Jo A Douglass

Anaphylaxis to Gelofusine® confirmed by in vitro basophil activation test: a case series*

The plasma expander Gelofusine® (succinylated gelatin) is a recognised cause of peri‐operative anaphylaxis. Current diagnosis of Gelofusine sensitivity is by skin testing, a procedure that itself carries a risk of allergic reaction. We evaluated the reliability of the in vitro basophil activation test as a diagnostic assay for Gelofusine sensitivity in subjects with a clinical history highly suggestive of Gelofusine allergy. Six patients with peri‐operative anaphylaxis clinically attributed to Gelofusine were skin tested to confirm sensitivity. Control subjects included three healthy subjects and five subjects allergic to a neuromuscular blocking drug, all negative on Gelofusine skin testing. Whole blood basophil activation to Gelofusine was analysed by flow cytometry for CD63 surface expression. All of the Gelofusine sensitive patients and one of the control allergic subjects showed positive basophil activation to Gelofusine. In this series of subjects, the basophil activation test for Gelofusine allergy had a sensitivity of 100% and a specificity of 87.5%. Our findings suggest that basophil activation testing is a safe and reliable in vitro assay for prediction or confirmation of Gelofusine sensitivity in patients with high clinical suspicion of Gelofusine‐induced anaphylaxis.

Impact of helminth infection on childhood allergic diseases in an area in transition from high to low infection burden

Background The effect of helminth infections on allergic diseases is still inconclusive. Furthermore, the effect of helminth infections on childhood allergic diseases in a tropical area where prevalence of helminth infections has undergone dramatic changes is not well documented. Objective To investigate the relationship between allergic diseases and helminth infection in a cohort of schoolchildren in an area that has undergone dramatic changes in intensity of helminth infections. Methods Children attending grade 5 were recruited from 17 schools in Western Province of Sri Lanka. They were assessed for allergic diseases using the International Study of Asthma and Allergies in Childhood questionnaire. Their serum total IgE (tIgE) and allergen-specific IgE (sIgE) for five common aeroallergens were measured by ImmunoCAP® method and stools were examined for the presence of helminth infections. Results A total of 640 children (mean age 10 years) were recruited to the study. Of them, 33.7% had evidence of allergic disease and 15.5% had helminth infections. Majority of infections (68.9%) were of low intensity. A significant relationship between allergic disease and helminth infections was not observed, however, a trend toward protective role of helminth infections against allergic diseases was noted. Multivariate analysis showed helminth infections to be an independent predictor of high tIgE levels whereas allergic disease was not. Allergic sensitization (atopy) was a significant risk factor for allergic disease only among non-infected children (odds ratio 3.025, p = 0.022) but not in infected children. The ratio of sIgE to tIgE was higher in non-infected children. Conclusion Though not significant, a reduced risk of allergy in helminth-infected children was observed in this population. A Decrease in intensity of helminth infections may have contributed to the reduced capacity of immune-modulation by helminths in this paediatric population.

Asthma 3+ Visit Plan: a qualitative evaluation

Abstract

Palliative care for patients with chronic obstructive pulmonary disease: exploring the landscape

Patients with chronic obstructive pulmonary disease experience a substantial symptom burden, high levels of psychosocial need and significant mortality. This epidemiological study reveals that the majority of patients are cared for in the public hospital system (64%) and generally die in hospital (72%) with a number of identifiable predictors of 6‐month mortality. Our results suggest that palliative care services need to be redirected from a community‐based admission focus to a model that is responsive to emergency and acute care hospital systems.

Immunotherapy in asthma

Background. Although allergen immunotherapy is effective for allergic rhinitis, its role in treating asthma is unclear. Methods. We examined the efficacy of immunotherapy for asthma exacerbated by seasonal ragweed exposure. During an observation phase, adults with asthma who were sensitive to ragweed kept daily diaries and recorded peak expiratory flow rates between July and October. Those who reported seasonal asthma symptoms and medication use as well as decreased peak expiratory flow were randomly assigned to receive placebo or ragweed-extract immunotherapy in doses that increased weekly for an additional two years. Results. During the observation phase, the mean (SE) peak expiratory flow rate measured in the morning during the three weeks representing the height of the pollination season was 454 (20) litres per minute in the immunotherapy group and 444 (16) litres per minute in the placebo group. Of the 77 patients who began the treatment phase, 64 completed one year of the study treatment and 53 completed two years. During the two treatment years, the mean peak expiratory flow rate was higher in the immunotherapy group (489 (16) litres per minute vs. 453 (17) in the placebo group (p= 0.06) during the first year, and 480 (12) litres per minute vs. 461 (13) in the placebo group (p = 0.03) during the second). Medication use was higher in the immunotherapy group than in the placebo group during observation and lower during the first treatment year (p = 0.01) but did not differ in the two groups during the second year (p=0.7). Asthma symptom scores were similar in the two groups (p = 0.08 in year 1 and p = 0.3 in year 2). The immunotherapy group had reduced hayfever symptoms, skin test sensitivity to ragweed, and sensitivity to bronchial challenges and increased IgG antibodies to ragweed as compared with the placebo group; there was no longer a seasonal increase in IgE antibodies to ragweed allergen in the immunotherapy group after two years of treatment. Reduced medication costs were counterbalanced by the costs of immunotherapy. Conclusions. Although immunotherapy for adults with asthma exacerbated by seasonal ragweed exposure had positive effects on objective measures of asthma and allergy, the clinical effects were limited and many were not sustained for two years.