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Kounis NG. Cardio-oncology guidelines, structural heart disease and Kounis syndrome in the upcoming guidelines. Rev Port Cardiol 2024:S0870-2551(24)00191-4. [PMID: 38945475 DOI: 10.1016/j.repc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/16/2024] [Indexed: 07/02/2024] Open
Affiliation(s)
- Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Patras, Greece.
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2
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Veres T, Kerestély M, Kovács BM, Keresztes D, Schulc K, Seitz E, Vassy Z, Veres DV, Csermely P. Cellular forgetting, desensitisation, stress and ageing in signalling networks. When do cells refuse to learn more? Cell Mol Life Sci 2024; 81:97. [PMID: 38372750 PMCID: PMC10876757 DOI: 10.1007/s00018-024-05112-7] [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: 10/09/2023] [Revised: 11/09/2023] [Accepted: 01/02/2024] [Indexed: 02/20/2024]
Abstract
Recent findings show that single, non-neuronal cells are also able to learn signalling responses developing cellular memory. In cellular learning nodes of signalling networks strengthen their interactions e.g. by the conformational memory of intrinsically disordered proteins, protein translocation, miRNAs, lncRNAs, chromatin memory and signalling cascades. This can be described by a generalized, unicellular Hebbian learning process, where those signalling connections, which participate in learning, become stronger. Here we review those scenarios, where cellular signalling is not only repeated in a few times (when learning occurs), but becomes too frequent, too large, or too complex and overloads the cell. This leads to desensitisation of signalling networks by decoupling signalling components, receptor internalization, and consequent downregulation. These molecular processes are examples of anti-Hebbian learning and 'forgetting' of signalling networks. Stress can be perceived as signalling overload inducing the desensitisation of signalling pathways. Ageing occurs by the summative effects of cumulative stress downregulating signalling. We propose that cellular learning desensitisation, stress and ageing may be placed along the same axis of more and more intensive (prolonged or repeated) signalling. We discuss how cells might discriminate between repeated and unexpected signals, and highlight the Hebbian and anti-Hebbian mechanisms behind the fold-change detection in the NF-κB signalling pathway. We list drug design methods using Hebbian learning (such as chemically-induced proximity) and clinical treatment modalities inducing (cancer, drug allergies) desensitisation or avoiding drug-induced desensitisation. A better discrimination between cellular learning, desensitisation and stress may open novel directions in drug design, e.g. helping to overcome drug resistance.
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Affiliation(s)
- Tamás Veres
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Márk Kerestély
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Borbála M Kovács
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Dávid Keresztes
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Klára Schulc
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
- Division of Oncology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Erik Seitz
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Zsolt Vassy
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
| | - Dániel V Veres
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary
- Turbine Ltd, Budapest, Hungary
| | - Peter Csermely
- Department of Molecular Biology, Semmelweis University, Budapest, Hungary.
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3
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Villarreal-González RV, González-Díaz S, Vidal-Gutiérrez O, Canel-Paredes A, de la Cruz-de la Cruz C, García-Campa M, López-Méndez A, Alvarado-Ruiz S, Castells M. Hypersensitivity Reactions to Taxanes: A Comprehensive and Systematic Review of the Efficacy and Safety of Desensitization. Clin Rev Allergy Immunol 2023; 65:231-250. [PMID: 37589840 DOI: 10.1007/s12016-023-08968-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 08/18/2023]
Abstract
Taxanes in the treatment of cancer are associated with a significant incidence of hypersensitivity reactions, which may preclude their use in patients in need of first line therapy. Drug desensitization induces transient immunological tolerance and has allowed the reintroduction of taxanes in highly allergic patients. Increase the knowledge of hypersensitivity reactions (HSR) during the administration of taxanes. A systematic review regarding the safety and efficacy of rapid drug desensitization (RDD) for taxanes HSR. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was registered in PROSPERO(CRD42021242324) and a comprehensive search was conducted in Medline, Embase, Web of Science and Scopus databases. 25 studies encompassing 10 countries were identified and 976 patients with initial HSR to paclitaxel (n = 707) and docetaxel (n = 284), that underwent a total of 2,396 desensitizations. The most common symptoms were cutaneous (74.6%) with paclitaxel and respiratory (72.6%) with docetaxel. Severe initial hypersensitivity reactions including anaphylaxis occurred in 39.6% and 13% of paclitaxel and docetaxel cases respectively and during the first (87.4%) or second exposure (81.5%). Patients tolerated well RDD and breakthrough reactions (BTR) occurred in 32.2% of paclitaxel-treated patients and in 20.6% of docetaxel treated patients. Premedications included corticosteroids, antihistamines and leukotriene receptor antagonists. The most commonly used protocol was the BWH 3 bags 12 steps, all protocols showed a success rate between 95-100%, with no reported deaths. RDD is a safe and effective procedure in patients with HSR to taxanes and protocols should be standardized for wide range implementation.
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Affiliation(s)
- Rosalaura Virginia Villarreal-González
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr. José Eleuterio González", Oncology Service. Centro Universitario Contra el Cáncer (CUCC), Monterrey, Nuevo León, México
| | - Sandra González-Díaz
- Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr., José Eleuterio González", Monterrey, Nuevo León, México
| | - Oscar Vidal-Gutiérrez
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr. José Eleuterio González", Oncology Service. Centro Universitario Contra el Cáncer (CUCC), Monterrey, Nuevo León, México
| | - Alejandra Canel-Paredes
- Instituto Tecnológico de Estudios Superiores de Monterrey ITESM, Monterrey, Nuevo León, México
| | - Carlos de la Cruz-de la Cruz
- Department of Internal Medicine. Monterrey, Universidad de Monterrey. Christus Muguerza Alta Especialidad, Nuevo León, México
| | - Mariano García-Campa
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr., José Eleuterio González", Monterrey, Nuevo León, México
| | - Alfonso López-Méndez
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr., José Eleuterio González", Monterrey, Nuevo León, México
| | - Sofía Alvarado-Ruiz
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr., José Eleuterio González", Monterrey, Nuevo León, México
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
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Kozubek P, Wołoszczak J, Gomułka K. Immune Reactions in Major Types of Oncological Treatment. Int J Mol Sci 2023; 24:11257. [PMID: 37511017 PMCID: PMC10378943 DOI: 10.3390/ijms241411257] [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: 05/30/2023] [Revised: 06/24/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
In recent years, there has been a noticeable development in oncological treatment, including chemotherapy and biological treatment. Despite their significant effectiveness, they are not free from side effects, such as allergic and dermatological reactions. These reactions can vary in severity and outcome, including potential death. Examples, among others, are type I-IV hypersensitivity reactions of various origins and skin reactions including rashes, itching and redness, but also severe cutaneous syndromes. Due to the therapy used, these may include Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptoms, drug-induced hypersensitivity syndrome and acute generalized exanthematous pustulosis. In some cases, it is necessary to interrupt therapy, which may result in a poorer outcome and shorten the patient's survival. This paper reviews various types of research documents published since 2016. It aims to systematize the latest knowledge and highlight the need for further research into ways to avoid adverse reactions.
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Affiliation(s)
- Patrycja Kozubek
- Student Scientific Group of Adult Allergology, 50-369 Wrocław, Poland
| | - Julia Wołoszczak
- Student Scientific Group of Adult Allergology, 50-369 Wrocław, Poland
| | - Krzysztof Gomułka
- Clinical Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, 50-369 Wrocław, Poland
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Barra-Castro A, Berges-Gimeno MP, Carrón-Herrero A, Arana-Fernández B, Solano-Solares E. Vocal cord paralysis induced by oxaliplatin: Differential diagnosis of hypersensitivity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:645-646. [PMID: 36423866 DOI: 10.1016/j.jaip.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/31/2022] [Accepted: 11/06/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Alicia Barra-Castro
- Allergology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain; Alcalá University, Madrid, Spain
| | - María Pilar Berges-Gimeno
- Allergology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain; Redes de Orientación Cooperativa Orientadas a Resultados de la Salud, Madrid, Spain
| | | | | | - Emilio Solano-Solares
- Allergology Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain; Alcalá University, Madrid, Spain.
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Management of adverse reactions induced by chemotherapy drugs. Curr Opin Allergy Clin Immunol 2022; 22:221-225. [DOI: 10.1097/aci.0000000000000833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Borrás Cuartero J, Farzanegan Miñano R, Torres Gorriz MC, Germán Sánchez A, Aznar RC, Raducan I, Castelló Carrascosa JV, Sanchez Hernandez A, Enrique E. Same-Day Desensitization in Patients Who Experience Their First Reaction to a Platin Agent at the Oncology Day Unit: A Pilot Study to Safely Include This Technique Within the Multidisciplinary Pathways for the Diagnosis & Management of Hypersensitivity to Platin Agents. FRONTIERS IN ALLERGY 2022; 3:868300. [PMID: 36238927 PMCID: PMC9552947 DOI: 10.3389/falgy.2022.868300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
One of the main objectives when assessing patients who react to antineoplastics must be to ensure that they receive the required treatments without delay. From January to July 2021, at the Allergy Department at the Provincial University Consortium Hospital a pilot study was performed in which those patients suspected of having suffered a type I hypersensitivity reaction (grade 1 or 2) following Brown's anaphylaxis severity grading to a platin agent at the Provincial University Consortium oncology day unit, and once the reaction was properly treated and completely resolved, were subjected to a new procedure named as Same-Day Desensitization, which consists in the reintroduction and administration of full chemotherapy dose by allergists on the same day of the reaction by following the 1 bag/10 step protocol, looking forwards to systematize same-day reexposure using Same-Day Desensitization, doing it in the safest way possible. In total, 9 oncological patients suspected of having suffered a type I hypersensitivity reaction (grade 1 or 2) to a platin agent received total dose administration the same day of the initial reaction by following Same-Day Desensitization 1 bag/10 step protocol, without presenting further reactions. The manuscript describes a new approach in the use of Rapid Drug Desensitizations in reactive oncologic patients in treatment with platin agents, presenting the first 9 cases of oncologic patients who have been submitted to this procedure.
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Affiliation(s)
- Julián Borrás Cuartero
- Allergy Department, Provincial University Consortium Hospital, Castellon, Spain
- *Correspondence: Julián Borrás Cuartero
| | | | | | | | | | - Isabela Raducan
- Allergy Department, Castellon University General Hospital, Castellon, Spain
| | | | | | - Ernesto Enrique
- Allergy Department, Castellon University General Hospital, Castellon, Spain
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González-Díaz SN, Canel-Paredes A, Macías-Weinmann A, Vidal-Gutiérrez O, Villarreal-González RV. Atopy, allergen sensitization and development of hypersensitivity reactions to paclitaxel. J Oncol Pharm Pract 2022:10781552221080415. [PMID: 35188862 DOI: 10.1177/10781552221080415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Paclitaxel is a chemotherapeutic agent used in the treatment of multiple types of malignant tumors which was discovered from the Taxus brevofilia tree. In some patients, anaphylaxis develops during the first exposure to paclitaxel, suggesting that primary sensitization may have occurred through hidden or unidentified allergens that produce cross-reactivity. Skin testing may be useful in identifying sensitization to these allergens. Atopy has also been reported in patients with hypersensitivity reactions (HSR) to paclitaxel.The aim of this study is to evaluate the association between atopy and sensitization to allergens with the development of immediate HSR to paclitaxel. METHODS Skin prick tests (SPT) for environmental and food allergens were applied to 76 patients recently diagnosed with cancer. A SPT to paclitaxel was applied and if negative, an intradermal test was performed. After paclitaxel's infusion, the development of immediate HSR was observed. RESULTS Of 76 skin tests, 43% of patients had allergen sensitization and 57% did not. HSR occurred in 12.1% and 11.6% of each group, respectively. Five percent of patients tested positive to paclitaxel and only one had an immediate HSR. Eighty-nine percent of patients who developed an HSR had a family or personal history of atopy. CONCLUSIONS Sensitization to environmental or food allergens does not appear to be a risk factor for the development of immediate HSR to paclitaxel, suggesting that there are other non-IgE-mediated immunologic mechanisms responsible for their development, however, a personal and family history of atopy increases 8x the risk of developing anaphylaxis.
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Affiliation(s)
- Sandra Nora González-Díaz
- 27771Autonomous University of Nuevo León, University Hospital "Dr José Eleuterio González", Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Monterrey, México
| | - Alejandra Canel-Paredes
- 27771Autonomous University of Nuevo León, University Hospital "Dr José Eleuterio González", Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Monterrey, México
| | - Alejandra Macías-Weinmann
- 27771Autonomous University of Nuevo León, University Hospital "Dr José Eleuterio González", Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Monterrey, México
| | - Oscar Vidal-Gutiérrez
- 27771Autonomous University of Nuevo León, University Hospital "Dr José Eleuterio González", Faculty of Medicine, Oncology Department, Monterrey, México
| | - Rosalaura Virginia Villarreal-González
- 27771Autonomous University of Nuevo León, University Hospital "Dr José Eleuterio González", Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Monterrey, México
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9
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Vega A, Peña MI, Torrado I. Use of Rapid Drug Desensitization in Delayed Hypersensitivity Reactions to Chemotherapy and Monoclonal Antibodies. FRONTIERS IN ALLERGY 2022; 2:786863. [PMID: 35387014 PMCID: PMC8974726 DOI: 10.3389/falgy.2021.786863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background:Rapid drug desensitization (RDD) allows first-line therapies in patients with immediate drug hypersensitivity reactions (DHR) to chemotherapeutic drugs (ChD) and monoclonal antibodies (mAb). Desensitization in delayed drug reactions has traditionally used slow protocols extending up to several weeks; RDD protocols have been scarcely reported.Patients and Method:We retrospectively analyzed the patients referred to the Allergy Department, who had experienced a delayed DHR (> 6 h) related to a ChD or mAb and underwent an RDD protocol. The rate of successful administration of the offending drug and the presence of adverse reactions were evaluated.Results:A total of 93 RDDs were performed in 11 patients (including 6 men and 5 women, with a median age of 61 years). The primary DHR were maculopapular exanthema (MPE) (8), generalized delayed urticaria (1), MPE with pustulosis and facial edema (1), and facial edema with desquamative eczema (1). The meantime for the onset of symptoms was 3 days (range 1–16 days). RDD was performed using a protocol involving 8–13 steps, with temozolomide (25), bendamustine (4), rituximab (9), infliximab (24), gemcitabine (23), and docetaxel (8), within 4.6–6.5 h. Sixteen breakthrough reactions were reported during the RDD (17.2 %) in 5 patients; all were mild reactions including 11 delayed and 5 immediate reactions. All patients completed their treatment.Conclusions:RDD is a potentially safe and effective procedure in patients suffering from delayed reactions to ChD and mAb. It allows them to receive full treatment in a short period, thereby reducing time and hospital visits.
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Affiliation(s)
- Arantza Vega
- Department of Allergy, University Hospital of Guadalajara, Guadalajara, Spain
- ARADyAL Spanish Thematic Network and Co-operative Research Centre RD16/0006/0023, Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
- *Correspondence: Arantza Vega
| | - M. Isabel Peña
- Department of Allergy, University Hospital of Guadalajara, Guadalajara, Spain
- ARADyAL Spanish Thematic Network and Co-operative Research Centre RD16/0006/0023, Instituto de Salud Carlos III (ISCIII), Fundación Española para la Ciencia y la Tecnología (FECyT), Madrid, Spain
| | - Inés Torrado
- Department of Allergy, University Hospital of Guadalajara, Guadalajara, Spain
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Jimenez-Rodriguez TW, Manuel Marco de la Calle F, Lozano-Cubo I, Montoyo-Anton RA, Soriano-Gomis V, Gonzalez-Delgado P, Burgos-San José A, Climent-Ballester S, Martínez-Banaclocha N, Fernández-Sanchez J. Converter Phenotype: A New Profile That Is Not Exclusive to Taxanes. FRONTIERS IN ALLERGY 2022; 2:785259. [PMID: 35387038 PMCID: PMC8974675 DOI: 10.3389/falgy.2021.785259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Phenotype I hypersensitivity reactions are the most commonly reported drug reactions; however, precision medicine has made it possible to characterize new phenotypes. A recent communication proposed the existence of a “converter phenotype,” which would affect patients who present non-immediate hypersensitivity reactions and in subsequent exposures develop immediate hypersensitivity reactions. This study aimed to describe the clinical characteristics of converter phenotype reactions and their evolution during desensitization to chemotherapeutic drugs and monoclonal antibodies. Methods: We retrospectively reviewed our database of patients undergoing desensitization to chemotherapy or biological agents and selected those with a converter phenotype. Demographic and clinical characteristics of the patients, the results of skin tests, tryptase and IL-6 levels, and desensitization outcomes were assessed. Results: Of 116 patients evaluated, 12 (10.3%) were identified as having a converter phenotype. The median interval between drug exposure and reaction was 90.6 h (range 8-288 h). After the conversion, phenotype I was the most frequent (58.3%), followed by cytokine release reactions (33.3%). Fifty-one desensitizations were undertaken and all treatments completed, with 10 (19.6%) breakthrough reactions. No new changes in the phenotype were detected. Conclusions: The symptoms of non-immediate drug hypersensitivity reactions may indicate the need for an early allergological evaluation to assess the risk of future immediate drug reactions. Clinical characteristics, skin test results, and biomarkers can help predict responses to rapid drug desensitization, guiding clinicians on how to optimize therapy delivery while maintaining patient safety.
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Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
| | - Francisco Manuel Marco de la Calle
- Immunology Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Inmaculada Lozano-Cubo
- Oncology Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Rosa Ana Montoyo-Anton
- Oncology Day Hospital Nursing Service, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Victor Soriano-Gomis
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
| | - Purificación Gonzalez-Delgado
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
| | - Amparo Burgos-San José
- Pharmacy Department, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Seira Climent-Ballester
- Pharmacy Department, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Natividad Martínez-Banaclocha
- Oncology Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Javier Fernández-Sanchez
- Allergy Section, Alicante General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), UMH, Alicante, Spain
- Spanish Research Network on Asthma and Adverse and Allergic Reactions (ARADyAL) Spanish Network (RD16/0006), Instituto de Salud Carlos III, Fundación Española para la Ciencia y la Tecnología, Madrid, Spain
- *Correspondence: Javier Fernández-Sanchez
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