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Mori F, Saretta F, Riscassi S, Caimmi S, Bottau P, Liotti L, Franceschini F, Bianchi A, Valluzzi RL, Crisafulli G, Caffarelli C. Risk factors for drug hypersensitivity reactions in children. Ital J Pediatr 2024; 50:127. [PMID: 39010141 PMCID: PMC11247891 DOI: 10.1186/s13052-024-01694-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024] Open
Abstract
Drug hypersensitivity reactions are common in children. Risk factors predisposing to IgE-mediated drug allergies and delayed drug reactions are a matter of debate. Gender, age, previous reactions to the same drug or to another drug, reduced drug metabolism, chronic diseases, polypharmacy, drug doses are linked with the onset of hypersensitivity reactions in some children. Novel advances in genetic polymorphisms can rapidly change the approach to the prevention of reactions since gene testing can be a useful screening test for severe cutaneous adverse reactions. Viral infections may act as cofactors in susceptible individuals. Polypharmacy, high doses, repeated doses and parental route of administration are also risk factors. Clinicians should take into account risk factors to allow the risk-benefit balance to be maintained.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139, Florence, Italy
| | - Francesca Saretta
- Dipartimento Materno-Infantile, SC Pediatria, Ospedale Latisana-Palmanova, Azienda Sanitaria Universitaria Friuli Centrale, 33100, Udine, Italy
| | - Sara Riscassi
- UOC Di Pediatria, Ospedale Bolzano, Azienda Sanitaria Dell'Alto Adige, Bolzano, 39100, Italy
| | - Silvia Caimmi
- SC Di Pediatria, Fondazione IRCSS Policlinico San Matteo, 27100, Pavia, Italy
| | - Paolo Bottau
- UOC Di Pediatria E Neonatologia, Ospedale Imola (BO), Imola, 40026, Italy
| | - Lucia Liotti
- UOC Pediatria, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", 60100, Ancona, Italy
| | | | - Annamaria Bianchi
- UOC Pediatria, Azienda Ospedaliera San Camillo Forlanini, 00152, Rome, Italy
| | - Rocco Luigi Valluzzi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Giuseppe Crisafulli
- Dipartimento Materno-Infantile, UOC Pediatria, University of Messina, Messina, 98122, Italy
| | - Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, 43123, Parma, Italy.
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Kwan N, Kang K, Carr RR, Mak R, Roberts A, Jin F, Bone JN, Rassekh SR, Wong T. True Rate of Allergy among Pediatric Inpatients with Penicillin Allergy Labels (TRIAL). Can J Hosp Pharm 2024; 77:e3531. [PMID: 38988874 PMCID: PMC11210598 DOI: 10.4212/cjhp.3531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/25/2024] [Indexed: 07/12/2024]
Abstract
Background Penicillin allergy is a common drug allergy diagnosis in pediatric patients; however, upon appropriate allergy testing, many of these patients are found not to have a true allergy. For patients with a reported allergy, alternative antibiotics are prescribed, which are less effective, more toxic, or more expensive. There is a lack of data evaluating allergies in hospitalized children and comparing allergy assessments conducted by pediatric allergists and pharmacists. Objective To estimate the percentage of pediatric patients admitted with reported penicillin allergy who did not have a true penicillin allergy. Methods This single-centre prospective cohort study included inpatients between 6 months and 17 years of age, with a documented penicillin allergy, who were admitted to the general pediatric and oncology units of a tertiary care children's hospital between November 2019 and March 2023. The allergy history, evaluation, and risk categorization were performed by pharmacists. The history was reviewed with the allergist, and the patient was then referred, underwent skin testing, or received oral amoxicillin challenge with monitoring for 1 hour. Results Thirty patients were included, of whom 29 (97%) had delabelling of their penicillin allergy. Four patients (13%) had delabelling on the basis of history alone, without risk assessment. Twenty-five (83%) of the patients were assessed as having low risk; 24 of these had delabelling following oral challenge, and 1 did not complete the oral challenge because of transfer to another hospital. One patient (3%) was assessed as having moderate risk, with delabelling on the basis of results of skin testing and oral challenge. The pharmacist's and allergist's risk assessments were in agreement in 29 (97%) of the 30 cases. Conclusions Pediatric patients, including those with oncologic malignancies, are often mislabelled as having a penicillin allergy. Pharmacists are able to accurately determine true allergy risk and delabel penicillin allergies for pediatric patients in the hospital setting.
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Affiliation(s)
- Natasha Kwan
- BSc(Pharm), ACPR, PharmD, is with the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia
| | - Kristopher Kang
- MD, FRCPC, is with the Division of General Pediatrics, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Roxane R Carr
- BSc, BSc(Pharm), ACPR, PharmD, FCSHP, BCPS, is with the Department of Pharmacy, Children's and Women's Health Centre of British Columbia, and the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Raymond Mak
- BSc, MD, FRCPC, is with the Division of Allergy and Immunology, Department of Pediatrics, and the Division of Allergy and Immunology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia
| | - Ashley Roberts
- MD, MEd, FRCPC, is with the Division of Infectious Diseases, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Falla Jin
- BA, is with the BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - Jeffrey N Bone
- MSc, is with the BC Children's Hospital Research Institute, Vancouver, British Columbia
| | - S Rod Rassekh
- , BSc, MD, MHSc, is with the Division of Hematology, Oncology and Bone Marrow Transplant, Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia
| | - Tiffany Wong
- MD, FRCPC, is with the Division of Allergy and Immunology, Department of Pediatrics, and the BC Children's Hospital Research Institute, The University of British Columbia, Vancouver, British Columbia
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Mori F, Liccioli G, Tomei L, Barni S, Giovannini M, Sarti L, Pessina B, Torres MJ. How to manage drug-virus interplay underlying skin eruptions in children. World Allergy Organ J 2024; 17:100877. [PMID: 38361746 PMCID: PMC10864808 DOI: 10.1016/j.waojou.2024.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/18/2024] [Accepted: 01/26/2024] [Indexed: 02/17/2024] Open
Abstract
The majority of viral rashes occurring during an antibiotic therapy are considered as a drug hypersensitivity reaction (DHR). Differentiating a viral rash versus a DHR is difficult or even impossible. In delayed DHRs the interplay between viruses and drugs is summarized according to the recent literature. The question is if the same reaction will again occur in case of drug re-exposure in absence of the concomitant viral infection because of persistent immune reactivity. Epstein Barr Virus (EBV) and Human Herpes virus 6 (HHV-6) models are analyzed in case of maculopapular exanthemas (MPEs) and drug reaction with eosinophilia and systemic symptoms (DRESS) over a course of drug therapy. MPEs are the most common skin manifestation during a viral infection and a concomitant drug therapy. In type IVb reactions to drugs a hapten/pro-hapten mechanism and a pharmacological interaction (p-i mechanism) are described as the 2 major ways to make T cells response functional. Rarely the altered repertoire model is involved. The Human Leukocyte Antigen (HLA) predisposition is an additional essential factor that can facilitate DHR. In MPEs rarely a DHR is confirmed by allergy testing. Severity and duration of MPEs, the presence of eosinophilia and systemic symptoms make more reliable the persistent nature of the reaction. Research on this topic is needed in order to provide the clinicians with instruments to decide when to suspect future reactions upon drug re-exposure even in the absence of a viral infection, because those patients should be investigated by a complete drug allergy work up.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Benedetta Pessina
- Allergy Unit, Department of Pediatrics, Meyer Children's Hospital IRCCS, Florence, Italy
| | - María José Torres
- Allergy Unit, Hospital Regional Universitario de Málaga-UMA-ARADyAL, Malaga, Spain
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Elzagallaai AA, Rieder MJ. Novel insights into molecular and cellular aspects of delayed drug hypersensitivity reactions. Expert Rev Clin Pharmacol 2023; 16:1187-1199. [PMID: 38018416 DOI: 10.1080/17512433.2023.2289543] [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: 09/18/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Delayed drug hypersensitivity reactions (DDHRs) represent a major health problem. They are unpredictable and can cause life-long disability or even death. The pathophysiology of DDHRs is complicated, multifactorial, and not well understood mainly due to the lack of validated animal models or in vitro systems. The role of the immune system is well demonstrated but its exact pathophysiology still a matter of debate. AREA COVERED This review summarizes the current understanding of DDHRs pathophysiology and abridges the available new evidence supporting each hypothesis. A comprehensive literature search for relevant publications was performed using PubMed, Google Scholar, and Medline databases with no date restrictions and focusing on the most recent 10 years. EXPERT OPINION Although multiple milestones have been achieved in our understanding of DDHRs pathophysiology as a result of the development of useful experimental models, many questions are yet to be fully answered. A deeper understanding of the mechanistic basis of DDHRs would not only facilitate the development of robust and reliable diagnostic assays for diagnosis, but would also inform therapy by providing specific target(s) for immunomodulation and potentially permit pre-therapeutic risk assessment to pursue the common goal of safe and effective drug therapy.
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Affiliation(s)
- Abdelbaset A Elzagallaai
- Department of Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Michael J Rieder
- Department of Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics and Physiology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Strobl J, Haniffa M. Functional heterogeneity of human skin-resident memory T cells in health and disease. Immunol Rev 2023; 316:104-119. [PMID: 37144705 PMCID: PMC10952320 DOI: 10.1111/imr.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/06/2023]
Abstract
The human skin is populated by a diverse pool of memory T cells, which can act rapidly in response to pathogens and cancer antigens. Tissue-resident memory T cells (TRM ) have been implicated in range of allergic, autoimmune and inflammatory skin diseases. Clonal expansion of cells with TRM properties is also known to contribute to cutaneous T-cell lymphoma. Here, we review the heterogeneous phenotypes, transcriptional programs, and effector functions of skin TRM . We summarize recent studies on TRM formation, longevity, plasticity, and retrograde migration and contextualize the findings to skin TRM and their role in maintaining skin homeostasis and altered functions in skin disease.
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Affiliation(s)
- Johanna Strobl
- Department of DermatologyMedical University of ViennaViennaAustria
- CeMM Research Center for Molecular MedicineViennaAustria
| | - Muzlifah Haniffa
- Wellcome Sanger InstituteCambridgeUK
- Department of Dermatology and NIHR Newcastle Biomedical Research CentreNewcastle Hospitals NHS Foundation TrustNewcastle upon TyneUK
- Biosciences InstituteNewcastle UniversityNewcastle upon TyneUK
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Zhang R, Mao Z, Xu C, Wang W, Kwong JSW, Xu M, Song Y, Lv T, Teng Z, Zhong R, Liu H, Liu Y, Wang Q, Wang Y, Zhang Y, Chen S, Chai X, He R, Zheng W, Zhang J. Association between Antibiotic Exposure and the Risk of Rash in Children with Infectious Mononucleosis: a Multicenter, Retrospective Cohort Study. Antimicrob Agents Chemother 2023; 67:e0024923. [PMID: 37219437 PMCID: PMC10269065 DOI: 10.1128/aac.00249-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/13/2023] [Indexed: 05/24/2023] Open
Abstract
Present evidence suggests that the administration of antibiotics, particularly aminopenicillins, may increase the risk of rash in children with infectious mononucleosis (IM). This retrospective, multicenter cohort study of children with IM was conducted to explore the association between antibiotic exposure in IM children and the risk of rash. A robust error generalized linear regression was performed to address the potential cluster effect, as well as confounding factors such as age and sex. A total of 767 children (aged from 0 to 18 years) with IM from 14 hospitals in Guizhou Province were included in the final analysis. The regression analysis implied that exposure to antibiotics was associated with a significantly increased incidence of overall rash in IM children (adjusted odds ratio [AOR], 1.47; 95% confidence interval [CI], ~1.04 to 2.08; P = 0.029). Of 92 overall rash cases, 43 were probably related to antibiotic exposure: two cases (4.08%) in the amoxicillin-treated group and 41 (8.15%) in the group treated with other antibiotics. Regression analysis indicated that the risk of rash induced by amoxicillin in IM children was similar to that induced by other penicillins (AOR, 1.12; 95% CI, ~0.13 to 9.67), cephalosporins (AOR, 2.45; 95% CI, ~0.43 to 14.02), or macrolides (AOR, 0.91; 95% CI, ~0.15 to 5.43). Antibiotic exposure may be associated with an increased risk of overall rash in IM children, but amoxicillin was not found to be associated with any increased risk of rash during IM compared to other antibiotics. We suggest that clinicians be vigilant against the occurrence of rash in IM children receiving antibiotic therapy, rather than indiscriminately avoiding prescribing amoxicillin.
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Affiliation(s)
- Rui Zhang
- Department of Pharmacy, Guizhou Provincial People’s Hospital, Guiyang, China
| | - Zhen Mao
- Department of Pharmacy, Guiyang Maternal and Child Health Care Hospital, Guiyang, China
| | - Chang Xu
- College of Public Health, Anhui Medical University, Hefei, China
| | - Wen Wang
- Chinese Evidence-Based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
| | - Joey Sum-wing Kwong
- Global Health Nursing, Graduate School of Nursing Science, St. Luke’s International University, Tokyo, Japan
| | - Minjie Xu
- Department of Pharmacy, Liupanshui Maternal and Child Health Care Hospital, Liupanshui, China
| | - Yi Song
- Department of Pharmacy, Tongren City People’s Hospital, Tongren, China
| | - Tianyi Lv
- Department of Pharmacy, Xingyi People’s Hospital, Xingyi, China
| | - Zhiyuan Teng
- Department of Pharmacy, Guiyang Second People’s Hospital, Guiyang, China
| | - Ruifeng Zhong
- Department of Pharmacy, Jinsha People’s Hospital, Bijie, China
| | - Hui Liu
- Department of Pharmacy, Anshun People’s Hospital of Guizhou Province, Anshun, China
| | - Yang Liu
- Department of Pharmacy, The Second Affiliated Hospital of Guizhou Medical University, Kaili, China
| | - Qin Wang
- Department of Pharmacy, People’s Hospital of Qianxinan Prefecture, Xingyi, China
| | - Ying Wang
- Department of Pharmacy, GuiHang GuiYang Hospital, Guiyang, China
| | - Yuan Zhang
- Department of Pharmacy, The First People’s Hospital of Bijie, Bijie, China
| | - Shuya Chen
- Department of Pharmacy, The First People’s Hospital of Guiyang, Guiyang, China
| | - Xiuli Chai
- Department of Pharmacy, Qiannan Buyei and Miao Autonomous Prefecture People’s Hospital, Duyun, China
| | - Rui He
- Department of Laboratory Medicine, Experimental Cancer Medicine, Karolinska Institute, Stockholm, Sweden
| | - Wenyi Zheng
- Department of Laboratory Medicine, Experimental Cancer Medicine, Karolinska Institute, Stockholm, Sweden
| | - Jiaxing Zhang
- Department of Pharmacy, Guizhou Provincial People’s Hospital, Guiyang, China
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In Vitro Assays for Diagnosis of Drug-Induced Nonsevere Exanthemas: A Systematic Review and Meta-Analysis. J Immunol Res 2022; 2022:2386654. [PMID: 36590449 PMCID: PMC9797304 DOI: 10.1155/2022/2386654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/20/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
Frequent mislabelled causal relationship between drug hypersensitivity reactions and culprit drugs reinforces the need for an accurate diagnosis. The systematic reviews and meta-analyses of in vitro assays published so far focused on immediate reactions and the most severe delayed reactions, while the most frequent drug-induced delayed reactions-nonsevere exanthemas-have been underestimated. We aim to fill this gap. A systematic review of studies on in vitro assays used in the diagnosis of nonsevere drug-induced delayed reactions was conducted following the methodology of Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies Statement. The EMBASE and PubMed databases were searched. We have included 33 studies from which we extracted the data, then performed meta-analysis where possible, or synthesised the evidence narratively. The quality of the analysed studies was assessed with the QUADAS-2 tool. The tests identified the most frequently were lymphocyte transformation test (LTT), ELISpot, and ELISA. In the meta-analysis carried out for LTT in reactions induce by beta-lactams, the pool estimate of sensitivity and specificity amounted to 49.1% (95% CI: 14.0%, 85.0%) and 94.6% (95% CI: 81.7%, 98.6%), respectively. The studies showed heterogeneity in study design and laboratory settings, which resulted in a wide range of specificity and sensitivity of testing.
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Amin MT, Abd El Aty MA, Ahmed SM, Elsedfy GO, Hassanin ES, El-Gazzar AF. Over prescription of antibiotics in children with acute upper respiratory tract infections: A study on the knowledge, attitude and practices of non-specialized physicians in Egypt. PLoS One 2022; 17:e0277308. [PMID: 36327297 PMCID: PMC9632891 DOI: 10.1371/journal.pone.0277308] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is currently one of the global public health threats. Increased antibiotic consumption in humans, animals, and agriculture has contributed directly to the spread of AMR. Upper respiratory tract infections (URIs) are one of the most common conditions treated by antibiotics, even if unnecessary as in cases of viral infections and self-limited conditions which represent the most cases of URIs. Investigating physicians' knowledge, attitudes, and practice regarding antibiotic prescriptions in children with acute URIs may reflect the problem of antibiotic over prescription. This study aims to assess the problem in our community and provide information for further planning of appropriate interventions to optimize antibiotic prescriptions. METHODS This is a cross-sectional study for all non-specialized physicians dealing with acute upper respiratory tract infections (URIs) in pediatrics sittings in Assiut district, Egypt. We used a self-administered questionnaire to assess physicians' knowledge, attitudes, and practice. In addition, four clinical vignettes addressing different URI scenarios were included in the questionnaire to assess the patterns of antibiotic prescriptions in common cases. RESULTS Our study included 153 physicians whose mean age was 32.2 ± 8.7, most of whom were pediatric residents in different health institutes in Assiut district. They had good knowledge as out of the 17 knowledge questions,the mean number of correct answers was 12.4 ± 2.9. Regarding their attitudes, mean attitude scores for inappropriate antibiotic prescribing were low. However, of those scores, the responsibility of others had the highest score (3.8 ± 0.61). Prescribing practice in special conditions of URIs showed that 80% of participants prescribed antibiotics if fever continued for more than five days and 61.4% if the child had a yellowish or greenish nasal discharge. Among 612 clinical vignettes, 326 contained antibiotic prescriptions (53.3%), and appropriate antibiotic prescriptions represented only 8.3% overall. CONCLUSIONS Physicians dealing with acute URIs in outpatients' clinics in the Assiut district have good knowledge about antibiotic use and resistance and demonstrate a good attitude toward appropriate antibiotic use. Although the percentage of inappropriate prescriptions in clinical vignettes in high, more research is required to investigate the factors of antibiotic inappropriate prescribing practice and non-adherence to guidelines. Also, it is essential to set up a national antibiotic stewardship program to improve antibiotic prescribing and contain antimicrobial resistance problems.
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Affiliation(s)
- Mariam Taher Amin
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
| | - Mahmoud Attia Abd El Aty
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
| | - Sabra Mohamed Ahmed
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
| | - Ghada Omar Elsedfy
- Faculty of Medicine, Department of Pediatrics, Children’s Hospital, Assiut University, Assiut, Egypt
| | | | - Amira Fathy El-Gazzar
- Faculty of Medicine, Public Health and Community Medicine Department, Assiut University, Assiut, Egypt
- Badr University, Cairo, Egypt
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Yang X, Wang T, Jiang Y, Ren F, Jiang H. Patients' Expectancies to Acupuncture: A Systematic Review. JOURNAL OF INTEGRATIVE AND COMPLEMENTARY MEDICINE 2022; 28:202-217. [PMID: 35294303 DOI: 10.1089/jicm.2021.0128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Objective: This systematic review aimed to document and describe how and when to assess patients' expectancies to acupuncture and the relationship between patients' expectancies and clinical effects. Materials and Methods: Three English databases, including PubMed, Cochrane Central Register of Controlled Trials, and EMBASE, and four Chinese databases, including the Chinese Biomedicine Literature Database, Chinese Journal Full-text Database, Chinese Scientific Journal Full-text Database, and Wanfang Database, were searched up to February 2020. Studies involving patients' expectancies to acupuncture were included. Based on the detailed situations of patients' expectancies, we made a standardized data extraction table that included the basic information of articles, study design details, and measurement of expectations. Based on the data, a descriptive analysis was performed, covering the characteristics of studies, measuring methods of expectations and the relationship between patients' expectancies and clinical effects. Methodology quality assessment was also performed by the risk of bias and the standards for reporting interventions in controlled trials of acupuncture. Results: There were 61 randomized controlled trials included in our analysis. The number of articles increased gradually over time and grew significantly after 2008. About half of trials focused on pain alleviation. Expectancies were measured before the treatment (N = 43), after the treatment (N = 3), and both before and after the treatment (N = 10), and five studies did not mention it. The measurement of expectancies used self-made questionnaires or scales (N = 27), the Acupuncture Expectations Scale (N = 6), and other scales (N = 11), while 17 studies did not describe what scale they used. The used questionnaires or scales mostly tried to ascertain the strength of confidence that acupuncture would help. Patients' expectancies and clinical effects were relevant in 19 studies, irrelevant in 21 studies, and were not mentioned in 21 studies. Conclusions: Patients' expectations to acupuncture have received increasing attention in recent years, but there is still no recognized measurement time and methods. It is critical to develop questions and answers regarding patients' expectations with better discrimination and reliability to accurately assess expectations and to explore the relationship between patients' expectations and acupuncture outcomes in future trials.
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Affiliation(s)
- Xingyue Yang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Tianlin Wang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Yu Jiang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Feihong Ren
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Honglin Jiang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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Schunkert EM, Shah PN, Divito SJ. Skin Resident Memory T Cells May Play Critical Role in Delayed-Type Drug Hypersensitivity Reactions. Front Immunol 2021; 12:654190. [PMID: 34497600 PMCID: PMC8419326 DOI: 10.3389/fimmu.2021.654190] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/06/2021] [Indexed: 12/31/2022] Open
Abstract
Delayed-type drug hypersensitivity reactions (dtDHR) are immune-mediated reactions with skin and visceral manifestations ranging from mild to severe. Clinical care is negatively impacted by a limited understanding of disease pathogenesis. Though T cells are believed to orchestrate disease, the type of T cell and the location and mechanism of T cell activation remain unknown. Resident memory T cells (TRM) are a unique T cell population potentially well situated to act as key mediators in disease pathogenesis, but significant obstacles to defining, identifying, and testing TRM in dtDHR preclude definitive conclusions at this time. Deeper mechanistic interrogation to address these unanswered questions is necessary, as involvement of TRM in disease has significant implications for prediction, diagnosis, and treatment of disease.
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Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2878-2895.e6. [PMID: 33039012 DOI: 10.1016/j.jaip.2020.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/17/2022]
Abstract
Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.
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Hossenbaccus L, Linton S, Thiele J, Steacy L, Walker T, Malone C, Ellis AK. Clinical validation of controlled exposure to house dust mite in the environmental exposure unit (EEU). Allergy Asthma Clin Immunol 2021; 17:34. [PMID: 33771217 PMCID: PMC7995585 DOI: 10.1186/s13223-021-00536-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/13/2021] [Indexed: 11/10/2022] Open
Abstract
Rationale The Environmental Exposure Unit (EEU), a controlled allergen exposure model of allergic rhinitis (AR), has traditionally utilized seasonal allergens. We sought to clinically validate the use of house dust mite (HDM), a perennial allergen, in the HDM-EEU, a specially designed facility within the larger EEU. Methods Forty-four HDM-allergic and eleven non-allergic participants were screened and deemed eligible for one of two 3-h exposure sessions in the HDM-EEU. Participants were exposed to a modest or higher HDM target, with blood and nasal brushing samples collected before and after allergen exposure. Symptomatic data, including Total Nasal Symptom Score (TNSS), Total Ocular Symptom Score (TOSS), Total Rhinoconjunctivitis Symptom Score (TRSS), and Peak Nasal Inspiratory Flow (PNIF) were collected at baseline, every 30 min until 3 h, on an hourly basis for up to 12 h, and at 24 h following the onset of HDM exposure. Results The modest and higher HDM target sessions respectively featured cumulative total particle counts of 156,784 and 266,694 particles (2.5–25 µm), Der f 1 concentrations of 2.67 ng/m3 and 3.80 ng/m3, and Der p 1 concentrations of 2.07 ng/m3 and 6.66 ng/m3. Allergic participants experienced an increase in symptoms, with modest target participants plateauing at 1.5 to 2 h and achieving a mean peak TNSS of 5.74 ± 0.65, mean peak TOSS of 2.47 ± 0.56, and mean peak TRSS of 9.16 ± 1.32. High HDM-target allergics reached a mean peak TNSS of 8.17 ± 0.71, mean peak TOSS of 4.46 ± 0.62, and mean peak TRSS of 14.08 ± 1.30 at 3 h. All allergic participants’ symptoms decreased but remained higher than baseline after exiting the HDM-EEU. Sixteen participants (37.2%) were classified as Early Phase Responders (EPR), eleven (25.6%) as protracted EPR (pEPR), seven (16.3%) as Dual Phase Responders (DPR), and nine (20.9%) as Poor Responders (PR). Allergic participants experienced significant percent PNIF reductions at hours 2 and 3 compared to healthy controls. Non-allergics were asymptomatic during the study period. Conclusions The HDM-EEU is an appropriate model to study HDM-induced AR as it can generate clinically relevant AR symptoms amongst HDM-allergic individuals.
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Affiliation(s)
- Lubnaa Hossenbaccus
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.,Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Canada
| | - Sophia Linton
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.,Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Jenny Thiele
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.,Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Canada
| | - Lisa Steacy
- Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Canada
| | - Terry Walker
- Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Canada
| | - Crystal Malone
- Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Canada
| | - Anne K Ellis
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada. .,Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Canada. .,Department of Medicine, Queen's University, Kingston, ON, Canada.
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13
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Anci E, Braun C, Marinosci A, Rodieux F, Midun E, Torres MJ, Caubet JC. Viral Infections and Cutaneous Drug-Related Eruptions. Front Pharmacol 2021; 11:586407. [PMID: 33776753 PMCID: PMC7988096 DOI: 10.3389/fphar.2020.586407] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
In the general population, up to 10% of children treated by antibiotics have cutaneous adverse drug reaction, but allergy is confirmed in less than 20% of patients. Most of the non-allergic reactions are probably due to virus, such as enterovirus acute infection or Ebstein-Barr Virus (EBV) acute infection or reactivation. Especially in children, viruses have the propensity to induce skin lesions (maculopapular rash, urticaria) due to their skin infiltration or immunologic response. In drug-related skin eruptions, a virus can participate by activating an immune predisposition. The culprit antibiotic is then the trigger for reacting. Even in severe drug-induced reactions, such as Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, viruses take part in immune phenomena, especially herpes viruses. Understanding the mechanisms of both virus- and drug-induced skin reaction is important to develop our clinical reflection and give an adaptive care to the patient. Our aim is to review current knowledge on the different aspects and potential roles of viruses in the different type of drug hypersensitivity reactions (DHR). Although major advances have been made those past year, further studies are needed for a better understanding of the link between viruses and DHR, to improve management of those patients.
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Affiliation(s)
- Eleonora Anci
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Camille Braun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Pediatric Allergy Unit, University Lyon 1 Claude Bernard, Villeurbanne, France
| | - Annalisa Marinosci
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Frédérique Rodieux
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland
| | - Elise Midun
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.,Pediatric Allergy Unit, University Lyon 1 Claude Bernard, Villeurbanne, France
| | - Maria-Jose Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Universidad de Málaga, Ibima-Bionand-Aradyal, Málaga, Spain
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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14
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Almeida L, Dhillon-LaBrooy A, Castro CN, Adossa N, Carriche GM, Guderian M, Lippens S, Dennerlein S, Hesse C, Lambrecht BN, Berod L, Schauser L, Blazar BR, Kalesse M, Müller R, Moita LF, Sparwasser T. Ribosome-Targeting Antibiotics Impair T Cell Effector Function and Ameliorate Autoimmunity by Blocking Mitochondrial Protein Synthesis. Immunity 2020; 54:68-83.e6. [PMID: 33238133 PMCID: PMC7837214 DOI: 10.1016/j.immuni.2020.11.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 02/08/2023]
Abstract
While antibiotics are intended to specifically target bacteria, most are known to affect host cell physiology. In addition, some antibiotic classes are reported as immunosuppressive for reasons that remain unclear. Here, we show that Linezolid, a ribosomal-targeting antibiotic (RAbo), effectively blocked the course of a T cell-mediated autoimmune disease. Linezolid and other RAbos were strong inhibitors of T helper-17 cell effector function in vitro, showing that this effect was independent of their antibiotic activity. Perturbing mitochondrial translation in differentiating T cells, either with RAbos or through the inhibition of mitochondrial elongation factor G1 (mEF-G1) progressively compromised the integrity of the electron transport chain. Ultimately, this led to deficient oxidative phosphorylation, diminishing nicotinamide adenine dinucleotide concentrations and impairing cytokine production in differentiating T cells. In accordance, mice lacking mEF-G1 in T cells were protected from experimental autoimmune encephalomyelitis, demonstrating that this pathway is crucial in maintaining T cell function and pathogenicity.
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Affiliation(s)
- Luís Almeida
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany; Institute of Medical Microbiology and Hygiene, University Medical Center of the Johannes Gutenberg-University, Mainz 55131, Germany
| | - Ayesha Dhillon-LaBrooy
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany; Institute of Medical Microbiology and Hygiene, University Medical Center of the Johannes Gutenberg-University, Mainz 55131, Germany
| | - Carla N Castro
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany
| | - Nigatu Adossa
- QIAGEN, Aarhus C 8000, Denmark; University of Turku, Computational Biomedicine, Turku Center for Biotechnology, Turku 20520, Finland
| | - Guilhermina M Carriche
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany; Institute of Medical Microbiology and Hygiene, University Medical Center of the Johannes Gutenberg-University, Mainz 55131, Germany
| | - Melanie Guderian
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany
| | | | - Sven Dennerlein
- Department of Cellular Biochemistry, University Medical Center, Göttingen 37073, Germany
| | - Christina Hesse
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover 30625, Germany
| | | | - Luciana Berod
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany; Institute of Molecular Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Bruce R Blazar
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN 55454, USA
| | - Markus Kalesse
- Institute for Organic Chemistry, Leibniz University Hannover, Hannover, Germany; Helmholtz Center for Infection Research (HZI), Braunschweig 38124, Germany
| | - Rolf Müller
- Helmholtz Institute for Pharmaceutical Research, Helmholtz Center for Infection Research and Department of Pharmaceutical Biotechnology, Saarland University, Saarbrücken 66123, Germany
| | - Luís F Moita
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Tim Sparwasser
- Institute of Infection Immunology, TWINCORE, Center for Experimental and Clinical Infection Research, Hannover Medical School and the Helmholtz Center for Infection Research, Hannover 30625, Germany; Institute of Medical Microbiology and Hygiene, University Medical Center of the Johannes Gutenberg-University, Mainz 55131, Germany.
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15
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Cyril G, Rathish B, Wilson A, Warrier A, Viswam V. A Case of Diphtheria and Infectious Mononucleosis Co-Infection in a Partially Vaccinated Boy. Cureus 2020; 12:e11227. [PMID: 33269155 PMCID: PMC7704157 DOI: 10.7759/cureus.11227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report the case of an eight-year-old partially immunized boy who presented with presumed bacterial tonsillitis. He was initially prescribed amoxicillin-clavulanic acid which resulted in the development of an erythematous maculopapular over the face which spread to the trunk and extremities including palms and soles and resolved over the next three days. He was diagnosed to have diphtheria and infectious mononucleosis (IMN) co-infection. He made an uneventful recovery and an extensive review of the literature showed that the incidence of diphtheria and IMN co-infection is a relatively rare clinical entity. We wish to highlight the possibility of such co-infections which often mimic one another.
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Affiliation(s)
| | | | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
| | | | - Vineeth Viswam
- Otolaryngology - Head and Neck Surgery, Aster Medcity, Kochi, IND
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16
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Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. Pharyngitis: Approach to diagnosis and treatment. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:251-257. [PMID: 32273409 PMCID: PMC7145142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To provide family physicians with an updated approach to diagnosis and treatment of pharyngitis, detailing key symptoms, methods of investigation, and a summary of common causes. SOURCES OF INFORMATION The approach described is based on the authors' clinical practice and peer-reviewed literature from 1989 to 2018. MAIN MESSAGE Sore throat caused by pharyngitis is commonly seen in family medicine clinics and is caused by inflammation of the pharynx and surrounding tissues. Pharyngitis can be caused by viral, bacterial, or fungal infections. Viral causes are often self-limiting, while bacterial and fungal infections typically require antimicrobial therapy. Rapid antigen detection tests and throat cultures can be used with clinical findings to identify the inciting organism. Pharyngitis caused by Streptococcus pyogenes is among the most concerning owing to its associated severe complications such as acute rheumatic fever and glomerulonephritis. Hence, careful diagnosis of pharyngitis is necessary to provide targeted treatment. CONCLUSION A thorough history is key to diagnosing pharyngitis. Rapid antigen detection tests should be reserved for concerns about antibiotic initiation. Physicians should exercise restraint in antibiotic initiation for pharyngitis, as restraint does not delay recovery or increase the risk of S pyogenes infections.
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Affiliation(s)
- Edward A Sykes
- First-year resident, Department of Otolaryngology-Head and Neck Surgery at the University of Toronto in Ontario
| | - Vincent Wu
- Second-year resident, Department of Otolaryngology-Head and Neck Surgery at the University of Toronto in Ontario
| | - Michael M Beyea
- Fifth-year resident in the Department of Emergency Medicine at Western University in London, Ont
| | - Matthew T W Simpson
- Family physician in the Department of Family Medicine at Queen's University in Kingston, Ont
| | - Jason A Beyea
- Assistant Professor and Research Director in the Department of Otolaryngology at Queen's University and Adjunct Scientist with ICES Queen's.
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17
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Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2020; 66:e119-e126. [PMID: 32273424 PMCID: PMC7145122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Objectif Offrir aux médecins de famille une approche diagnostique et thérapeutique actualisée de la pharyngite, en décrivant en détail les principaux symptômes, les méthodes d’investigation et un résumé des causes courantes. Sources d’information L’approche décrite est basée sur la pratique clinique des auteurs et sur les publications revues par les pairs de 1989 à 2018. Message principal Le mal de gorge causé par la pharyngite est couramment observé dans les cliniques de médecine familiale; il est causé par l’inflammation du pharynx et des tissus environnants. La pharyngite est causée par une infection virale, bactérienne ou fongique. Les causes virales sont souvent spontanément résolutives, alors que les infections bactériennes et fongiques nécessitent habituellement l’antibiothérapie. Le test de détection rapide de l’antigène et la culture de gorge sont jumelés aux observations cliniques pour identifier l’organisme en cause. La pharyngite causée par streptococcus pyogenes fait partie des organismes les plus préoccupants en raison de ses complications graves, telles la fièvre rhumatismale aiguë et la glomérulonéphrite. Ainsi, il est nécessaire de poser un diagnostic attentif de pharyngite afin de pouvoir dispenser un traitement ciblé. Conclusion L’anamnèse détaillée est la clé du diagnostic de pharyngite. Le test de détection rapide de l’antigène doit être réservé aux cas où l’instauration de l’antibiothérapie est préoccupante. Les médecins doivent user de retenue lorsqu’ils instaurent l’antibiothérapie contre la pharyngite, puisque la retenue ne retarde pas le rétablissement ni n’augmente le risque d’infection à s. pyogenes.
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Affiliation(s)
| | - Vincent Wu
- Résident de deuxième année au département d'oto-rhino-laryngologie - Chirurgie de la tête et du cou à l'Université de Toronto, en Ontario
| | - Michael M Beyea
- Résident de cinquième année au département de médecine d'urgence à l'Université Western à London, Ontario
| | - Matthew T W Simpson
- Médecin de famille au département de médecine familiale à l'Université Queen's à Kingston, Ontario
| | - Jason A Beyea
- Professeur adjoint et directeur de la recherche au département d'oto-rhino-laryngologie de l'Université Queen's, et scientifique agrégé à l'ICES de l'Université Queen's.
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18
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Santiago LG, Morgado FJ, Baptista MS, Gonçalo M. Hypersensitivity to antibiotics in drug reaction with eosinophilia and systemic symptoms (DRESS) from other culprits. Contact Dermatitis 2020; 82:290-296. [DOI: 10.1111/cod.13462] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/29/2019] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Luis G. Santiago
- Department of DermatologyCoimbra University Hospital Coimbra Portugal
| | | | | | - Margarida Gonçalo
- Department of DermatologyCoimbra University Hospital Coimbra Portugal
- Faculty of MedicineUniversity of Coimbra Coimbra Portugal
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19
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Kwda A, Gldc P, Baui B, Kasr K, Us H, S W, Kantha L, Ksh DS. Effect of long term inhaled corticosteroid therapy on adrenal suppression, growth and bone health in children with asthma. BMC Pediatr 2019; 19:411. [PMID: 31684902 PMCID: PMC6829958 DOI: 10.1186/s12887-019-1760-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/09/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are the most effective treatment for children with persistent asthma. However adverse effects of ICS on Hypothalamo Pituitary Adrenal (HPA) axis, growth and bone metabolism are a concern. Hence the primary objective of this study was to describe the effects of long term inhaled corticosteroid therapy (ICS) on adrenal function, growth and bone health in children with asthma in comparison to an age and sex matched group of children with asthma who were not on long term ICS. Describing the association between the dose of ICS and duration of therapy on the above parameters were secondary objectives. METHOD Seventy children with asthma on ICS and 70 controls were studied. Diagnosis of asthma in selected patients was reviewed according to the criteria laid down by GINA 2018 guidelines. The estimated adult heights were interpreted relative to their Mid Parental Height (MPH) range. Serum calcium, alkaline phosphatase and vitamin D levels were analyzed in both groups and cortisol value at 30 min following a low dose short synacthen test was obtained from the study group. The average daily dose of ICS (Beclamethasone) was categorized as low, medium and high (100-200, 200-400, > 400 μg /day) respectively according to published literature. RESULTS Heights of all children were within the MPH range. There was no statistically significant difference in the bone profiles and vitamin D levels between the two groups (Ca: p = 0.554, vitamin D: p = 0.187) but vitamin D levels were insufficient (< 50 nmol/l) in 34% of cases and 41% of controls. Suppressed cortisol levels were seen in 24%. Doses of ICS were low, medium and high in 56, 32 and 12% of children respectively. The association between adrenal suppression with longer duration of therapy (p < 0.01) and with increasing dose of ICS (p < 0.001) were statistically significant. CONCLUSION ICS had no impact on the growth and bone profiles but its dose and duration were significantly associated with adrenal suppression.
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Affiliation(s)
- Anuradha Kwda
- Lecturer Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
- Acting paediatric pulmonologist, University paediatric unit, Lady Ridgeway Hospital for children, Colombo, Sri Lanka.
| | - Prematilake Gldc
- Acting paediatric endocrinologist, Lady Ridgeway Hospital for children, Colombo, Sri Lanka
| | - Batuwita Baui
- Research Assistant, University paediatrc unit, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Kannangoda Kasr
- Medical Officer, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Hewagamage Us
- Medical Officer, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Wijeratne S
- Laboratory Director, Vindana Reproductive Health Centre, Colombo, Sri Lanka
| | - Lankatilake Kantha
- Associate Professor, Department of Community Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - de Silva Ksh
- Professor in paeditrics ,Faculty of Medicine, University of Colombo and Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
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20
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Turkmani MG, De Boulle K, Philipp-Dormston WG. Delayed hypersensitivity reaction to hyaluronic acid dermal filler following influenza-like illness. Clin Cosmet Investig Dermatol 2019; 12:277-283. [PMID: 31118731 PMCID: PMC6501047 DOI: 10.2147/ccid.s198081] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/15/2019] [Indexed: 12/20/2022]
Abstract
Background: Delayed reactions after facial hyaluronic acid injection are relatively rare complications. Their cause may be infectious or immune-mediated in origin, and their outbreak can be triggered, for example, by an influenza-like illness. Objective: To describe potential adverse event of influenza like illness following dermal filler injection. Methods: We report fourteen unusual cases of delayed hypersensitivity reaction to several brands of hyaluronic acid dermal filler following influenza like illness. Results: Increasing evidence implicates influenza infection in the pathogenesis of late onset filler reaction. Conclusion: Although there is a low risk of late onset adverse reaction with hyaluronic acid fillers, injecting physicians must be aware of the possible filler reaction following the influenza infection.
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Sensitization to amoxicillin/clavulanic acid may underlie severe rashes in children treated for infectious mononucleosis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:728-731.e1. [DOI: 10.1016/j.jaip.2018.06.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 06/16/2018] [Accepted: 06/20/2018] [Indexed: 11/18/2022]
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22
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Washington NR, Petersen K, Petersen M. The Clindamycin Catastrophe: A Case of Antibiotic-Induced Skin Eruption. Clin Pediatr (Phila) 2019; 58:120-122. [PMID: 30288987 DOI: 10.1177/0009922818805204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Maureen Petersen
- 1 Walter Reed National Military Medical Center, Bethesda, MD, USA
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Brockow K, Ardern‐Jones MR, Mockenhaupt M, Aberer W, Barbaud A, Caubet J, Spiewak R, Torres MJ, Mortz CG. EAACI position paper on how to classify cutaneous manifestations of drug hypersensitivity. Allergy 2019; 74:14-27. [PMID: 30028512 DOI: 10.1111/all.13562] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are common, and the skin is by far the most frequently involved organ with a broad spectrum of reaction types. The diagnosis of cutaneous DHRs (CDHR) may be difficult because of multiple differential diagnoses. A correct classification is important for the correct diagnosis and management. With these guidelines, we aim to give precise definitions and provide the background needed for doctors to correctly classify CDHR.
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Affiliation(s)
- Knut Brockow
- Department of Dermatology und Allergology Biederstein Technical University of Munich Munich Germany
| | - Michael R. Ardern‐Jones
- Department of Dermatology Southampton General Hospital University Hospitals Southampton NHS Foundation Trust Southampton UK
- Department of Dermatoimmunology Sir Henry Wellcome Laboratories Clinical, Experimental Sciences Faculty of Medicine University of Southampton Southampton UK
| | - Maja Mockenhaupt
- “Dokumentationszentrum schwerer Hautreaktionen” (dZh) Department of Dermatology Medical Center and Medical Faculty University of Freiburg Freiburg Germany
| | - Werner Aberer
- Department of Dermatology Medical University of Graz Graz Austria
| | - Annick Barbaud
- Department of Dermatology and Allergology Tenon Hospital (AP‐HP) Sorbonne Universities, Pierre et Marie Curie University Paris 6 France
| | | | - Radoslaw Spiewak
- Department of Experimental Dermatology and Cosmetology Jagiellonian University Medical College Krakow Poland
| | - María José Torres
- Allergy Unit IBIMA‐ Regional University Hospital of Malaga‐UMA, Aradyal Malaga Spain
| | - Charlotte G. Mortz
- Department of Dermatology and Allergy Center Odense Research Center for Anaphylaxis (ORCA) Odense University Hospital Odense Denmark
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Adkinson NF, Mendelson LM, Ressler C, Keogh JC. Penicillin minor determinants: History and relevance for current diagnosis. Ann Allergy Asthma Immunol 2018; 121:537-544. [PMID: 30248407 DOI: 10.1016/j.anai.2018.09.459] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To review the history of the penicillin minor determinants and evaluate their relevance for current diagnosis. DATA SOURCES Skin testing to detect immunoglobulin E (IgE) sensitivity to penicillins in patients with a history of penicillin allergy has been the subject of more than 55 years of published research involving tens of thousands of patients. STUDY SELECTIONS Selection of data was based on its relevance to the objective of this article. RESULTS It was established early on that testing with the major penicilloyl determinant using the polyvalent penicilloyl-polylysine (PPL) is negative in a substantial portion (10% to 64%, including recent increases) of those at risk for immediate hypersensitivity reactions. A variety of minor penicillin determinants are clinically significant in that their use in skin testing is essential to detect all those at risk. In particular, a minor determinant mixture of benzylpenicillin, benzylpenicilloate, and benzylpenilloate, used in conjunction with PPL, has been shown in numerous studies to achieve an average negative predictive value (NPV) of 97.9% in history-positive patients. Benzylpenicillin alone, as the sole minor determinant, leaves many skin test-positive patients undiscovered. Use of amoxicillin as an additional minor determinant reagent appears to identify another 2% to 8% of skin test-positive patients in some populations. CONCLUSION IgE skin testing, using both the major and appropriate minor determinants of penicillin, can identify, with a high degree of reliability (NPV ∼97%), penicillin allergy history-positive patients who can receive beta-lactam antibiotics without concern for serious acute allergy, including anaphylaxis. The few false-negative skin tests reported globally are largely confined to minor, self-limited cutaneous reactions.
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Affiliation(s)
- N Franklin Adkinson
- Division of Allergy & Clinical Immunology, Johns Hopkins Asthma & Allergy Center, Baltimore, Maryland; AllerQuest LLC, Plainville, Connecticut.
| | - Louis M Mendelson
- AllerQuest LLC, Plainville, Connecticut; University of Connecticut School of Medicine, New England Food Allergy Center, Farmington, Connecticut
| | - Charlotte Ressler
- AllerQuest LLC, Plainville, Connecticut; University of Connecticut School of Medicine, Farmington, Connecticut
| | - John C Keogh
- AllerQuest LLC, Plainville, Connecticut; Keogh Medical Writing, LLC, Guilford, Connecticut
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Kearns PKA, Casey HA, Leach JP. Hypothesis: Multiple sclerosis is caused by three-hits, strictly in order, in genetically susceptible persons. Mult Scler Relat Disord 2018; 24:157-174. [PMID: 30015080 DOI: 10.1016/j.msard.2018.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/25/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
Abstract
Multiple Sclerosis is a chronic, progressive and debilitating neurological disease which, despite extensive study for over 100 years, remains of enigmatic aetiology. Drawn from the epidemiological evidence, there exists a consensus that there are environmental (possibly infectious) factors that contribute to disease pathogenesis that have not yet been fully elucidated. Here we propose a three-tiered hypothesis: 1) a clinic-epidemiological model of multiple sclerosis as a rare late complication of two sequential infections (with the temporal sequence of infections being important); 2) a proposal that the first event is helminthic infection with Enterobius Vermicularis, and the second is Epstein Barr Virus infection; and 3) a proposal for a testable biological mechanism, involving T-Cell exhaustion for Epstein-Barr Virus protein LMP2A. We believe that this model satisfies some of the as-yet unexplained features of multiple sclerosis epidemiology, is consistent with the clinical and neuropathological features of the disease and is potentially testable by experiment. This model may be generalizable to other autoimmune diseases.
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Tonson la Tour A, Michelet M, Eigenmann PA, Caubet JC. Natural History of Benign Nonimmediate Allergy to Beta-Lactams in Children: A Prospective Study in Retreated Patients After a Positive and a Negative Provocation Test. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1321-1326. [DOI: 10.1016/j.jaip.2017.10.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 12/01/2022]
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Lampejo T, Lambourne J, Armstrong M, Checkley AM, Nastouli E. Epstein-Barr virus and cytomegalovirus mononucleosis: Important causes of febrile illness in returned travellers. Travel Med Infect Dis 2017; 19:28-32. [PMID: 28943374 DOI: 10.1016/j.tmaid.2017.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 09/19/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Diagnosing the cause of fever in the returned traveller is challenging. Efforts often focus on identifying 'exotic' pathogens. Primary Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections cause clinical features that overlap with many exotic pathogens. The age-matched seroprevalence of both EBV and CMV is greater in tropical than temperate areas. We describe the clinical and laboratory features of returned travellers diagnosed with primary CMV and EBV syndromes. METHODS Patients with laboratory-confirmed primary EBV and CMV infections who had attended the Hospital for Tropical Diseases (HTD), London between 1st October 2011 and 1st October 2016 were identified. Clinical and laboratory data were obtained and analysed. RESULTS Twenty-two patients with primary EBV infection and 31 with primary CMV infection were identified. The commonest presenting features of both infections were fever (81.1%), headache (50.9%) and arthralgia/myalgia (49.1%). Cervical lymphadenopathy was seen more frequently with EBV than with CMV (59.1% vs. 25.8%, P = 0.02). Transaminitis (79.2%) and lymphocytosis (52.8%) were the commonest laboratory abnormalities in both groups. CONCLUSIONS Primary EBV and CMV infections are important causes of febrile illness in returning travellers. Identification of these pathogens prevents unnecessary, expensive investigations for more 'exotic' pathogens and impacts clinical management for example facilitating prognostication and antimicrobial stewardship.
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Affiliation(s)
- Temi Lampejo
- University College London Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Jonathan Lambourne
- Division of Infection, Royal London Hospital, 80 Newark Street, London E1 2ES, United Kingdom
| | - Margaret Armstrong
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Anna M Checkley
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Eleni Nastouli
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
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[DRESS and viruses]. Ann Dermatol Venereol 2017; 145:120-124. [PMID: 28911824 DOI: 10.1016/j.annder.2017.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 05/26/2017] [Accepted: 07/21/2017] [Indexed: 12/20/2022]
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Homsy A, Rüegg EM, Jandus P, Pittet-Cuénod B, Modarressi A. Immunological reaction after facial hyaluronic acid injection. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2017; 4:68-72. [PMID: 28804742 PMCID: PMC5532757 DOI: 10.1080/23320885.2017.1356202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 07/12/2017] [Indexed: 11/01/2022]
Abstract
We report two rare cases of inflammatory reactions with multiple subcutaneous facial painful collections after Hyaluronic acid injections, expose their management and discuss aetiologic hypothesis. Due to unfavourable evolution despite antibiotic treatment, surgical drainage was performed. Immune-mediated delayed hypersensitivity reactions were the most probable cause.
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Affiliation(s)
- Antoine Homsy
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Geneva University Hospitals, University of GenevaGenevaSwitzerland
| | - Eva Meia Rüegg
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Geneva University Hospitals, University of GenevaGenevaSwitzerland
| | - Peter Jandus
- Immunology and Allergology Unit, Faculty of Medicine, Geneva University Hospitals, University of GenevaGenevaSwitzerland
| | - Brigitte Pittet-Cuénod
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Geneva University Hospitals, University of GenevaGenevaSwitzerland
| | - Ali Modarressi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Geneva University Hospitals, University of GenevaGenevaSwitzerland
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Roujeau JC, Dupin N. Virus Reactivation in Drug Reaction with Eosinophilia and Systemic Symptoms (Dress) Results from a Strong Drug-Specific Immune Response. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:811-812. [DOI: 10.1016/j.jaip.2016.11.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 10/19/2022]
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Konvinse KC, Phillips EJ, White KD, Trubiano JA. Old dog begging for new tricks: current practices and future directions in the diagnosis of delayed antimicrobial hypersensitivity. Curr Opin Infect Dis 2016; 29:561-576. [PMID: 27753687 PMCID: PMC5113146 DOI: 10.1097/qco.0000000000000323] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antimicrobials are a leading cause of severe T cell-mediated adverse drug reactions (ADRs). The purpose of this review is to address the current understanding of antimicrobial cross-reactivity and the ready availability of and evidence for in-vitro, in-vivo, and ex-vivo diagnostics for T cell-mediated ADRs. RECENT FINDINGS Recent literature has evaluated the efficacy of traditional antibiotic allergy management, including patch testing, skin prick testing, intradermal testing, and oral challenge. Although patch and intradermal testing are specific for the diagnosis of immune-mediated ADRs, they suffer from drug-specific limitations in sensitivity. The use of ex-vivo diagnostics, especially enzyme-linked immunospot, has been highlighted as a promising new approach to assigning causality. Knowledge of true rates of antimicrobial cross-reactivity aids empirical antibiotic choice in the setting of previous immune-mediated ADRs. SUMMARY In an era of increasing antimicrobial resistance and use of broad-spectrum antimicrobial therapy, ensuring patients are assigned the correct 'allergy label' is essential. Re-exposure to implicated antimicrobials, especially in the setting of severe adverse cutaneous reaction, is associated with significant morbidity and mortality. The process through which an antibiotic label gets assigned, acted on and maintained is still imprecise. Predicting T cell-mediated ADRs via personalized approaches, including human leukocyte antigen-typing, may pave future pathways to safer antimicrobial prescribing guidelines.
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Affiliation(s)
- Katherine C Konvinse
- aDepartment of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA bInstitute for Immunology and Infectious Diseases, Murdoch University, Western Australia, Australia cDepartment of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA dDepartment of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA eDepartment of Infectious Diseases, Austin Hospital, Victoria, Australia fDepartment of Infectious Diseases, Alfred Hospital, Victoria, Australia gDepartment of Infectious Diseases, Peter MacCallum Cancer Centre, Victoria, Australia hDepartment of Medicine, University of Melbourne, Victoria, Australia
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Santos-Alarcón S, Sanchis-Sánchez C, Benavente-Villegas F, García-Briz M, de Asís-Cuestas S. Erupción exantemática en paciente con mononucleosis infecciosa inducida por aminopenicilina. Semergen 2016; 42:e136-e137. [DOI: 10.1016/j.semerg.2015.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/04/2015] [Indexed: 10/22/2022]
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Abstract
Objective: To provide an extensive review of case reports, epidemiological data, and the underlying mechanism of antibiotic-induced skin rash in patients with concurrent infectious mononucleosis (IM). Data Sources: A MEDLINE literature search inclusive of the dates 1946 to June 2016 was performed using the search terms anti-bacterial agents and infectious mononucleosis. EMBASE (1980 to June 2016) was searched using the terms mononucleosis and antibiotic agent and drug eruption. References of all relevant articles were reviewed for additional citations and information. Study Selection and Data Extraction: We selected English-language, primary literature, review articles, and mechanistic articles that addressed antibiotic-induced skin rash in patients with concurrent IM. We assessed all case reports available for causality utilizing a modified Naranjo nomogram specifically designed for this subject. We assembled the available epidemiological data into tables to identify trends in incidence rates over the years. Data Synthesis: We identified 17 case reports of antibiotic-associated rash in patients with IM. The median Naranjo score was 6 (range = 1 to 8). The top 3 reported drugs were ampicillin, azithromycin, and amoxicillin. Incidence of this adverse effect was higher in the 1960s (55.6%, 45%, and 33%) than in 2013 (33% and 15%). The mechanism most commonly proposed is a transient virus-mediated immune alteration that sets the stage for loss of antigenic tolerance and the development of a reversible, delayed-type hypersensitivity reaction to the antibiotic. Conclusion: A reassessment of the long-held belief of the high incidence (80%-100%) of antibiotic-induced skin rash in patients with IM seems prudent. Additional studies will be necessary to clarify this issue.
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Fox R, Ghedia R, Nash R. Amoxicillin-associated rash in glandular fever. BMJ Case Rep 2015; 2015:bcr-2015-211622. [PMID: 26370631 DOI: 10.1136/bcr-2015-211622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Richard Fox
- Department of ENT, Northwick Park Hospital, London, UK
| | - Reshma Ghedia
- Department of ENT, Charing Cross Hospital, London, UK
| | - Robert Nash
- Department of ENT, Charing Cross Hospital, London, UK
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