Transport of Escherichia coli phage through saturated porous media considering managed aquifer recharge

Abstract

Virus is one of the most potentially harmful microorganisms in groundwater. In this paper, the effects of hydrodynamic and hydrogeochemical conditions on the transportation of the colloidal virus considering managed aquifer recharge were systematically investigated. Escherichia coli phage, vB_EcoM-ep3, has a broad host range and was able to lyse pathogenic Escherichia coli. Bacteriophage with low risk to infect human has been found extensively in the groundwater environment, so it is considered as a representative model of groundwater viruses. Laboratory studies were carried out to analyze the transport of the Escherichia coli phage under varying conditions of pH, ionic strength, cation valence, flow rate, porous media, and phosphate buffer concentration. The results indicated that decreasing the pH will increase the adsorption of Escherichia coli phage. Increasing the ionic strength, either Na⁺ or Ca²⁺, will form negative condition for the migration of Escherichia coli phage. A comparison of different cation valence tests indicated that changes in transport and deposition were more pronounced with divalent Ca²⁺ than monovalent Na⁺. As the flow rate increases, the release of Escherichia coli phage increases and the retention of Escherichia coli phage in the aquifer medium reduces. Changes in porous media had a significant effect on Escherichia coli phage migration. With increase of phosphate buffer concentration, the suspension stability and migration ability of Escherichia coli phage are both increased. Based on laboratory-scale column experiments, a one-dimensional transport model was established to quantitatively describe the virus transport in saturated porous medium.

The Normative Foundations of Defamatory Meaning

Abstract

This paper assesses normative arguments regarding four views about defamatory meaning. The moralised view holds that a statement about a person is defamatory if and only if we ought to think less of that person if the statement is true. The nonmoralised view holds that a statement is defamatory if and only if people in fact think less of the subject on hearing the statement. A third - the dual view - can be split into two versions. The first version holds that a statement is defamatory if and only if it satisfies either the moralised or non-moralised views. The second version holds that statements satisfying either view can be defamatory, but they ought to be considered fundamentally different forms of personal defamation, with different remedies, defences and conditions of liability attached. Both the moralised and non-moralised views are rejected because they fail to acknowledge instrumental and intrinsic reputational value respectively. The first version of the dual view is rejected because it compromises the expressive value of defamation, implausibly suggests that truth should be a general defence and fails to recognise that different objections apply to the moralised and nonmoralised views. The upshot is that we ought to accept the second version of the dual view.

Improved medical image fusion based on cascaded PCA and shift invariant wavelet transforms

Abstract

Purpose

In the medical field, radiologists need more informative and high-quality medical images to diagnose diseases. Image fusion plays a vital role in the field of biomedical image analysis. It aims to integrate the complementary information from multimodal images, producing a new composite image which is expected to be more informative for visual perception than any of the individual input images. The main objective of this paper is to improve the information, to preserve the edges and to enhance the quality of the fused image using cascaded principal component analysis (PCA) and shift invariant wavelet transforms.

Methods

A novel image fusion technique based on cascaded PCA and shift invariant wavelet transforms is proposed in this paper. PCA in spatial domain extracts relevant information from the large dataset based on eigenvalue decomposition, and the wavelet transform operating in the complex domain with shift invariant properties brings out more directional and phase details of the image. The significance of maximum fusion rule applied in dual-tree complex wavelet transform domain enhances the average information and morphological details.

Results

The input images of the human brain of two different modalities (MRI and CT) are collected from whole brain atlas data distributed by Harvard University. Both MRI and CT images are fused using cascaded PCA and shift invariant wavelet transform method. The proposed method is evaluated based on three main key factors, namely structure preservation, edge preservation, contrast preservation. The experimental results and comparison with other existing fusion methods show the superior performance of the proposed image fusion framework in terms of visual and quantitative evaluations.

Conclusion

In this paper, a complex wavelet-based image fusion has been discussed. The experimental results demonstrate that the proposed method enhances the directional features as well as fine edge details. Also, it reduces the redundant details, artifacts, distortions.

MR scanning, tattoo inks, and risk of thermal burn: An experimental study of iron oxide and organic pigments

Abstract

Background

Tattooed persons examined with magnetic resonance imaging (MRI) can develop burning sensation suggested in the literature to be thermal burn from the procedure. MRI-induced thermal effect and magnetic behavior of known tattoo pigments were examined ex vivo.

Materials and Methods

Magnetic resonance imaging effects on 3 commonly used commercial ink stock products marketed for cosmetic tattooing was studied. A main study tested 22 formulations based on 11 pigment raw materials, for example, one line of 11 called pastes and another called dispersions. Samples were spread in petri dishes and tested with a 0.97 T neodymium solid magnet to observe visual magnetic behavior. Before MRI, the surface temperature of the ink was measured using an infrared probe. Samples were placed in a clinical 3T scanner. Two scans were performed, that is, one in the isocenter and one 30 cm away from the center. After scanning, the surface temperature was measured again. Chemical analysis of samples was performed by mass spectroscopy.

Results

Mean temperature increase measured in the isocenter ranged between 0.14 and 0.26°C (P < .01) and in the off-center position from −0.16 to 0.21°C (P < .01). Such low increase of temperature is clinically irrelevant. Chemical analysis showed high concentrations of iron, but also nickel and chrome were found as contaminants. High concentration of iron was not associated with any increase of temperature or any physical draw or move of ink.

Conclusion

The study could not confirm any clinically relevant temperature increase of tattoo pigments after MRI.

Transcriptome analysis of ultraviolet A-induced photoaging cells with deep sequencing

Abstract

Gene expression changes associate with many biological processes. However, the relative consequences of the genetic alterations induced by ultraviolet (UV)-A radiation on skin photoaging are still not clear. Here, we performed deep sequencing of the transcriptome and explored altered genes related to biological changes in repeated UV-A-irradiated human dermal fibroblasts (HDF) to better understand the skin photoaging mechanisms. The repeatedly UV-A-irradiated group (HDF were induced by 10 J/cm² UV-A twice daily for 7 days) and the control group (HDF without irradiation) were evaluated. Expression genes profile was measured and compared using high-throughput sequencing on an Illumina HiSeq 2500 platform and DEGseq. Functional annotation and metabolic pathway analysis of genes with altered expression were preformed via National Center for Biotechnology Information, Uniprot, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes databases. Genes related to skin photoaging were verified by quantitative reverse transcription polymerase chain reaction. Transcriptome comparison revealed that 607 genes exhibited significant changes (P < 0.05), of which 238 genes were upregulated and 369 downregulated in UV-A-irradiated HDF. Functional annotations showed that genes altered by UV-A irradiation took part in a variety of biological process, cellular component synthesis, molecular function and metabolic pathway. Photoaging-related genes encoding elastin, sprout, cathepsin K, cathepsin D, cathepsin B ribose-phosphate diphosphokinase and phosphoglucomutase were identified to be changed. We obtained the comprehensive transcriptome and altered genes in repeated UV-A-irritated HDF and identified that the modulated genes were related to a wide panel of pathways and functions. Our results provide new insights into photoaging molecular mechanisms and suggest some novel targets for interfering in skin photoaging.

Azathioprine monotherapy in autoimmune blistering diseases: A feasible option for mild to moderate cases

Abstract

Azathioprine (AZP) is used as a corticosteroid (CS)-sparing medication to treat autoimmune blistering diseases. In this study, we examined the efficacy of AZP and the feasibility of using AZP monotherapy (without CS) to treat pemphigus and pemphigoid. We performed a retrospective study of 10 Japanese patients (seven with pemphigus and three with pemphigoid) with mild to moderate disease activity who had been treated using AZP. The treatment efficacy was evaluated based on decreases in the disease activity scores and autoantibody titers. The results demonstrate that seven out of 10 cases (70%) were treated successfully using AZP monotherapy with no severe adverse effects. The disease activity scores of the successfully-treated patients decreased to zero after 1–37.5 months (average, 11.9) and the average disease activity scores in these cases decreased significantly at 2 months (38.2 ± 36.6%) compared with the scores of the three patients who required additional systemic CS therapy (77.5 ± 3.5%) (P < 0.05). Additionally, the autoantibody titers of five cases treated successfully using AZP decreased by half at 6 months. In conclusion, our findings suggest that AZP monotherapy is a viable treatment option for mild to moderate pemphigus and pemphigoid.

Complications of botulinum toxin injection for masseter hypertrophy: Incidence rate from 2036 treatments and summary of causes and preventions

Summary

Background

Masseter hypertrophy is a common, prominent feature in many Asian patients, and correction procedures are often requested for esthetic reasons. Toxin masseter injections have a high efficacy and safety profile, but the risks of a variety of side effects or complications remain.

Objectives

The categorization of various complications was based on etiology, with a presentation of the author's own incidence rates for consideration and comparison.

Methods

Six hundred and eighty patients received a total of 2036 sessions of toxin injection for masseter hypertrophy from 2011 to 2016, and complications or complaints were recorded through follow-up on a by-treatment basis. Complications were grouped together based on etiology and discussed.

Results

Of 2036 sessions, temporary mastication force decrease was reported after 611 (30%), bruising after 51 (2.5%), headaches after 12 (0.58%), smile limitation after 3 (0.15%), paradoxical bulging after 10 (0.49%), sunken cheeks (subzygomatic volume loss) after 9 (0.44%), and sagging after 4 (0.20%).

Conclusions

Masseter injections remain very safe. To further decrease the incidence rate, injections should only be inside the recommended safety zone, a quadrilateral within the muscle that avoids most important local structures. Keeping injections inside the safe zone, and ideally in 3-4 different locations at least 1 cm from any border, is crucial for the prevention of complications.

Possible role of interleukin-17 and macrophage migration inhibitory factor in cutaneous warts

Summary

Background/Objectives

Cutaneous warts (CW), or verrucae, are benign proliferation of skin that result from infection with human papilloma viruses. Cellular immune reactivity plays a significant role in wart regression. The aim of this study was to elucidate the cellular immune status of patients with CW through measurements of their serum levels of interleukin-17 (IL-17) and macrophage migration inhibitory factor (MIF,) and, identify the possible role of IL-17 and MIF in CW. We assessed serum IL-17 and MIF levels in patients with different forms of CW and compare the results with controls.

Patient and methods

Serum levels of IL-17 and MIF were measured using commercially available ELISA assay kits in 60 patients with CW and 20 healthy controls.

Results

Serum levels of IL-17 and MIF were significantly lower in patients with CW when compared with the controls (P-value <.01, <.05, respectively). There was nonsignificant correlation between IL-17 and MIF.

Conclusion

Low IL-17 and MIF levels may have a contributory role in occurrence, maintenance, severity, and recurrence of different types of CW which depend mainly on the defect of cell-mediated immunity. This may shed new light on nontraditional strategies for the future medical treatments of CW through regulation of IL-17 and MIF.

A web-based survey to identify current practice in skeletal pin site management

Infections associated with percutaneous pins and wires are common complications which can have a significant impact on patient outcomes. A survey was undertaken to identify current practice and gain insight into variations of clinical practice. Invitations were sent by email to complete an electronic questionnaire using SurveyMonkey. The survey was left open for 100 days. The single largest group of respondents (37.4%, n = 120) cleansed pin sites daily, with significant differences identified between medical and nursing professions (P = 0.02), and country of practice (P < 0.001). Significant differences were also identified in the use of different cleansing solutions between medical and nursing professions (P < 0.001) and country (P < 0.001). The majority group preferences were saline 30% (n = 96) and alcoholic chlorhexidine 29.6% (n = 95). Pin site crusts were routinely removed by 57.9% (n = 186). Pin sites were left exposed by 50.3% (n = 160). Dry gauze was identified as the most common dressing used to dress pin sites, however, substantial variation was identified in the types of dressings used. Compression was not routinely applied to pin sites by 51.6% (n = 165). There remains considerable diversity of practice when caring for pin sites. Further research is required to identify the most effective methods in preventing pin site infection.

An uncommon localization of black heels in a free climbing instructor

Black heels, also known as talon noir or calcaneal petechiae, are asymptomatic superficial cutaneous haemorrhages of the feet, mostly seen as post-traumatic lesions in young athletic individuals who practice sports such as tennis, football, or gymnastics. Here, we present a case of black heels in a young male rock climber.

Subepidermal moisture detection of heel pressure injury: The pressure ulcer detection study outcomes

We examined subepidermal moisture (SEM) and visual skin assessment of heel pressure injury (PrI) among 417 nursing home residents in 19 facilities over 16 weeks. Participants were older (mean age 77 years), 58% were female, over half were ethnic minorities (29% African American, 12% Asian American, 21% Hispanic), and at risk for PrI (mean Braden Scale Risk score = 15.6). Blinded concurrent visual assessments and SEM measurements were obtained at heels weekly. Visual skin damage was categorised as normal, erythema, stage 1 PrI, deep tissue injury (DTI) or stage 2 or greater PrI. PrI incidence was 76%. Off-loading occurred with pillows (76% of residents) rather than heel boots (21%) and often for those with DTI (91%). Subepidermal moisture was measured with a device where higher readings indicate greater moisture (range: 0-70 tissue dielectric constant), with normal skin values significantly different from values in the presence of skin damage. Subepidermal moisture was associated with concurrent damage and damage 1 week later in generalised multinomial logistic models adjusting for age, diabetes and function. Subepidermal moisture detected DTI and differentiated those that resolved, remained and deteriorated over 16 weeks. Subepidermal moisture may be an objective method for detecting PrI.

Effects of ambient conditions on the risk of pressure injuries in bedridden patients—multi-physics modelling of microclimate

Scientific evidence regarding microclimate and its effects on the risk of pressure ulcers (PU) remains sparse. It is known that elevated skin temperatures and moisture may affect metabolic demand as well as the mechanical behaviour of the tissue. In this study, we incorporated these microclimate factors into a novel, 3-dimensional multi-physics coupled model of the human buttocks, which simultaneously determines the biothermal and biomechanical behaviours of the buttocks in supine lying on different support surfaces. We compared 3 simulated thermally controlled mattresses with 2 reference foam mattresses. A tissue damage score was numerically calculated in a relevant volume of the model, and the cooling effect of each 1°C decrease of tissue temperature was deduced. Damage scores of tissues were substantially lower for the non-foam mattresses compared with the foams. The percentage tissue volume at risk within the volume of interest was found to grow exponentially as the average tissue temperature increased. The resultant average sacral skin temperature was concluded to be a good predictor for an increased risk of PU/injuries. Each 1°C increase contributes approximately 14 times as much to the risk with respect to an increase of 1 mmHg of pressure. These findings highlight the advantages of using thermally controlled support surfaces as well as the need to further assess the potential damage that may be caused by uncontrolled microclimate conditions on inadequate support surfaces in at-risk patients.

Identifying risk factors associated with infection in patients with chronic leg ulcers

Leg ulcers are hard to heal. Infection causes delayed healing, negatively impacting patients' quality of life, the healthcare system, and society. Early recognition of patients at high risk of infection is essential to prevent complications and reduce negative impacts. However, at present, factors associated with infection in this population are not yet clearly understood.

The study aimed to identify factors that were significantly associated with infection in chronic leg ulcers. A sample of 561 patients with chronic leg ulcers, who were previously recruited at outpatient clinics and community settings within Australia between 2008 and 2015, were selected for the current analysis. The prevalence of infection in the sample at study recruitment was 7.8%.

A multivariate logistic regression model was used to identify factors associated with infection. The study identified 7 factors that were significantly independently associated with infection, including depression, chronic pulmonary disease, anti-coagulant use, calf ankle circumference ratio < 1.3, ulcer area ≥ 10 cm², slough in the wound bed tissue, and ulcers with heavy exudate.

These findings could assist clinicians in the early recognition of patients at risk of infection and individualise treatment for these patients, thereby promoting wound healing.

Commentary on: Surgical Site Irrigation in Plastic Surgery: What is Essential?

"There Is Nothing New Except What Has Been Forgotten."―Marie Antoinette

ASJ’s Position on Publishing Papers That Discuss Off-Label Product Usage

As the Editor-in-Chief of Aesthetic Surgery Journal (ASJ), I would like to thank Dr Solomon for his Letter to the Editor entitled "Comments on 'Nonsurgical Medical Penile Girth Augmentation: Experience-Based Recommendations.'"¹ One of Dr Solomon's remarks calls for a response.

The Micromort Concept and its Applicability to Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Risk Assessment

I read with interest the article by Sieber and Adams about the micromort concept and its applicability to anaplastic large cell lymphoma (ALCL) risk assessment.¹ While I concur with the conclusions of the article, I wish to point out some issues with the source data in Table 1 for risks associated with common activities. I recently attempted to locate the original reference for the micromort concept and this proved challenging. The only reference from Ronald Howard listed in PubMed is from 1989.² A 1979 article by Richard Wilson in Technology Review³ is the first appearance of the table of lifestyle risks that I could locate. The author's methodology in drafting the table appears to have simply taken averages such as the number of deaths from alcoholic cirrhosis and national average drinking, and deriving risk of a single drink from that. More sophisticated analysis shows a J-shaped curve for alcohol, especially wine, with lower risk at moderate consumption.⁴ The risk we run is missing more nuanced aspects of risk for ALCL by not factoring in the positive aspects of breast implant use. For example, there is some evidence that breast cancer survival is improved with reconstruction⁵; breast implants may have their own J-shaped curve. So while micromort analysis offers a reassuring perspective on the ALCL situation, we need to be cautious about citing outdated and poorly documented data on comparative risk.

Response to “Comments on ‘Nonsurgical Medical Penile Girth Augmentation: Experience-Based Recommendations’”

We thank Dr Solomon¹ for his interest in our article.² We agree that penile augmentation using injectable materials, including hyaluronic acid (HA), does have some disadvantages. HA fillers do slowly reabsorb over time and so are not a permanent solution. However, our in-progress research suggests that the nonpermanency of the procedure is potentially part of the appeal for at least some patients. These men consider a nonpermanent procedure on such an important part of their body, which they closely associate with their sense of masculinity, to be less daunting.

Comments on “Nonsurgical Medical Penile Girth Augmentation: Experience-Based Recommendations”

I am writing to express my concern regarding this article.¹ The authors support the use of hyaluronic acid as an injectable material for penis enlargement. As a plastic surgeon who has been performing procedures for penis enlargement for more than 20 years, I have concerns about this endorsement. Hyaluronic acid dissipates in all cases over time. Its absorption is irregular creating nodules in every case (Figure 1). About half of the patients that I treat have unsatisfactory results from injection of a variety of materials, including hyaluronic acid, polymethylmethacrylate, fat (Figure 2), liquid silicone (Figure 3), and silicone devices (Figure 4). Each of these has unique challenges for surgical removal and each of these patients is very unhappy when they present to me. While there are options for increasing the length and girth of the penis, they are surgically demanding (Figure 5). Unlike hyaluronic acid, or any of the other fillers mentioned, the results are permanent. This is not to say that complications of surgery cannot occur. Complications do occur and as surgeons, we should be prepared to manage them to restore our patients to full function. I think it is incumbent for our members to be aware that the US Food and Drug Administration has not approved any filler for penile injection therapy. These are dermal fillers and there is no significant dermal layer in the penis. Due to the anatomy of the penis, these materials are placed in the superficial fascial layer of the penis. Placement of these materials disrupts the blood supply to the skin of the penis. When removing these materials, the blood supply to the overlying skin is compromised, which can cause skin loss as a subsequent challenge for reconstruction. I would discourage our members from adopting this method of penis enlargement.

Response to “The Micromort Concept and its Applicability to Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Risk Assessment”

Thank you for your insightful comments¹ on our article entitled "What's Your Micromort? A Patient-Oriented Analysis of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Risk Assessment."² Activities such as drinking wine present risk in a J-shaped curve, in part because wine consumption may occur along a spectrum from none to excess. Whereas moderate wine consumption, even alongside heavy alcohol consumption, demonstrates multiple health benefits.³ Although the activities demonstrated by Wilson occur along a spectrum as well, many may present as all or none events, such as riding a bicycle 10 miles, riding 300 miles in a car, or traveling 1000 miles in a jet.⁴ Despite his data being older, these events would not present in a J-shaped curve as riding less in a car will not impose health benefits, but will instead only decrease risk. Likewise, having breast implants is an all or nothing event. Therefore, one cannot have "less" of a breast augmentation in hopes of pursuing health benefits. For this reason, we believe using the micromort terminology is well founded and is a valuable tool for patient education on BIA-ALCL.

Effect of plants in constructed wetlands for organic carbonand nutrient removal: a review of experimental factors contributing to higher impact and suggestions for future guidelines

Abstract

Constructed wetland is a proven technology for water pollution removal, but process mechanisms and their respective contribution are not fully understood. The present review details the effect of plants on removal efficiency of constructed wetlands by focusing on literature that includes experiments with unplanted controls for organic carbon and nutrient (N and P) removal. The contribution of plant direct uptake is also assessed. Although it was found that several studies, mostly at laboratory or pilot scales, showed no statistical differences between planted and unplanted controls, some factors were found that help maximize the effect of plants. This study intends to contribute to a better understanding of the significance of the effect of plants in a constructed wetland, as well as to suggest a set of experimental guidelines in this field.

Liposomal Bupivacaine in Implant-Based Breast Reconstruction

Purpose: This study evaluates the role of liposomal bupivacaine in implant-based breast reconstruction. Methods: A prospective, randomized, single-blind trial of liposomal bupivacaine in implant-based breast reconstruction was performed. Patients in the control arm were treated with 20 mL 0.25% bupivacaine with epinephrine 1:200,000 to each breast pocket. Patients in the experimental arm were treated with 10 mL 1.3% liposomal bupivacaine delivered to each breast pocket. Pain scores were recorded over the course of patients' hospital stay. Consumption of pain medications, benzodiazepines, and anti-emetics was monitored. Length of stay and other direct cost data were collected. Results: Twenty-four patients were enrolled, with 12 women randomized to each arm. Average postoperative pain scores were 3.66 for patients in the control arm and 3.68 for patients in the experimental arm. Opioid consumption was 1.43 morphine equivalent dosing/h for patients in the control arm and 0.76 morphine equivalent dosing/h for patients in the experimental arm (P = 0.017). Diazepam consumption was 0.348 mg/h for patients in the control arm and 0.176 mg/h for patients in the experimental arm (P = 0.011). Average length of hospital stay was 46.7 hours for patients in the control arm and 29.8 hours for patients in the experimental arm (P = 0.035). Average hospital charges were $18,632 for patients in the control arm and $10,828 for patients in the experimental arm (P = 0.039). Conclusions: Liposomal bupivacaine reduces opioid and benzodiazepine consumption, length of stay, and hospital charges. These data support a role for liposomal bupivacaine in implant-based breast reconstruction.

Breathing New Life Into Mite-Impermeable Bedcovers

Publication date: Available online 10 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Torie Grant, Elizabeth C. Matsui

Information for Readers

Publication date: November–December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice, Volume 5, Issue 6

Use of a Penicillin Allergy Screening Algorithm and Penicillin Skin Testing for Transitioning Hospitalized Patients to First-Line Antibiotic Therapy

Publication date: Available online 11 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Allison Ramsey, Mary L. Staicu
BackgroundPenicillin allergy is the most commonly reported antibiotic allergy. Avoidance of β-lactam antibiotics in hospitalized patients leads to the use of second-line therapies.ObjectiveThe utility of a penicillin allergy history algorithm (PAHA) and subsequent penicillin skin testing (PST) in transitioning hospitalized patients from second- to first-line antibiotic therapy is described.MethodsThrough an electronic medical record report, pharmacists identified adult inpatients with penicillin allergy receiving moxifloxacin, intravenous vancomycin, aztreonam, daptomycin, or linezolid, in which a β-lactam antibiotic was preferred. The PAHA was administered to identify patients for PST. Skin-test negative patients were transitioned to first-line β-lactam antibiotic therapy.ResultsFifty patients consented to the study. Historical reactions included hives (16 patients, 32%), angioedema (15, 30%), anaphylaxis (6, 12%), unknown (6, 12%), rash (6, 12%), and dyspnea (1, 2%). Pre-PST antibiotic regimens included vancomycin (82%), aztreonam (22%), moxifloxacin (6%), daptomycin (4%), and/or linezolid (2%). Forty-seven patients (94%) were skin-test negative and were subsequently transitioned to a β-lactam antibiotic. Two patients were skin-test positive and one was histamine nonreactive. No patients experienced an immediate adverse reaction when challenged with a penicillin-based antibiotic. A total of 982 days of second-line antibiotic therapy and at least 23 hospital days to administer the antibiotic were avoided.ConclusionsThe use of the PAHA and subsequent PST is a safe, effective multidisciplinary intervention that facilitates the transition to β-lactam antibiotics. Our approach is unique in that it prioritizes patients based on the use of second-line antibiotics, and then applies an algorithm to determine eligibility for PST.

DRESS Syndrome Induced by Ranitidine

Publication date: Available online 6 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Timothy J. Watts, Rubaiyat Haque

Anaphylaxis to invasive chlorhexidine administration despite tolerance of topical chlorhexidine use

Publication date: Available online 7 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Anna Postolova, Jonathan T. Bradley, David Parris, Janell Sherr, Sean A. McGhee, Joseph D. Hernandez

FeNO and Exercise Testing in Children at Risk of Asthma

Publication date: Available online 10 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Ann-Marie Malby Schoos, Christina Figgé Christiansen, Jakob Stokholm, Klaus Bønnelykke, Hans Bisgaard, Bo Lund Chawes
BackgroundExercise testing is the gold standard for diagnosing exercise-induced bronchoconstriction in children, but requires considerable cooperation and medical resources. Therefore, fraction of exhaled nitric oxide (FeNO) has been proposed as a tool to predict the need for exercise testing.ObjectiveThe objective of this study was to investigate the relationship between FeNO, exercise test results, and a history of respiratory symptoms during exercise in children at risk of asthma.MethodsFeNO measurement, exercise testing, and interview about respiratory symptoms during exercise were completed in 224 seven-year-old children from the at-risk Copenhagen Prospective Studies on Asthma in Childhood2000 birth cohort. The associations between FeNO, exercise test results, and reported respiratory symptoms during exercise were analyzed adjusting for gender, respiratory infections, and inhaled corticosteroid treatment. The associations were also analyzed stratified by asthma and atopic status.ResultsOf the 224 children, 28 (13%) had an established asthma diagnosis and 58 (26%) had a positive exercise test (≥15% drop in forced expiratory volume in 1 second [FEV1] from baseline). FeNO and bronchial obstruction after exercise were linearly associated with a doubling of FeNO corresponding to a 2.4% drop in FEV1 (95% confidence interval, 0.8-4.1; P < .01). However, a receiver operating characteristic curve analysis showed that the best cutoff of FeNO for predicting exercise test outcome among children who reported respiratory symptoms during exercise was 17 ppb, which only had 74% negative predictive value. There was no association between FeNO and reported respiratory symptoms during exercise (odds ratio = 1.3 [0.8-1.9]; P = .29) or reported symptoms during exercise and exercise test results (odds ratio = 1.0 [1.0-1.1]; P = .12).ConclusionsA history of respiratory symptoms during exercise was not associated with either elevated FeNO or a positive exercise test in children at risk of asthma. FeNO and exercise test results were linearly associated traits, but FeNO could not reliably be used dichotomized to predict the need of exercise testing.

Underestimation of specific IgE measurements using extract-based assays on undiluted sera revealed through dilution

Publication date: Available online 7 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Alexander J. Schuyler, Anubha Tripathi, Lisa J. Workman, Jeffrey M. Wilson, Elizabeth A. Erwin, Monica G. Lawrence, Emily C. McGowan, Robert G. Hamilton, Thomas A.E. Platts-Mills

The Value of Fractional Exhaled Nitric Oxide and Forced Mid-Expiratory Flow as Predictive Markers of Bronchial Hyperresponsiveness in Adults With Chronic Cough

Publication date: Available online 8 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Wuping Bao, Xue Zhang, Chengjian Lv, Luhong Bao, Junfeng Yin, Zhixuan Huang, Bing Wang, Xin Zhou, Min Zhang
BackgroundBronchial provocation tests are standard for diagnosing the etiology of chronic cough, but they are time consuming and can induce severe bronchospasm. A safer and faster clinical examination to predict bronchial hyperresponsiveness (BHR) is needed.ObjectiveThe objective of this study was to investigate whether small-airway function tests can predict BHR in adult patients with chronic cough.MethodsA retrospective, cross-sectional study of diagnoses made using spirometry and bronchial provocation test results was performed in 290 patients with chronic nonproductive cough. BHR-predictive values were analyzed via the area under receiver operating characteristic curves (AUCs). Optimal cutoff values were determined by maximizing the sum of sensitivity and specificity.ResultsPatients with chronic cough with BHR showed lower forced expiratory flow between 25% and 75% (FEF25%-75%), higher fractional exhaled nitric oxide (FENO), and a higher percentage of eosinophils in blood than patients without BHR (P < .0001 for all). The AUCs of FENO and FEF25%-75% for a BHR diagnosis were 0.788 (95% CI, 0.725-0.851) and 0.702 (95% CI, 0.641-0.763), respectively. Optimal cutoff values were 43 ppb for FENO and 78.5% for FEF25%-75%, with negative predictive values of 85.38% and 81.34%, respectively. The combined use of FENO and FEF25%-75% increased the AUC to 0.843 (95% CI, 0.794-0.892), significantly higher than either FENO (P = .012) or FEF25%-75% (P < .0001) alone.ConclusionsSmall-airway dysfunction is present in patients with chronic cough and BHR. FEF25%-75% has value as a negative predictive parameter for BHR, especially when combined with FENO. FENO > 43 ppb and FEF25%-75% < 78.5% strongly predicted a positive bronchial provocation test.

Increased Tolerance to Less Extensively Heat-Denatured (Baked) Milk Products in Milk-Allergic Children

Publication date: Available online 7 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Anna Nowak-Węgrzyn, Kaitie Lawson, Madhan Masilamani, Jacob Kattan, H.T. Bahnson, Hugh A. Sampson
BackgroundMost milk-allergic children tolerate baked milk.ObjectiveTo investigate the effect of more frequent versus less frequent introduction of higher doses of more allergenic (less heat-denatured) forms of milk (MAFM) on progression to tolerance.MethodsMilk-allergic children were challenged with increasing doses of MAFM; baked foods were incorporated into the diet; challenges were repeated at 6- or 12-month intervals over 36 months.ResultsA total of 136 children (70% males) were enrolled in the active group (median age, 7 years). At baseline, 41 (30%) reacted to muffin, 31 (23%) to pizza, 11 (8%) to rice pudding, 43 (32%) to non–baked milk; and 10 (7%) tolerated non–baked milk. Children who tolerated baked milk but reacted to non–baked liquid milk were randomized to MAFM challenges every 6 months (n = 41) or 12 months (n = 44). At month 36, 61% children in the 6-month and 73% in the 12-month escalation groups tolerated MAFM. Overall, 41 (48%) children who ingested baked-milk diet became tolerant to non–baked milk; no difference was seen between 6- and 12- month escalations. Among children who reacted to muffin at baseline and continued avoidance, 20% developed tolerance to baked milk and 0% tolerated non–baked milk. None of the 34 children who qualified for inclusion but chose not to take part in the active study became tolerant to any form of milk by history.ConclusionsMajority of children tolerated baked milk at baseline. Baked-milk diets were associated with progressive immunomodulation. Most children who incorporated baked milk into their diet progressed to tolerating MAFM, but there was no advantage to more frequent attempts to escalate to MAFM, per intention-to-treat analysis.

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Publication date: November–December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice, Volume 5, Issue 6

Asthma, Family History of Drug Allergy, and Age Predict Amoxicillin Allergy in Children

Publication date: Available online 7 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Yoram Faitelson, Mona Boaz, Ilan Dalal
BackgroundSuspected adverse reactions to amoxicillin are common, but there are no known factors that can predict amoxicillin allergy in children. In addition, methods used for the diagnosis of amoxicillin allergy are not standardized and their role in diagnosis is not clear.ObjectiveTo identify predictive factors and to assess the role of skin test in the diagnosis of amoxicillin allergy in children.MethodsChildren with a history of immediate (excluding anaphylaxis) or nonimmediate reactions to amoxicillin were tested by skin prick test, followed by oral graded challenge with amoxicillin. Clinical characteristics of the reaction before and after the challenge were recorded, and data of personal and relatives' drug allergies and atopy were collected for statistical analysis.ResultsSkin prick tests followed by an oral graded challenge with amoxicillin were performed on 133 children. The skin test result was not of clinical value because it was negative in all children. Three children (2%) had an immediate reaction and 7 children (5%) had a nonimmediate reaction. Asthma (odds ratio [OR], 0.12; 95% CI, 0.017-0.869; P = .03), family history of drug allergy (OR, 0.12; 95% CI, 0.026-0.613; P = .01), older age at reaction (OR, 0.837; 95% CI, 0.699-1; P = .05), and angioedema (OR, 0.22; 95% CI, 0.043-1.12; marginally significant at P = .069) were associated with reduced chance to pass the oral challenge.ConclusionsSkin prick test did not contribute to the diagnosis of amoxicillin allergy. The presence of asthma, family history of drug allergy, and older age at reaction can be used as predictive factors for true amoxicillin allergy in children.

Assessment of Antihistamines and Corticosteroids as Premedication in Rapid Drug Desensitization to Paclitaxel: Outcomes in 155 Procedures

Publication date: Available online 13 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Paula Lopez-Gonzalez, Ricardo Madrigal-Burgaleta, Laura Victoria Carpio-Escalona, Lorena Bernal-Rubio, Eva Guerra, Maria Pilar Berges-Gimeno, Emilio Alvarez-Cuesta
BackgroundIn early clinical trials, infusion reactions during the administration of taxanes were managed using systematic premedication with antihistamines and corticosteroids before standard infusions. Consequently, these premedications are also administered before rapid drug desensitization (RDD) with taxanes. However, their role in RDD has not been studied.ObjectiveTo assess the need for premedication with antihistamines and corticosteroids to prevent hypersensitivity reactions in RDD to paclitaxel.MethodsOver a 4-year period, we selected patients with confirmed hypersensitivity to paclitaxel (positive skin testing and/or drug provocation testing results) who had received paclitaxel through RDD. These patients were assigned to 2 prospective noninception cohorts: one cohort premedicated with antihistamine and corticosteroids and another cohort that was not.ResultsWe assessed 66 paclitaxel-reactive patients, of whom 22 met the inclusion criteria. A total of 155 RDDs to paclitaxel were performed. There were no significant differences in tolerance to RDD between the cohorts.ConclusionsAdministering systematic premedication with corticosteroids and antihistamines had no significant effect on the effectiveness or safety of RDD in patients with confirmed hypersensitivity to paclitaxel in the study population. Moreover, these premedications can mask early signs of hypersensitivity and delay treatment. We believe that systematic premedication with these drugs for patients undergoing RDD should be carefully and individually assessed if their only purpose is to prevent breakthrough reactions during RDD.

Impact of Lifestyle Interventions Targeting Healthy Diet, Physical Activity, and Weight Loss on Asthma in Adults: What Is the evidence?

Publication date: Available online 6 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Sharmilee M. Nyenhuis, Anne E. Dixon, Jun Ma
Unhealthy lifestyle factors such as poor diet quality, sedentary lifestyle, and obesity are associated with negative health consequences in asthma including poor asthma control, impaired quality of life, and greater health care utilization. Lifestyle modification is the cornerstone of behavioral treatments and has been effective in chronic diseases such as atherothrombotic vascular disease and diabetes. There is a critical need for lifestyle interventions in asthma care that address obesity and its intimately linked risk behaviors in terms of poor diet and physical inactivity. We present in this commentary the promising lifestyle interventions emerging in asthma care that target poor diet, physical inactivity and weight loss, the proposed mechanisms of these lifestyle interventions, and the critical need for guideline-concordant lifestyle interventions in asthma care.

Phenotypical Differences of Childhood- and Adult-Onset Atopic Dermatitis

Publication date: Available online 10 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Jonathan I. Silverberg, Paras P. Vakharia, Rishi Chopra, Ryan Sacotte, Neha Patel, Supriya Immaneni, Takeisha White, Robert Kantor, Derek Y. Hsu
BackgroundLittle is known about adult-onset atopic dermatitis (AD).ObjectiveTo determine the associations and clinical characteristics of adult-onset AD.MethodsA prospective study of 356 adults with AD (age ≥18 years) was performed using standardized questionnaires and examination. AD severity was assessed using the Patient-Oriented Eczema Measure, Eczema Area and Severity Index, Scoring Atopic Dermatitis, body surface area, and numeric rating scale for itch and sleeplessness. Latent class analysis was used to determine dominant clinical phenotypes. Multivariate logistic regression was used to determine the relationship between adult-onset AD and distinct phenotypes.ResultsOne hundred forty-nine adults (41.9%) reported onset of AD during adulthood, with 87 (24.4%) after the age of 50 years. Adult- versus childhood-onset AD was associated with birthplace outside the United States (χ², P = .0008), but not sex, race/ethnicity, current smoking status, or alcohol consumption (P ≥ .11); and decreased personal history of asthma, hay fever, and food allergy and family history of asthma and food allergy (P ≤ .0001 for all). There was no significant difference in the Eczema Area and Severity Index, Scoring Atopic Dermatitis, body surface area, numeric rating scale for itch and sleeplessness, or Patient-Oriented Eczema Measure between adult- and childhood-onset AD (Mann-Whitney U test, P ≥ .10). Latent class analysis identified 3 classes: (1) high probability of flexural dermatitis and xerosis with intermediate to high probabilities of head, neck, and hand dermatitis; (2) high probability of flexural dermatitis and xerosis, but low probabilities of head, neck, and hand dermatitis; and (3) lower probability of flexural dermatitis, but the highest probabilities of virtually all other signs and symptoms. Adult-onset AD was significantly associated with class 1 (multivariate logistic regression; adjusted odds ratio, 5.54; 95% CI, 1.59-19.28) and class 3 (adjusted odds ratio, 14.03; 95% CI, 2.33-85.50).ConclusionsSelf-reported adult-onset AD is common and has distinct phenotypes with lesional predilection for the hands and/or head/neck.

Low Variability in Peak Expiratory Flow Predicts Successful Inhaled Corticosteroid Step-Down in Adults with Asthma

Publication date: Available online 6 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Naomi Tsurikisawa, Chiyako Oshikata, Toshio Sato, Goro Kimura, Masami Mizuki, Takahiro Tsuburai, Shunsuke Shoji, Hiroshi Saito, Terufumi Shimoda
BackgroundThe prognosis for patients beyond 1 year after reduction of their inhaled corticosteroid (ICS) dose remains unknown. Predictive factors that can be evaluated before the initiation of asthma treatment or at ICS dose reduction are unknown.MethodsWe prospectively studied 223 patients in 6 hospitals in the National Hospital Organization of Japan during the 36 months after 50% reduction of their daily ICS dose. All patients recorded their morning and evening peak expiratory flows (PEFs) in their diaries. Lung function, bronchial hyperresponsiveness, fractional nitric oxide levels, number of eosinophils in sputum, and serum IgE levels were measured in most patients. Serum levels of IL-10, IL-33, and thymic stromal lymphopoietin before ICS dose reduction were measured in all patients.ResultsDuring the 36-month study period, asthma control was retained in 127 (59.6%) of the 213 enrolled patients who underwent ICS dose reduction. Multivariate logistic regression analysis revealed that, at the initiation of dose reduction, the factors most predictive of maintenance of asthma control after ICS dose reduction were a low serum IL-33 level (P < .01), low PEF variability over 1 week (P = .014), childhood onset of asthma (at age <10 years) (P = .03), and low serum IL-10 level (P = .035).ConclusionsWe demonstrated that low PEF variability over 1 week, high serum IL-10 level, and low serum IL-33 concentration were useful factors for predicting that an adult's asthma will remain in control for months to years after a 50% reduction in the daily ICS dose.

Effects of Exercise and Diet in Nonobese Asthma Patients—A Randomized Controlled Trial

Publication date: Available online 10 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Louise Lindhardt Toennesen, Howraman Meteran, Morten Hostrup, Nina Rica Wium Geiker, Camilla Bjoern Jensen, Celeste Porsbjerg, Arne Astrup, Jens Bangsbo, Debbie Parker, Vibeke Backer
BackgroundBehavioral interventions focusing on exercise and healthy diet improve asthma control in obese patients with asthma, but whether these interventions can lead to improvements in nonobese patients remains unclear.ObjectivesIn a randomized, controlled parallel-group design, we studied the effects of an 8-week intervention of either exercise (high-intensity interval training), diet (high protein/low glycemic index), or a combination of the 2, on asthma control and clinical outcomes in nonobese patients with asthma.MethodsNonobese adult patients with asthma (n = 149) were randomized to 1 of 4 groups: an exercise group, a diet group, an exercise + diet group, or a control group. Outcomes included Asthma Control Questionnaire (ACQ) score, asthma-related quality-of-life (Asthma-Related Quality-of-Life Questionnaire [AQLQ]) score, inflammatory cell counts in induced sputum, FEV1, fractional exhaled nitric oxide, and airway hyperresponsiveness (AHR).ResultsA total of 125 patients completed the study and were included in the data analysis. Patients in the exercise + diet group improved the ACQ score from 1.9 ± 0.7 to 1.0 ± 0.7 and the AQLQ score from 5.2 ± 0.8 to 6.2 ± 0.7, which was statistically significant when compared with changes in the control group (P < .05 and <.01, respectively). The exercise group and the diet group did not improve either the ACQ score or the AQLQ score significantly compared with the control group and there were no significant changes in sputum cell counts, FEV1, fractional exhaled nitric oxide, or AHR within any groups following the intervention period.ConclusionsThe combination of exercise and diet improves asthma control in nonobese patients, but does not affect AHR or airway inflammation.

Successful Intravenous Immunoglobulin Treatment in Pediatric Severe DRESS Syndrome

Publication date: Available online 1 December 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Nufar Marcus, Keren Smuel, Moran Almog, Dario Prais, Rachel Straussberg, Daniel Landau, Oded Scheuerman
BackgroundDrug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, potentially life-threatening delayed drug-induced hypersensitivity reaction. The most frequently reported drugs causing DRESS are aromatic antiepileptic agents. Prompt withdrawal of the offending drug and administering systemic corticosteroids is the most widely accepted and used treatment. The treatment of severe DRESS not responsive to systemic corticosteroids is uncertain.ObjectiveThe objective of this study was to describe a case series of pediatric patients with DRESS who were treated successfully with intravenous immunoglobulins (IVIGs).MethodsA retrospective review of all children hospitalized in a tertiary care children's hospital with severe DRESS syndrome who received IVIG in addition to offending drug withdrawal and systemic corticosteroids during 1999-2017 is performed.ResultsSeven severe DRESS patients (4 males, age: 9.5 ± 5.7 years) are described. The offending drugs were antiepileptics in all but one case. Clinical findings included fever, rash, lymphadenopathy, dyspnea, anasarca, and hepatic involvement. After IVIG treatment (total dosage: 1-2 g/kg), fever resolved within a median time of 1 (range, 0-5) day, rash disappeared after 6.3 ± 1.6 days, and liver enzymes substantially improved after 3.8 ± 1.6 days. Patients were discharged 6.1 ± 2.7 days after IVIG commencement. There was no mortality.ConclusionThe addition of IVIG in DRESS syndrome resistant to regular drug withdrawal and systemic corticosteroid therapy may hasten disease recovery.

Hereditary Angioedema with Normal C1 Inhibitor and F12 Mutations in 42 Brazilian Families

Publication date: Available online 8 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Camila Lopes Veronez, Adriana S. Moreno, Rosemeire Navickas Constantino-Silva, Luana S.M. Maia, Mariana P.L. Ferriani, Fábio F.M. Castro, Solange Rodrigues Valle, Victor Koji Nakamura, Nathália Cagini, Rozana Fátima Gonçalves, Eli Mansour, Faradiba Sarquis Serpa, Gabriela Andrade Coelho Dias, Miguel Alberto Piccirillo, Eliana Toledo, Marli de Souza Bernardes, Sven Cichon, Christiane Stieber, L. Karla Arruda, João Bosco Pesquero, Anete Sevciovic Grumach
BackgroundHereditary angioedema (HAE) with normal C1 inhibitor (C1-INH) is a rare condition with clinical features similar to those of HAE with C1-INH deficiency. Mutations in the F12 gene have been identified in subsets of patients with HAE with normal C1-INH, mostly within families of European descent.ObjectivesOur aim was to describe clinical characteristics observed in Brazilians from 42 families with HAE and F12 gene mutations (FXII-HAE), and to compare these findings with those from other populations.MethodsWe evaluated a group of 195 individuals, which included 102 patients clinically diagnosed with FXII-HAE and their 93 asymptomatic relatives.ResultsGenetic analysis revealed that of the 195 subjects, 134 individuals (77.6% females) carried a pathogenic mutation in F12. The T328K substitution was found in 132 individuals, and the c.971_1018+24del72 deletion was found in 2 patients. The mean age at onset of symptoms in patients with FXII-HAE was 21.1 years. The most common symptoms were subcutaneous edema (85.8% of patients), abdominal pain attacks (69.7%), and upper airway edema (32.3%). Of male individuals carrying F12 mutations, 53.3% (16 of 30) were symptomatic. Compared with reports from Europe, fewer female patients (68.6%) reported an influence of estrogen on symptoms.ConclusionsOur study included a large number of patients with FXII-HAE, and, as the first such study conducted in a South American population, it highlighted significant differences between this and other study populations. The high number of symptomatic males and patients with estrogen-independent FXII-HAE found here suggests that male sex and the absence of a hormonal influence should not discourage clinicians from searching for F12 mutations in cases of HAE with normal C1-INH.

A patient with anaphylaxis to diphenhydramine without cross-reactivity to loratadine

Publication date: Available online 29 November 2017
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Elaine Y.L. Au, Jaime S. Rosa Duque, Chak Sing Lau, Eric Chan