VIT had a subsequent systemic allergic reaction to a sting, compared with 37/93 (39.8%) untreated participants (risk ratio [RR] 0.10, 95% confidence interval [CI] 0.03 to 0.28). The efficacy of VIT was similar across studies; we were unable to identify a patient group or mode of treatment with different efficacy, although these analyses were limited by small numbers. We were unable to confirm whether VIT prevents fatal reactions to insect stings, because of the rarity of this outcome.Venom immunotherapy was also effective for preventing large local reactions to a sting (5 studies; 112 follow-up stings; RR 0.41, 95% CI 0.24 to 0.69) and for improving quality of life (mean difference [MD] in favour of VIT 1.21 points on a 7-point scale, 95% CI 0.75 to 1.67).We found a significant risk of systemic adverse reaction to VIT treatment: 6 trials reported this outcome, in which 14 of 150 (9.3%) participants treated with VIT and 1 of 135 (0.7%) participants treated with placebo or no treatment suffered a systemic reaction to treatment (RR 8.16, 95% CI 1.53 to 43.46; 2 studies contributed to the effect estimate). Our analysis of 11 observational studies found systemic adverse reactions occurred in 131/921 (14.2%) participants treated with bee venom VIT and 8/289 (2.8%) treated with wasp venom VIT. AUTHORS' CONCLUSIONS We found venom immunotherapy using extracted insect venom to be an effective therapy for preventing further allergic reactions to insect stings, which can improve quality of life. The treatment carries a small but significant risk of systemic adverse reaction.
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Affiliation(s)
- Robert J Boyle
- Department of Medicine, Section of Paediatrics, Imperial College London, London, UK.
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Novak N, Mete N, Bussmann C, Maintz L, Bieber T, Akdis M, Zumkehr J, Jutel M, Akdis C. Early suppression of basophil activation during allergen-specific immunotherapy by histamine receptor 2. J Allergy Clin Immunol 2012; 130:1153-1158.e2. [PMID: 22698521 DOI: 10.1016/j.jaci.2012.04.039] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 03/23/2012] [Accepted: 04/26/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Early desensitization of FcεRI-bearing mast cells and basophils has been demonstrated in allergen-specific immunotherapy and drug desensitization. However, its mechanisms have not been elucidated in detail. Histamine is one of the main mediators released on FcεRI triggering of basophils and mast cells, and it exerts its functions through histamine receptors (HRs). OBJECTIVES We sought to investigate HR expression on basophils of patients undergoing venom immunotherapy (VIT) and its effect on allergen, IgE, and FcεRI cross-linking-mediated basophil function and mediator release. METHODS Basophils were purified from the peripheral blood of patients undergoing VIT and control subjects and were studied functionally by using real-time PCR, flow cytometry and ELISA assays. RESULTS Rapid upregulation of H2R within the first 6 hours of the build-up phase of VIT was observed. H2R strongly suppressed FcεRI-induced activation and mediator release of basophils, including histamine and sulfidoleukotrienes, as well as cytokine production in vitro. CONCLUSION Immunosilencing of FcεRI-activated basophils by means of selective suppression mediated by H2R might be highly relevant for the very early induction of allergen tolerance and the so-called desensitization effect of VIT.
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Affiliation(s)
- Natalija Novak
- Department of Dermatology and Allergy, University of Bonn, Bonn, Germany.
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Tunis MC, Dawicki W, Carson KR, Wang J, Marshall JS. Mast cells and IgE activation do not alter the development of oral tolerance in a murine model. J Allergy Clin Immunol 2012; 130:705-715.e1. [PMID: 22607990 DOI: 10.1016/j.jaci.2012.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 04/04/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND In addition to their well-known role as potent effector cells in patients with allergic disease, mast cells have important immunomodulatory roles regulating tolerance in allograft rejection models. The roles of mast cells in oral tolerance development have not previously been examined. OBJECTIVE We sought to evaluate the importance of mast cells, IgE-mediated mast cell activation, and histamine receptor 1 or 2 blockade on oral tolerance development in mice. METHODS Oral tolerance was assessed in 2 mast cell-deficient murine strains (Kit(W-sh/W-sh) and Kit(W/W-v) mice) and control mice. Mice were fed ovalbumin (OVA) or peanut butter for 1 week and then immunized and boosted with relevant protein antigens. Antibody responses were assessed by using ELISA. The oral antihistamines pyrilamine and ranitidine were administered during tolerance induction to OVA. IgE-mediated mast cell activation was initiated during oral tolerance induction or OVA immunization. OVA-specific regulatory T cells were assessed in the Peyer patches, mesenteric lymph nodes, and spleens by using flow cytometry after adoptive transfer. RESULTS Oral tolerance was successfully induced to OVA and peanut butter in mast cell-deficient mice. Kit(W-sh/W-sh) mice had higher proportions of antigen-specific regulatory T cells in the mesenteric lymph nodes than mast cell-containing control mice. However, mast cell reconstitution studies suggested this effect was mast cell independent. Oral antihistamine treatments with pyrilamine or ranitidine did not impair tolerance and neither did IgE-mediated activation. CONCLUSIONS Mast cells are not necessary for the induction of oral tolerance, and allergic activation of mast cells does not impair tolerance to OVA. Oral antihistamine treatments do not disrupt the development of oral tolerance.
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Affiliation(s)
- Matthew C Tunis
- Department of Microbiology and Immunology, Dalhousie University, Halifax, Nova Scotia, Canada
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Hedlin G, van Hage M. The role of immunotherapy in the management of childhood asthma. Ther Adv Respir Dis 2012; 6:137-46. [PMID: 22438265 DOI: 10.1177/1753465812439793] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Subcutaneous immunotherapy (SCIT) is still questioned as a safe and efficacious way of treating allergic asthma in children. In a Cochrane review published in 2010 it was, however, concluded that SCIT has significant and beneficial effects on symptoms and medication use in both children and adults with mostly mild asthma. Only a few studies have been performed to specifically study if SCIT in children with moderate asthma reduces the need for inhaled corticosteroids. There are conflicting results that illustrate the problem of the heterogeneity of the asthma disease and the fact that allergies may play different roles on the severity and symptoms of the disease. Furthermore, children with severe allergic asthma are often sensitized to multiple allergens, which makes SCIT both complicated and less safe to administer. On the other hand, if the child suffers from asthmatic symptoms despite adherence to pharmacotherapy, omalizumab or a combination of omalizumab and allergen immunotherapy might be useful. There is a need for more studies on this combination before it can be considered as an additional therapy in children with asthma and severe allergies. Sublingual immunotherapy (SLIT) has also been shown to improve asthma symptoms and medication use. SLIT is safe although its efficacy compared with SCIT has been studied very little. Another approach is to try to prevent asthma by treating children with SCIT for allergic rhinoconjunctivitis before asthma has developed. The most attractive prospect, however, is to find ways of preventing asthma by vaccination against the most common viruses, particularly rhinovirus. There is evidence that there are children at high risk of developing asthma in whom a viral infection can also enhance the risk of allergen sensitization. So far this vaccination has not been achievable although research is in progress.
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Affiliation(s)
- Gunilla Hedlin
- Centre for Allergy Research, Karolinska Institutet, PO Box 287, SE-17177 Stockholm, Sweden.
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Abstract
Drugs that are used in relation to allergen-specific immunotherapy (SIT) can be separated into pharmacoprophylaxis to avoid or decrease local and systemic adverse effects of SIT and in co-medications to treat other diseases. Regarding pharmacoprophylaxis, H1-antihistamines are able to reduce local and mild systemic, but not severe systemic side effects of SIT. H1-antihistamines do not attenuate the efficacy of SIT. Severe systemic side effects have been blocked in some cases with omalizumab; currently this agent can be used off-label during venom SIT. With regard to co-medication, the concomitant use of immunomodulating drugs during SIT must be individualized, if the effective profile and side effects of the immunomodulating drug are well-known and a negative effect on SIT is not likely. Recently approved immunosuppressive drugs and biologics are perceived critically due to their unpredictable immunologic effects. For forensic reasons cardioselective beta blockers should be discontinued although no data are available demonstrating adverse effects. If discontinuation is not justified and venom SIT is indicated, SIT can be performed while taking beta blockers. In contrast, ACE-inhibitors should always be stopped in patients with insect venom allergy.
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Simons FER, Simons KJ. Histamine and H1-antihistamines: Celebrating a century of progress. J Allergy Clin Immunol 2011; 128:1139-1150.e4. [DOI: 10.1016/j.jaci.2011.09.005] [Citation(s) in RCA: 238] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 09/06/2011] [Accepted: 09/07/2011] [Indexed: 02/06/2023]
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González-de-Olano D, Alvarez-Twose I, Vega A, Orfao A, Escribano L. Venom immunotherapy in patients with mastocytosis and hymenoptera venom anaphylaxis. Immunotherapy 2011; 3:637-51. [PMID: 21554093 DOI: 10.2217/imt.11.44] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Systemic mastocytosis (SM) is typically suspected in patients with cutaneous mastocytosis (CM). In recent years, the presence of clonal mast cells (MCs) in a subset of patients with systemic symptoms associated with MC activation in the absence of CM has been reported and termed monoclonal MC activation syndromes or clonal systemic MC activation syndromes. In these cases, bone marrow (BM) MC numbers are usually lower than in SM with CM, there are no detectable BM MC aggregates, and serum baseline tryptase is often <20 µg/l; thus, diagnosis of SM in these patients should be based on careful evaluation of other minor WHO criteria for SM in reference centers, where highly sensitive techniques for immunophenotypic analysis and investigation of KIT mutations on fluorescence-activated cell sorter-purified BM MCs are routinely performed. The prevalence of hymenoptera venom anaphylaxis (HVA) among SM patients is higher than among the normal population and it has been reported to be approximately 5%. In SM patients with IgE-mediated HVA, venom immunotherapy is safe and effective and it should be prescribed lifelong. Severe adverse reactions to hymenoptera stings or venom immunotherapy have been associated with increased serum baseline tryptase; however, presence of clonal MC has not been ruled out in most reports and thus both SM and clonal MC activation syndrome might be underdiagnosed in such patients. In fact, clonal BM MC appears to be a relevant risk factor for both HVA and severe reactions to venom immunotherapy, while the increase in serum baseline tryptase by itself should be considered as a powerful surrogate marker for anaphylaxis. The Spanish Network on Mastocytosis has developed a scoring system based on patient gender, the clinical symptoms observed during anaphylaxis and serum baseline tryptase to predict for the presence of both MC clonality and SM among individuals who suffer from anaphylaxis.
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Krishna MT, Ewan PW, Diwakar L, Durham SR, Frew AJ, Leech SC, Nasser SM. Diagnosis and management of hymenoptera venom allergy: British Society for Allergy and Clinical Immunology (BSACI) guidelines. Clin Exp Allergy 2011; 41:1201-20. [DOI: 10.1111/j.1365-2222.2011.03788.x] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ozdemir C, Kucuksezer UC, Akdis M, Akdis CA. Mechanisms of immunotherapy to wasp and bee venom. Clin Exp Allergy 2011; 41:1226-34. [PMID: 21729181 DOI: 10.1111/j.1365-2222.2011.03812.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hymenoptera venoms are important allergens that can elicit both local and systemic allergic reactions, including life-threatening anaphylaxis. Venom immunotherapy (VIT) remains the most effective treatment, reducing the risk of systemic reactions in individuals with Hymenoptera venom allergy. VIT can restore normal immunity against venom allergens and provide patients with a lifetime of tolerance to venoms. During VIT, peripheral tolerance is induced by the generation of allergen-specific regulatory T (Treg) cells, which suppress proliferative and cytokine responses against the venom allergens. Treg cells are characterized by IL-10 secretion that directly or indirectly influence effector cells of allergic inflammation, such as mast cells, basophils and eosinophils. Treg cells also have influence on B cells, suppressing IgE production and inducing the production of blocking type IgG4 antibodies against venom allergens. An accumulating body of evidence suggests that Treg cells may affect allergen sensitization and methods for enhancing this cell population may eventually improve the efficacy of VIT. In this article, immune mechanisms enrolled in bee and wasp VIT are reviewed.
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Affiliation(s)
- C Ozdemir
- Swiss Institute of Allergy and Asthma Research, Davos, Switzerland
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Ozdemir C, Kucuksezer UC, Akdis M, Akdis CA. Specific immunotherapy and turning off the T cell: how does it work? Ann Allergy Asthma Immunol 2011; 107:381-92. [PMID: 22018608 DOI: 10.1016/j.anai.2011.05.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 03/08/2011] [Accepted: 05/17/2011] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To examine T-regulatory (Treg) cell functions in allergic immune responses and their roles during allergen specific immunotherapy based on recent developments and current understanding of immune regulation. DATA SOURCES PubMed search of English-language articles regarding Treg cells and allergen specific immunotherapy. STUDY SELECTION Articles on the subject matter were selected and reviewed. RESULTS Allergen specific immunotherapy is the ultimate treatment modality targeting the immunopathogenic mechanisms of allergic disorders. A diminished allergen-specific T-cell proliferation and suppressed secretion of T(H)1- and T(H)2-type cytokines are the characteristic hallmarks. In addition, Treg cells inhibit the development of allergen-specific T(H)2 and T(H)1 cell responses and therefore exert key roles in healthy immune response to allergens. Treg cells potently suppress IgE production and directly or indirectly control the activity of effector cells of allergic inflammation, such as eosinophils, basophils, and mast cells. CONCLUSION As advancements in the field of allergen specific immunotherapy ensue, they may provide novel progression of more rational and safer approaches for the prevention and treatment of allergic disorders. Currently, the Treg cell field is an open research area to increase our understanding in mechanisms of peripheral tolerance to allergens.
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Affiliation(s)
- Cevdet Ozdemir
- Division of Pediatric Allergy and Immunology, Marmara University, Istanbul, Turkey
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Abstract
Subcutaneous venom immunotherapy is the only effective treatment for patients who experience severe hymenoptera sting-induced allergic reactions, and the treatment also improves health-related quality of life. This article examines advances in various areas of this treatment, which include the immunological mechanisms of early and long-term efficacy, indications and contraindications, selection of venom, treatment protocols, duration, risk factors for systemic reactions in untreated and treated patients as well as for relapse following cessation of treatment. Current and future strategies for improving safety and efficacy are also examined. However, although progress in the past few years has been fruitful, much remains to be accomplished.
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Affiliation(s)
- Beatrice M Bilò
- Department of Internal Medicine, Immunology, Allergy & Respiratory Diseases, University Hospital, Ospedali Riuniti di Ancona, Ancona, Italy.
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Abstract
The studies on the mechanisms of specific immunotherapy (SIT) point out its targets that decide on the efficacy of SIT and hence might be used for its further improvement. Several mechanisms have been proposed to explain the beneficial effects of immunotherapy. The knowledge of the mechanisms underlying allergic diseases and curative treatment possibilities has experienced exciting advances over the last three decades. Studies in several clinical trials in allergen-SIT have demonstrated that the induction of a tolerant state against allergens in many ways represents a key step in the development of a healthy immune response against allergens. Several cellular and molecular mechanisms have been demonstrated: allergen-specific suppressive capacities of both inducible subsets of CD4(+) CD25(+) forkhead box P3(+) T-regulatory and IL-10-secreting type 1 T-regulatory cells increase in peripheral blood; suppression of eosinophils, mast cells, and basophils; Ab isotype change from IgE to IgG4. This review aims at the better understanding of the observed immunological changes associated with allergen SIT.
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Affiliation(s)
- Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wrocław, Poland.
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Golden DBK, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011; 127:852-4.e1-23. [PMID: 21458655 DOI: 10.1016/j.jaci.2011.01.025] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 01/05/2011] [Accepted: 01/11/2011] [Indexed: 11/26/2022]
Abstract
These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Stinging insect hypersensitivity: a practice parameter update II." Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. These parameters are not designed for use by pharmaceutical companies in drug promotion. The Joint Task Force understands that the cost of diagnostic tests and therapeutic agents is an important concern that may appropriately influence the work-up and treatment chosen for a given patient. The Joint Task Force recognizes that the emphasis of our primary recommendations regarding a medication may vary, for example, depending on third party payer issues and product patent expiration dates. However, since a given test or agent's cost is so widely variable, and there is a paucity of pharmacoeconomic data, the Joint Task Force generally does not consider cost when formulating Practice Parameter recommendations. In extraordinary circumstances, when the cost benefit of an intervention is prohibitive as supported by pharmacoeconomic data, commentary may be provided.
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Affiliation(s)
- David B K Golden
- Joint Council of Allergy, Asthma and Immunology, 50 N Brockway St, #3-3, Palatine, IL 60067, USA
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Calabria CW, Cox L. Accelerated Immunotherapy Schedules and Premedication. Immunol Allergy Clin North Am 2011; 31:251-63, ix. [DOI: 10.1016/j.iac.2011.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Akdis CA, Akdis M. Mechanisms of allergen-specific immunotherapy. J Allergy Clin Immunol 2011; 127:18-27; quiz 28-9. [PMID: 21211639 DOI: 10.1016/j.jaci.2010.11.030] [Citation(s) in RCA: 304] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 11/22/2010] [Accepted: 11/22/2010] [Indexed: 01/05/2023]
Abstract
Allergen-specific immunotherapy has been used for 100 years as a desensitizing therapy for allergic diseases and represents the potentially curative and specific method of treatment. The mechanisms of action of allergen-specific immunotherapy include the very early desensitization effects, modulation of T-and B-cell responses and related antibody isotypes, and migration of eosinophils, basophils, and mast cells to tissues, as well as release of their mediators. Regulatory T (Treg) cells have been identified as key regulators of immunologic processes in peripheral tolerance to allergens. Skewing of allergen-specific effector T cells to a regulatory phenotype appears as a key event in the development of healthy immune response to allergens and successful outcome in patients undergoing allergen-specific immunotherapy. Naturally occurring forkhead box protein 3-positive CD4(+)CD25(+) Treg cells and inducible T(R)1 cells contribute to the control of allergen-specific immune responses in several major ways, which can be summarized as suppression of dendritic cells that support the generation of effector T cells; suppression of effector T(H)1, T(H)2, and T(H)17 cells; suppression of allergen-specific IgE and induction of IgG4; suppression of mast cells, basophils, and eosinophils; and suppression of effector T-cell migration to tissues. New strategies for immune intervention will likely include targeting of the molecular mechanisms of allergen tolerance and reciprocal regulation of effector and Treg cell subsets.
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Affiliation(s)
- Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.
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Shin JH, Kim BG, Kim SW, Cho JH, Park YJ, Kim SW. Immunomodulatory role of histamine H2 receptor in allergen-specific immunotherapy: a mouse model of allergic rhinitis. Otolaryngol Head Neck Surg 2011; 144:500-5. [PMID: 21493224 DOI: 10.1177/0194599810392154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The purpose of this pilot study was to investigate the effects of HR2 on allergen-specific immunotherapy in a mouse model of allergic rhinitis. STUDY DESIGN An in vivo study using an animal model. SETTING Catholic Research Institutes of Medical Science. METHODS Fifty mice were divided into 5 groups: control, allergic rhinitis (AR), immunotherapy (IT), immunotherapy with HR2 agonist (HI), and immunotherapy with HR2 antagonist (HB). All mice except for the control group were sensitized with ovalbumin (OVA). After 1 week, mice in the IT, HI, and HB groups underwent immunotherapy by intradermal injections of OVA. During immunotherapy, the HI group was injected with HR2 agonist, whereas the HB group was injected with HR2 antagonist. All sensitized mice were challenged with intranasal OVA. After the final challenge, allergic behavior was evaluated. Interleukin (IL)-13, interferon-γ, IL-10, and transforming growth factor (TGF)-β levels in nasal lavage fluid (NALF), as well as OVA-specific IgE levels in serum, were measured. The number of eosinophils in lamina propria was evaluated. RESULTS The levels of serum OVA-specific IgE and IL-13 in NALF were significantly increased in the HB group compared with the IT group (P < .05). Also, the tissue eosinophil counts were higher in the HB group than in the IT group (P < .05). CONCLUSION HR2 antagonist impaired OVA-specific immunotherapy in mice. Although confirmation of this preliminary result is needed, these findings suggest that HR2 receptors may have inhibitory effects on immune tolerance. The authors suggest that application of this property could enhance the efficiency of allergen-specific immunotherapy.
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Affiliation(s)
- Ji-Hyeon Shin
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, the Catholic University of Korea, Seoul, Korea
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