Supine Test: Detecting Lacrimal Gland Prolapse Before Upper Blepharoplasty

Supine Test: A New Test for Detecting Lacrimal Gland Prolapse Before Upper Blepharoplasty

Ophthalmic Plastic & Reconstructive Surg.. - 5d ago Preview

 
 
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Purpose: To introduce a new (Supine) test and assess the values of lateral eyelid bulging for diagnosis of lacrimal gland (LG) prolapse before upper blepharoplasty. Methods: In a prospective case series (2011–2017), lateral eyelid bulging and Supine Test were recorded, preoperatively. Lacrimal gland prolapse was graded as mild (7 mm). A few spots of cautery on LG capsule was performed in patients with bilateral mild and suture repositioning in unilateral or bilateral moderate and severe LG prolapse. Patients with asymmetric LG prolapse were treated based on more severe grade, bilaterally. Results: Included were 1,207 patients. Frequency of positive Supine Test (11.8%, 142/1,207) increased from almost 10% in patients less than 41 years of age to 15% in more than 60 years of age. Their mean age was significantly older, and 53.2% showed asymmetric LG prolapse. Septum was just opened in patients with positive Supine Test, and all had LG prolapse of ≥3 mm (mean: 5.6 mm, range: 3–14 mm). Mild LG prolapse, moderate LG prolapse, and severe LG prolapse were observed in 22.5%, 62.6%, and 14.7% of the patients, respectively. Mean follow-up time was 22 months (12–60 months). Recurrence was observed in 1 patient (bilateral) after suture repositioning. Lateral eyelid bulging had a high negative (96.2%) and low positive (30.6%) predictive value when compared with the Supine Test. Conclusions: Positive Supine Test means LG prolapse of ≥3 mm (100% positive predictive value). Negative lateral eyelid bulging was highly predictive of no LG prolapse. Accepted for publication April 5, 2019. Iran University Eye Research Center has funded the study but had no role in the design or conduct of this research. The authors have no conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.op-rs.com.). The test (not the data) was introduced in the annual meeting of European Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS), Bucharest, September 2018. The Video Clip was presented at the annual meeting of American Society of Ophthalmic Plastic and Reconstructive Surgery (ESOPRS) on October 2018, in Chicago, IL. Address correspondence and reprint requests to Mohsen Bahmani Kashkouli, M.D., Eye Department, Rasoul Akram Hospital, Sattarkhan Niayesh St, Tehran 1455364, Iran. E-mail: mkashkouli2@gmail.com © 2019 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.

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Alexandros Sfakianakis
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Laboratory Physicians

M2G1G2 white blood cell flag by three-part automated hematology analyzer: A hint to dengue infection in appropriate clinical context Maitrayee Roy, Akshay Bali Journal of Laboratory Physicians 2019 11(2):103-106 BACKGROUND: Automated hematology analyzers often generate many flags which can provide important clues to the underlying hematological abnormality. Although pathologists are generally well versed in recognizing the importance of flags indicating potential leukemic blasts, their utility in hinting toward infectious etiology, especially during epidemics, is less well known. We analyzed any abnormal flags generated by a three-part automated hematology analyzer in serologically confirmed cases of dengue. MATERIALS AND METHODS: The study included 28 patients diagnosed with serologically confirmed dengue infection. The venous samples were run on ABX Miros-60 three-part hematology analyzer. The complete blood count data and any abnormal flags were noted and correlated with peripheral blood film findings in all patients. RESULTS: An abnormal white blood cell (WBC) flag was noted in all 28 patients, including two in whom all other hematological parameters were within normal limits. In 26 (93%) patients, M2G1G2 WBC flag was noted while the samples of the remaining two patients generated M2G1 and L1M2G1G2 WBC flags, respectively. CONCLUSION: An abnormal WBC flag, when correlated in appropriate clinical context, especially during a dengue outbreak, can aid in targeting the cohort of patients who will require immediate referral for serological confirmation.

Detection of carbapenemase production in Enterobacteriaceae and Pseudomonas species by carbapenemase Nordmann–Poirel test Morubagal R Rao, Pooja Chandrashaker, Rashmi P Mahale, Sowmya G Shivappa, Ranjitha S Gowda, Vidyavathi B Chitharagi Journal of Laboratory Physicians 2019 11(2):107-110 PURPOSE: Multidrug-resistant organisms causing community-acquired and hospital-acquired infections are increasing at a dangerous rate. Carbapenemase-producing Enterobacteriaceae and Pseudomonas species are an important source of concern since these organisms are not only resistant to beta-lactam antibiotics but also show cross-resistance to other groups of antibiotics. In the present study, rapid detection of these carbapenemase-producing Enterobacteriaceae and Pseudomonas species by carbapenemase Nordmann–Poirel (Carba NP) test was evaluated by comparing with modified Hodge test (MHT). MATERIALS AND METHODS: Imipenem-resistant Enterobacteriaceae and Pseudomonas species isolated from various samples such as pus, blood, sputum, urine, and endotracheal aspirates were processed for carbapenemase detection by MHT and Carba NP test. Kappa analysis was done to evaluate the percentage agreement between the two tests. RESULTS: Seventy imipenem-resistant Enterobacteriaceae and Pseudomonas isolates were analyzed in the present study for carbapenemase production. 63.41% of Enterobacteriaceae and 34.48% of Pseudomonas species were carbapenemase producers considering both the methods. By MHT, 36 (51.42%) isolates and, by Carba NP test, 35 (50%) isolates were positive for carbapenemase production out of the 70 isolates. CONCLUSION: Carba NP test when compared to MHT is a simple, rapid, cost-effective biochemical test which can be used in all laboratories in the identification of life-threatening carbapenemase-producing Gram-negative bacteria.

Epidemiology of carbapenem-resistant Enterobacteriaceae in a Tertiary Care Center in the Kingdom of Bahrain Nermin Kamal Saeed, Safaa Alkhawaja, Nashawa Fawzy Abd El Moez Azam, Khalil Alaradi, Mohammed Al-Biltagi Journal of Laboratory Physicians 2019 11(2):111-117 PURPOSE: The purpose of the study is to estimate the rate of infection with carbapenem-resistant Enterobacteriaceae (CRE) in the main governmental tertiary care hospital in Bahrain. MATERIALS AND METHODS: All clinical samples with positive growth of CRE over 6-year period (January 2012–December 2017) were collected from the microbiology laboratory data. RESULTS: The CRE incidence was high in the first half of study period (2012–2014) and then decreased between 2015 and 2017, after implementation of intensified CRE control measure bundle. About 49.4% of CRE-positive samples were isolated from the elderly age group (above 65 years old), most of them were admitted in the intensive care unit (ICU). The most common isolated organisms were Klebsiella pneumoniae (87.0%), followed by Escherichia coli (7.9%). Isolates from deep tracheal aspirate and midstream urine specimens were the most common source of CRE isolates (27.3%) and (26.3%), respectively. Bacteremia was documented in 21.2% of cases. CRE isolates in the study showed high rates of resistance to aminoglycosides (72.2% resistant to amikacin and 67.3% to gentamicin). Alternatively, most isolates retained their susceptibility to colistin and tigecycline with sensitivity of 83.9% and 85.7%, respectively. Combined resistance to both colistin and tigecycline was observed in 0.06% of total isolates. CONCLUSION: Elderly population and ICU admission were important risk factors for CRE acquisition. Most of CRE isolates were sensitive to both colistin and tigecycline, which make them the best combination for empiric frontline therapy for suspected serious CRE infection in our facility. Implementing CRE-bundled infection control measures significantly reduced the incidence of CRE infection in our hospital.

A substitute to xylene in deparaffinization and clearing prior to coverslipping in histopathology Nasar Yousuf Alwahaibi, Sirin Hamed Aldughaishi Journal of Laboratory Physicians 2019 11(2):118-122 INTRODUCTION: Deparaffinization and clearing prior to coverslipping are important steps in all staining methods in histopathology. Xylene is the most commonly used agent worldwide. However, xylene is toxic. We evaluated safer alternative dewaxing and clearing agents prior to coverslipping in a histopathology laboratory. MATERIALS AND METHODS: Thirteen different fresh surgical tissues were cut into two halves. One half processed using xylene and the other half processed using UltraClear™. Five groups were designed. For each Group of A, B, C, and D, 100 slides were cut from xylene-processed blocks. For Group E, 100 slides were cut from UltraClear™-processed blocks. Group A is the standard method. Group B evaluates UltraClear™ as a dewaxing agent only. Group C evaluates UltraClear™ as a clearing agent prior to coverslipping only. Group D evaluates UltraClear™ as both dewaxing and clearing agents prior to coverslipping. Group E evaluates UltraClear™ as both dewaxing and clearing agents prior to coverslipping. Six parameters were evaluated: nuclear staining, cytoplasmic staining, cell morphology, clarity of staining, uniformity of staining, and cost. RESULTS: Groups B, C, and D showed 79% (P = 0.054), 83% (P = 0.221), and 80% (P = 0.079) adequacy when compared with Group A (89%), respectively. However, Group E showed only 76% (P = 0.016) adequacy. UltraClear™ is more expensive than xylene. CONCLUSION: UltraClear™ is a promising dewaxing agent. It is also a good clearing agent for use prior to coverslipping in histopathology laboratory. Cost-benefit balance between safety of laboratory workers, good quality staining, and cost-effective strategy needs to be further studied.

Prevalence and characterization of beta-lactamase-producing Escherichia coli isolates from a tertiary care hospital in India Aishwarya Govindaswamy, Vijeta Bajpai, Surbhi Khurana, Anjana Aravinda, Priyam Batra, Rajesh Malhotra, Purva Mathur Journal of Laboratory Physicians 2019 11(2):123-127 BACKGROUND: The purpose of the study was to determine the prevalence and characterize the resistance profiles of Escherichia coli isolated from various clinical specimens by various phenotypic and genotypic methods. MATERIALS AND METHODS: A total of 196 consecutive, nonduplicate strains of clinically significant E. coli isolated from various clinical specimens were included in the study. Identification and antimicrobial susceptibility testing was performed by using Vitek-2 system (Biomerieux, France). Phenotypic detection of extended spectrum beta-lactamase (ESBLs), Amp-C-β lactamase (Amp C), and carbapenemase production was done by various combination of disc diffusion methods, minimum inhibitory concentration determination by E-test, followed by polymerase-chain-reaction for the detection of β-lactamase-encoding genes. RESULTS: Overall prevalence of ESBLs, Amp C, and carbapenemase production was found to be 88.3%, 42.2%, and 65.1% by the phenotypic detection methods. Our study also revealed high resistance rates against other antibiotics such as cefepime (89%), cefotaxime (95.4%), ceftazidime (85.4%), ceftriaxone (91.8%), cefpodoxime (92.7%), aztreonam (56.3%), piperacillin/tazobactam (89.2%), and ticarcillin/clavulanic acid (76.3%). The most prevalent ESBL gene was blaTEM(67.30%), and least prevalent ESBL gene was blaVEB(2.61%). In case of Amp C, blaFOXgene (21.9%) was predominant. Among the genes encoding for carbapenemases, the most common gene was blaNDM(61.7%) followed by blaVIM(30.8%), blaKPC(10.6%), blaOXA-48 (5.3%), and blaIMP(2.1%). CONCLUSION: Our findings suggest a high rate of ESBLs, Amp C, and carbapenemase production among the E. coli isolates. A combination of both phenotypic and genotypic methods would be ideal for better characterization of resistance patterns among the E. coli isolates.

Antibiotic resistance profile and co-production of extended spectrum beta lactamases and AmpC in Acinetobacter spp. in a level 1 trauma center from India Priyam Batra, Surbhi Khurana, Aishwarya Govindaswamy, Anjana Aravinda, Vijeta Bajpai, Muruganantham Ayyanar, Purva Mathur, Rajesh Malhotra Journal of Laboratory Physicians 2019 11(2):128-132 INTRODUCTION: Acinetobacter baumannii has now emerged as a significant nosocomial pathogen in health-care setting ESP in intensive care units. Rapidly growing resistance among clinical isolates suggests a need to detect resistance mechanisms in this organism. The present study was designed to compare the various phenotypic tests available with the gold standard of genotype. METHODOLOGY: The present study was conducted to include all isolates of Acinetobacter spp. isolated over 3 years. Their resistance to various antibiotics was determined and extended spectrum beta-lactamases (ESBL) and AmpC production in the isolates showing resistance to ceftazidime/ceftriaxone/cefotaxime (CAZ/CTR/CTX) was determined. ESBL and AmpC production was confirmed using polymerase chain reaction (PCR). RESULTS: A total of 154 strains were isolated, and all the strains were tested for ESBL and AmpC detection. Of the strains tested, 15 (9.7%), 17 (11%), 24 (15.6%), 27 (17.5%), 54 (35%), 67 (43.5%), and 72 (46.7%) strains showed ESBL production using CTX/CTX-clavulanate double-disc synergy test (DDST), CTX/CTX-clavulanate E-test, CAZ/CAZ-clavulanate DDST, CAZ/CAZ-clavulanate E-test, Piperacillin/Piperacillin-tazobactam (TZ) DDST, CTR/CTR-Sulbactum DDST, and Piperacillin/Piperacillin-TZ E-test, respectively. 20 (12.9%) and 19 (12.3%) of strains were positive for AmpC production using AmpC disc test and Boronic acid inhibition test, respectively. Genotype analysis using PCR for TEM, SHV, CTXM, PER, and VEB genes was done and 69 (51.5%) strains were positive for TEM gene. DISCUSSION: ESBL detection in Acinetobacter spp. is difficult as standard guidelines for the same are not available unlike in enterobacteriaceae, and there are no zone diameter breakpoints for aztreonam and cefpodoxime. In comparison, piperacillin/piperacillin-TZ E-test had the best sensitivity and specificity for ESBL detection. CONCLUSION: Standard guidelines for ESBL detection in nil fermeners like Acinetobacter spp. must be laid down for ease of detection. Use of piperacillin/piperacillin-tazobactam E-test could be used as one of the standard methods.

Cytogenetics' impact on the prognosis of acute myeloid leukemia Monika Gupta, Manoranjan Mahapatra, Renu Saxena Journal of Laboratory Physicians 2019 11(2):133-137 INTRODUCTION: Acute myeloid leukemia (AML) is a group of disorders characterized by a spectrum of clinical, morphological, immunophenotypic, and associated chromosomal abnormalities. The identification of cytogenetic abnormalities at diagnosis is important for the evaluation of the response to therapy and the identification of an early reemergence of disease. MATERIALS AND METHODS: Newly diagnosed cases of AML were included in the study. Diagnosis of AML was based on morphology on bone marrow (BM) aspirates, cytochemistry, and flow cytometric immunophenotyping. Chromosomal analysis was performed on BM by short-term unstimulated cultures using standard cytogenetic technique. RESULTS: There were 25 males and 13 females with age group between 15 and 64 years. Cytogenetic analysis of these cases showed normal karyotype in 10 (26.3%) cases and abnormal karyotype in 28 (73.6%) cases. Cytogenetic finding in AML was divided into three groups: favorable risk, intermediate risk, and unfavorable risk. Patients in the standard risk group responded well to the chemotherapy while patients with intermediate and unfavorable karyotype had relapsed. CONCLUSION: We recommend that cytogenetics should be performed routinely in all cases of AML. A correlation must be done with various biochemical and hematological parameters, immunophenotyping, and BM morphology. Molecular studies must be integrated with cytogenetic studies for risk stratification at diagnosis to improve therapeutic strategies.

Detection of VIM and NDM-1 metallo-beta-lactamase genes in carbapenem-resistant Pseudomonas aeruginosa clinical strains in Bahrain Ronni Mol Joji, Nouf Al-Rashed, Nermin Kamal Saeed, Khalid Mubarak Bindayna Journal of Laboratory Physicians 2019 11(2):138-143 INTRODUCTION: Carbapenem-resistant Pseudomonas aeruginosa has emerged as a life-threatening infectious agent worldwide. Carbapenemase genes are reported to be some of the most common mechanisms for carbapenem resistance in P. aeruginosa. No reports are available from the Kingdom of Bahrain about carbapenem resistance and the underlying cause. In this study, we determined to study the presence of the metallo-beta-lactamase (M b L) genes of VIM family and NDM-1 in carbapenem-resistant P. aeruginosa strains. METHODOLOGY: Fifty carbapenem-resistant P. aeruginosa isolates were obtained from three main hospitals of Bahrain. They were subjected to antimicrobial susceptibility testing by disc diffusion test. Subsequently, MβL was detected by imipenem-ethylene diamine tetraacetic acid (EDTA) combined disc test and conventional polymerase chain reaction. RESULTS: Among 50 P. aeruginosa strains, 40 (80%) were imipenem resistant. Among the 40 imipenem-resistant strains, 35 (87.5%) strains were positive for the imipenem-EDTA combined disc test, and 21 (52%) were carrying MβL genes. Nineteen (47.5%) strains were positive for the VIM gene; one (2.5%) strain was carrying the NDM-1 gene, while one strain was carrying both the VIM and NDM-1 genes. None of the imipenem sensitive strains carried the VIM or NDM-1 gene. CONCLUSION: This is the first study to report the presence of the VIM family gene and NDM-1 genes in imipenem-resistant P. aeruginosa isolates in the Kingdom of Bahrain. The study also confirms the multiple drug resistance by the MβL strains, attention should therefore from now on, be focused on prevention of further spread of such isolates by firm infection control measures, and to reduce its threat to public health.

Microbiological profile and antibiotic susceptibility pattern of Gram-positive isolates at a tertiary care hospital Dhruv Mamtora, Sanjith Saseedharan, Pallavi Bhalekar, Surekha Katakdhond Journal of Laboratory Physicians 2019 11(2):144-148 OBJECTIVES: Gram-positive infections such as those by Staphylococcus aureus have contributed to the disease burden by increasing the morbidity and mortality rates in India. This study aims to determine the prevalence and the antibiotic susceptibility pattern of Gram-positive pathogens at a tertiary care hospital, Mumbai, Maharashtra, India. MATERIALS AND METHODS: This retrospective cross-sectional study was carried out from January, 2015 to December, 2017, at a tertiary care hospital in Mumbai, India. The clinical isolates were cultured, and identification was done using Vitek 2 culture system. The antibiotic susceptibility testing was done as per the Clinical Laboratory Standard Institute guidelines. RESULTS: Out of 2132 (29%) Gram-positive isolates, S. aureus (49%) was the most common encountered pathogen, followed by Enterococcus spp. (24.5%) and coagulase-negative Staphylococcus (16%). Majority of the S. aureus were observed in patients with skin and soft-tissue infections (61.2%) followed by those suffering from respiratory (41%) and bloodstream infections (35%). Among the infections caused by S. aureus, the prevalence of methicillin resistance was 30%. While the MRSA isolates showed lower sensitivity toward co-trimoxazole (39%), clindamycin (30%), erythromycin (23%), and ciprofloxacin (10%), they showed higher susceptibility to linezolid (98%), vancomycin (98%), and teicoplanin (98%). All the isolates were found to be sensitive to daptomycin and tigecycline. While vancomycin-resistant enterococci (VRE) formed 7.5%, the linezolid-resistant enterococcus species was as high as 4.1%. CONCLUSION: The study showed a high prevalence of MRSA and VRE, thereby emphasizing the increasing antimicrobial resistance pattern of the Gram-positive pathogens. Therefore, there is an urgent need for novel antimicrobial stewardship to restrict the ongoing resistance rate among the isolates.

Subclinical inflammation markers in hyperemesis gravidarum and ketonuria: A case–control study Ersin Cintesun, Serra Akar, Ayhan Gul, Feyza Nur Incesu Çintesun, Gözde Sahin, Huriye Ezveci, Fikret Akyürek, Çetin Çelik Journal of Laboratory Physicians 2019 11(2):149-153 INTRODUCTION: Subclinical inflammation markers play a significant role in hyperemesis gravidarum (HEG). Simple hematological markers such as mean platelet volume (MPV), platelet distribution width (PDW), neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), plateletcrit (PCT), and platelet-to-lymphocyte ratio (PLR) have been shown to reflect inflammatory burden and disease activity in several disorders. Ketonuria is a parameter used in the diagnosis of severe HEG, but its correlation with disease severity remains controversial. The relationship of subclinical inflammation markers with degree of ketonuria has not been examined previously. In this study, we aimed to determine the diagnostic value of these subclinical inflammation markers and the relationship between these markers and grade of ketonuria in patients with HEG. MATERIALS AND METHODS: A total of 94 pregnant women with a diagnosis of HEG and 100 gestational age-matched healthy pregnant women were enrolled in this retrospective study. MPV, PDW, NLR, PLR, PCT, and ketonuria were calculated and analyzed from complete blood cell counts and total urine analyses. RESULTS: Lymphocyte count was significantly higher in the control group (P < 0,001); NLR and PLR values were significantly higher in the HEG group (P < 0,001). Among inflammation markers, RDW increased significantly (P = 0,008) with an increase in ketonuria in patients with HEG. A statistically significant correlation was found between white blood cell (WBC) and NLR, PLR, PCT. A moderate uphill relationship was observed between NLR and WBC and a weak uphill linear relationship was observed between WBC and PLR and between WBC and PCT CONCLUSIONS: PLR and NLR can be considered effective markers to aid in the diagnosis of HEG. No marker was found to correlate with ketonuria grade except RDW, although the relationship of the severity of ketonuria with severity of disease is controversial. RDW increases as the degree of ketonuria increases.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Δifferentiated and undifferentiated mesenchymal stem cells (MSCs) seeded on nerve allografts

Adhesion, distribution and migration of differentiated and undifferentiated mesenchymal stem cells (MSCs) seeded on nerve allografts

British Association of Plastic Surgeons - 4d ago Preview

 
 
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Publication date: Available online 22 May 2019

Source: Journal of Plastic, Reconstructive & Aesthetic Surgery

Author(s): Femke Mathot, Nadia Rbia, Allen T. Bishop, Steven E.R. Hovius, Andre J. Van Wijnen, Alexander Y. Shin

Summary

Background

Although undifferentiated MSCs and MSCs differentiated into Schwann-like cells have been extensively compared in vitro and in vivo, studies on the ability and efficiency of differentiated MSCs for delivery to nerve allografts are lacking. As this is essential for their clinical potential, the purpose of this study was to determine the ability of MSCs differentiated into Schwann-like cells to be dynamically seeded on decellularized nerve allografts and to compare their seeding potential to that of undifferentiated MSCs.

Methods

Fifty-six sciatic nerve segments from Sprague-Dawley rats were decellularized and MSCs were harvested from Lewis rat adipose tissue. Control and differentiated MSCs were dynamically seeded on the surface of decellularized allografts. Cell viability, seeding efficiencies, cell adhesion, distribution and migration were evaluated.

Results

The viability of both cell types was not influenced by the processed nerve allograft. Both cell types achieved maximal seeding efficiency after 12 hours of dynamic seeding, albeit that differentiated MSCs had a significantly higher mean seeding efficiency than control MSCs. Dynamic seeding resulted in a uniform distribution of cells among the surface of the nerve allograft. No cells were located inside the nerve allograft after seeding.

Conclusion

Differentiated MSCs can be dynamically seeded on the surface of a processed nerve allograft, in a similar fashion as undifferentiated MSCs. Schwann-like differentiated MSCs have a significantly higher seeding efficiency after 12 hours of dynamic seeding. We conclude that differentiation of MSCs into Schwan-like cells may improve the seeding strategy and the ability of nerve allografts to support axon regeneration.

  

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Foam and liquid Bleomycin in the Management of Venous Malformations in Head and Neck Region

Effect of Foam and liquid Bleomycin in the Management of Venous Malformations in Head and Neck Region. A Comparative Study

British Association of Plastic Surgeons - 3d ago Preview

 
 
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Publication date: Available online 22 May 2019

Source: Journal of Plastic, Reconstructive & Aesthetic Surgery

Author(s): Hesham A. Helal, Nada A. Mahmoud

Abstract

Background

Many treatment options for venous malformations (VMs) have been documented in the literature but injection sclerotherapy has been considered a current mainstay for their treatment. We conducted this study to determine the efficacy and durability of injection of different forms of bleomycin sclerotherapy in the treatment of VMs in cervico-facial region

Patients and Methods

Thirty patients with clinically diagnosed venous malformations of the head and neck region, confirmed by magnetic resonance imaging, had been injected with bleomycin sclerosing material. They were divided into 2 groups according to the form of bleomycin injected; Group A: foam form was injected and Group B: liquid form was injected. Patients' data, anatomical sites, type and volume of the VM, number of injection sessions and the average dose of injected agents were documented and statistically compared between the 2 groups.

Results

MRI imaging showed a decline of more than 90% from the initial size of the lesions in 66.7% of the cases and considerable decline (60%-90%) in 33.3% of the cases. In group A the number of sessions and the amount of sclerosant material injected were lower than that in group B. The cumulative dose in the equal size lesions was lower in the foam form than in the liquid form.

Conclusion

We recommend using bleomycin in its foam form on a greater number of patients with larger venous malformations and in different sites as in this form the results are more promising than in the liquid form.

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Alexandros Sfakianakis
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CLINICAL THYROIDOLOGY FOR THE PUBLIC A publication of the American Thyroid Association Summaries for the Public from recent articles in Clinical Thyroidology

IODINE DEFICIENCY

Iodine content is low or absent in some US multivitamin and prenatal vitamin brands

CTFP Volume 12 Issue 5

https://www.thyroid.org/patient-thyroid-information/ct-for-patients/may-2019/vol-12-issue-5-p-3-4/

BACKGROUND

Iodine is essential for the production of thyroid hormone and for normal development of the baby during pregnancy. During pregnancy and breastfeeding there is an increased requirement for iodine both because of a need for higher thyroid hormone production and for secretion of iodine into breast milk. Many studies have shown that iodine deficiency has been associated with adverse effects in babies and infants that range from severe mental retardation to mild brain deficits. Therefore, organizations such as the American Thyroid Association and the American Academy of Pediatrics have recommended that women who are planning a pregnancy, are pregnant or are breastfeeding should ingest a daily supplement that contains 150 mcgs of iodine.

In the US, it has been challenging to identify the sources of dietary iodine, because most food packaging does not detail their contents for this element. Dairy products and seafood are two important sources, but the consumption of these two types of foods is highly variable across the US population. Although in many regions of the world, universal salt iodization has been successful in preventing iodine deficiency, iodization of salt has never been mandated in the US. Currently, only 53% of salt sold for use in homes contains iodine and salt used in processed foods typically is not iodized.

Due to the variable intake of iodine content in food sources and different types of diets followed by the US population, there is concern that some groups of people are at risk for iodine deficiency. Specifically, mild iodine deficiency has been recently documented to be present among pregnant US women. The importance of multivitamin supplements as a source of iodine for pregnant and non-pregnant US adults is not well understood. A study reviewing the use of multivitamin supplements in the US and Canada reported that supplement use ranged from 7% to 85%, showing how difficult it is to accurately determine the extent of multivitamin use. In addition, it has been reported that only 60% of the different types of prenatal multivitamin supplements marketed in the US list iodine among the ingredients. It also has been shown that iodine content is the most variable and least accurately labeled nutrient contained in US adult multivitamins.

This study aimed to assess whether multivitamins are a significant source of iodine in nonpregnant and pregnant adults by looking at the iodine content reported in the most frequently purchased US adult and prenatal multivitamin preparations, knowing how many purchases for these supplements were made over the course of one year.

THYROID AND PREGNANCY

Pregnancy and perinatal outcome among hypothyroid mothers

Vol 12 Issue 5 p.5-6 | American Thyroid Association

Vol 12 Issue 5 p.5-6 | American Thyroid Association Hypothyroidism is common in women of reproductive age and has known adverse effects on pregnancy. This study too...

BACKGROUND

Hypothyroidism is common in women of reproductive age. About 1% of women will have known hypothyroidism before getting pregnant and another 0.5% of women will be diagnosed with hypothyroidism during pregnancy. Overt hypothyroidism (low T4 and high TSH) has known adverse effects on pregnancy outcome including a higher risk of miscarriage and lower IQ in offspring. The effect of less severe hypothyroidism (high TSH but normal T4, subclinical hypothyroidism) varies with some studies, but not all, showing increased rates of caesarean section, labor induction and ICU admission of the babies. This study took advantage of national registries in Finland where nearly all women receive free maternity care and deliver at national hospitals and data is collected. The goal of the study was to look at pregnancy complications in a large group of patients and evaluate whether consistent use of thyroid hormone in hypothyroid mothers effected the outcomes.

THE FULL ARTICLE TITLE:

Turunen S et al Pregnancy and perinatal outcome among hypothyroid mothers: a population-based cohort study. Thyroid 2019 29:135–141

SUMMARY OF THE STUDY

The investigators studied all pregnancies with a single baby in Finland from 2004-2013. There were 16,364 mothers with a diagnosis of hypothyroidism and 550,860 mothers who were not hypothyroid. They used the extensive Finnish Medical Birth Registry that collects data on mothers and newborns within 7 days of delivery, the Finnish Malformation Registry to identify congenital malformations and the Prescription Register to track thyroid hormone use. Women were considered to be hypothyroid if they had a diagnosis of hypothyroidism or if they purchased thyroid medication within 3 mo prior to pregnancy or during pregnancy.

HYPERTHYROIDISM

Treatment of hyperthyroidism resulting in hypothyroidism decreases the risk of heart disease related hospitalization and death risk

https://www.thyroid.org/patient-thyroid-information/ct-for-patients/may-2019/vol-12-issue-5-p-7-8/

BACKGROUND

Hyperthyroidism is a state when the thyroid is overactive and there is too much thyroid hormone in the body. The main cause of hyperthyroidism in the United States is Graves' disease. This is an autoimmune disease where the body makes an antibody that attacks and turns on the thyroid. There are 3 major options for treatment of hyperthyroidism: 1) antithyroid drugs, such as methimazole or PTU, that decrease the thyroid hormone production; 2) surgery to remove the overactive thyroid and 3) radioactive iodine that is taken up by the thyroid and destroys the gland. The most common result of surgery and radioactive iodine therapy is hypothyroidism. Hypothyroidism can also develop if the dose of antithyroid drug is too high.

Thyroid hormone has major effects on the heart. Hyperthyroidism can cause major problems and symptoms such as irregular heart rhythms and palpitations. Rarely, these problems can lead to death. Despite treatment, the negative effects related to hyperthyroidism may persist. This study examined the effect of radioactive iodine therapy and surgery on heart disease related problems, hospitalizations and mortality.

THE FULL ARTICLE TITLE:

Essi et al 2018 Cardiovascular morbidity and mortality after treatment of hyperthyroidism with either radioactive iodine or thyroidectomy. Thyroid 28:1111–1120. Epub 2018 Jul 23.

SUMMARY OF THE STUDY

Two groups of patients who had been treated for hyperthyroidism in Finland from 1986 to 2007 were identified from a registry. Patients were treated either with surgery or with radioactive iodine therapy. A control group of Finnish residents was formed by randomly selecting 3 age and sex-matched subjects for each patient from a national population registry. A nationwide database system was used to identify causes of all heart related hospitalizations and death.

HYPOTHYROIDISM

Levothyroxine treatment increases mortality in patients with heart failure

https://www.thyroid.org/patient-thyroid-information/ct-for-patients/may-2019/vol-12-issue-5-p-9-10/

BACKGROUND

Hypothyroidism is a common condition that can affect the entire body and is treated with levothyroxine. It is clear that patients with overt hypothyroidism (high TSH and a low T4) should be treated with levothyroxine. It is less clear if patients with mild hypothyroidism (high TSH, normal T4) benefit from treatment. Finally, patients with thyroid abnormalities due to medical illnesses and not due to problems with the thyroid itself should not be treated.

In terms of heart function, it is well known that overt hypothyroidism has negative effects on the heart function that improve with levothyroxine treatment. However, studies of treating patients with subclinical (mild) hypothyroidism with heart problems have shown controversial results, with some studies suggesting that treating does not provide any benefit to the patient. This is especially true in patients with heart failure. While levothyroxine replacement may improve heart failure, it is possible that in this group it could have harmful effects, especially if the levothyroxine dose is too high. This Danish nationwide study evaluated the long-term effects of levothyroxine therapy in patients with heart failure.

THE FULL ARTICLE TITLE:

Einfeldt MN 2018 Long-term outcome in heart failure patients treated with levothyroxine: an observational nationwide cohort study. J Clin Endocrinol Metab. Epub 2018 Dec 4. PMID: 30517746.

SUMMARY OF THE STUDY

This study used the Danish national registers to identify and collect clinical information for all Danish citizens >18 years of age who were diagnosed with heart failure during a hospital admission between 1997 and 2012. The patients who received levothyroxine treatment were identified from a nationwide database of all claimed prescriptions. The patients were divided in three groups: (1) patients already receiving levothyroxine at the time of the heart failure diagnosis, (2) patients who started levothyroxine treatment after being diagnosed with heart failure and (3) patients with heart failure not treated with levothyroxine The study compared the overall death rate, the heart-specific death rate, the number of heart attacks and the combination of major adverse cardiovascular events (including death, heart attack, and stroke) between these patient groups.

Active surveillance for low risk papillary thyroid cancer can be considered in select patients

https://www.thyroid.org/patient-thyroid-information/ct-for-patients/may-2019/vol-12-issue-5-p-11-12/

BACKGROUND

The number of new thyroid cancer cases has increased over recent years, especially the number of small, low-risk papillary thyroid cancers. It is clear now that treating these small cancers aggressively with surgery results in more potential harm to patients than if the small cancer was simply watched. Because of this, simply watching, known as active surveillance, became a promising alternative to surgery for these low-risk cancers in select patients. Active surveillance involves closely monitoring the thyroid cancer over time, instead of treating it with immediate surgery. Prior studies have shown that active surveillance is safe in papillary thyroid cancers measuring 1 cm or smaller and confined to the thyroid without any lymph node involvement or spread outside of the neck. However, little is known about outcomes of active surveillance for patients with larger cancers measuring 1-2 cm and confined to the thyroid. This study compared outcomes of active surveillance for these patients to this with cancers <1 cm. The authors also examined outcomes of patients who had surgery for these small cancers.

THE FULL ARTICLE TITLE:

Sakai T et al 2019 Active surveillance for T1bN0M0 papillary thyroid carcinoma. Thyroid 29:59–63. Epub 2019 Jan 8. PMID: 30560718.

SUMMARY OF THE STUDY

The study included patients who were followed at the Cancer Institute Hospital in Tokyo, Japan, since 1995. Among 406 patients with papillary thyroid cancer < 1 cm, 360 (89%) underwent active surveillance and 46 (11%) underwent surgery. Among 392 patients with papillary thyroid cancer 1-2 cm, 331 (84%) underwent active surveillance and 61 (16%) underwent surgery.

THYROID CANCER

The TIRADS ultrasound system can decrease unnecessary biopsies of PET-positive thyroid nodules

https://www.thyroid.org/patient-thyroid-information/ct-for-patients/may-2019/vol-12-issue-5-p-13-14/

BACKGROUND

PET scanning is a type of imaging commonly used to locate areas of cancer in the human body. This is done in patients with a diagnosed cancer to see if it has spread to other parts if the body. This works because cancer cells are more active than normal cells and will take up more of the tracer (18F-FDG) and will light up positive on the PET scan. However, not all areas that are PET-positive are cancer. Some thyroid nodules are PET-positive and occasionally, PET scanning will identify unexpected/ previously undetected thyroid nodules. Up to 1/3 of PET-positive thyroid nodules will end up being thyroid cancer. For this reason, most experts recommend biopsy of these nodules, especially when they are >1 cm in diameter, in order to determine whether or not a thyroid cancer is present. Unfortunately, thyroid biopsy results do not always rule out cancer and, in such cases, thyroid surgery is often needed. This means that some surgically removed thyroid nodules will ultimately be found to be benign (noncancerous).

An important area of research is the development of new technologies that might allow doctors to avoid thyroid surgery (and even thyroid biopsy) for patients having PET-positive thyroid nodules, but for whom these nodules are benign. One such technology is thyroid ultrasound, which can identify thyroid nodule features that may predict the presence of thyroid cancer. Several different systems have been developed for predicting, on the basis of ultrasound findings, whether or not a thyroid cancer is present in a thyroid nodule. One of these systems is called TIRADS. The TIRADS system places thyroid nodules into one of four different categories (2 thorough 5), depending on how many ultrasound features suspicious for thyroid cancer are identified. The greater number of suspicious ultrasound features identified, the higher the probability of thyroid cancer and the higher the TIRADS category (with TIRADS category 5 having the highest risk of cancer and category 2 having the lowest risk). It is important to note that, although thyroid cancer risk does increase as the TIRADS category number increases, the TIRADS system is by no means perfect. A TIRADS 5 category, for example, does not mean a 100% probability of thyroid cancer.

ALEXANDROS SFAKIANAKIS ANAPAFSEOS 5 AGIOS NIKOLAOS CRETE 72100 GREECE +306932607174 +302841026182

https://www.thyroid.org/patient-thyroid-information/ct-for-patients/may-2019/vol-12-issue-5-p-11-12/

Allergy and Clinical Immunology

Role of T cells in non-immediate drug allergy reactions Purpose of review Nonimmediate drug hypersensitivity reactions (NI-DHR) constitute the most complex group of drug allergy, with many drugs involved. Both parent drugs and their reactive metabolites can be implicated. Although with some drugs the number of metabolites is limited, with others it is quite extensive and many still remain to be identified. The diagnostic approaches are insufficient for the diagnosis and realistic approaches that reproduce the pathological response are lacking. Recent findings A wider view has now been considered, with the inclusion of several mechanisms that may contribute to drug hypersensitivity reactions (DHR): the classical hapten hypothesis, the danger signal and the pharmacological interaction. Monitoring the acute response provides relevant information about the mechanisms involved, with the identification of a large number of genes that can be over-expressed or under-expressed in the acute phase of the response. Assessment of risk of developing reactions can be verified by HLA associations. Summary Further knowledge of these NI-DHR, including molecular genetics and transcriptomic analysis, has enabled a better understanding and management of these reactions. Correspondence to E. Gómez, Roche Pharma Research and Early Development, Pharmaceutical Sciences, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Brunngasse, 40. 4153. Reinach. BL., Switzerland. Tel: +41 76 321 40 37; e-mail: enriquegomezalcaide@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Treatable traits in chronic rhinosinusitis with nasal polyps Purpose of review Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory sinonasal disease that deserves a multidisciplinary precision medicine approach. In a precision medicine model, a more pragmatic approach taking in consideration disease features that are potentially treatable should be considered. Recent findings Several treatable traits in CRSwNP can be identified: from disease-related ones, to extra-ENT features, to behavioral and environmental factors. This review article summarizes primarily the recent findings of CRSwNP-related treatable traits and how they can be modified by given treatments. Summary The advent of biological agents acting directly to the endotype underlying CRSwNP pushes the scientific community to integrate clinical, surgical and immunological evaluations for each single patient; this naturally leads to the identification of specific treatable traits that can serve as possible outcomes for any single biological. Correspondence to Enrico Heffler, Personalized Medicine, Asthma and Allergy, Humanitas University, Via Rita Levi Montalcini 4; 20089 - Pieve Emanuele, Milan, Italy. Tel: +39 0282247013; e-mail: heffler.enrico@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cutaneous drug hypersensitivity: developments and controversies Purpose of review Cutaneous drug hypersensitivity reactions (CDHRs) are a complicated area with multiple clinical manifestations and differential diagnoses, requiring differentiated diagnostic measurements and optimized therapeutic management. Recent findings Disseminated CDHRs to classical drugs can be classified by a simple algorithm, whereas chemotherapeuticals or biopharmaceuticals may show drug-specific and atypical clinical presentations. Controversies in drug hypersensitivity diagnosis exist about the benefit and accuracy of in-vitro tests. Although skin tests are the best means of detecting sensitization to drugs, methods have not been sufficiently standardized. The necessity for skin tests before performing drug provocation test (DPT) and of prolonged DPTs is discussed in selected patients. If a suspicion has been documented, β-lactam allergy should be excluded. The standard allergy diagnosis is done by an allergist. In case of urgent need because of an infection and low risk according to history, faster delabeling pathways have been developed. There is weak evidence that patients with mastocytosis may have a slightly increased risk of developing immediate-type drug hypersensitivity; however, if considerations are taken, drugs do not have to be withheld for this patient group. There is particular need for improved diagnostic measurements in patients with drug-induced severe cutaneous adverse reactions (SCARs), both identifying the offending drug and detecting individuals at risk. Further challenges encompass appropriate treatments during the acute as well as chronic phase of SCARs. Summary Recent literature has contributed to our understanding of clinical manifestations and existing controversies and future needs in this area. Correspondence to Knut Brockow, Department of Dermatology and Allergology Biederstein, School of Medicine, Technical University Munich, Biedersteiner Str. 29, 80802 München, Germany. Tel:+ 0049 89 4140 3182; fax+: 0049 89 4140 3127; e-mail: knut.brockow@tum.de Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

New phenotypes in hypersensitivity reactions to nonsteroidal anti-inflammatory drugs Purpose of review Nonsteroidal anti-inflammatory drug (NSAID) is one of the most frequently prescribed medications in the medical field, and hypersensitivity to NSAID is a common adverse drug reaction encountered. However, NSAID hypersensitivity presents a variety of symptoms caused by diverse pharmacological and immunological mechanisms. Recent findings Owing to the heterogeneity of the disease, a new concept for the classification of NSAID hypersensitivity has recently been proposed to diagnose and manage NSAID hypersensitivity for personalized treatment. Acute and delayed reactions were distinguished in this classification, and identification of symptoms and speculation of putative mechanisms help physicians make the right diagnosis. NSAID-exacerbated respiratory disease is a noticeable phenotype of NSAID hypersensitivity that involves upper airway comorbidities (chronic rhinosinusitis with nasal polyps) as well as asthmatic features. The cutaneous phenotypes of NSAID hypersensitivity occur, and cross-reactivity with other types of NSAID should be considered in establishing a proper diagnosis. Hypersensitivity to a single NSAID can present urticaria/angioedema and anaphylaxis, in which an IgE-mediated immune response is suggested to be a prime mechanism. Management of NSAID hypersensitivity reactions includes avoidance, pharmacological treatment following standard guidelines, and aspirin desensitization. Summary The classification, diagnosis, and management of NSAID hypersensitivity should be individually reached by identifying its phenotype. Correspondence to Hae-Sim Park, Department of Allergy and Clinical Immunology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Korea. Tel: +82 31 219 5150; fax: +82 31 219 5154; e-mail: hspark@ajou.ac.kr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Microbiome and skin biology Purpose of review The skin is home to a diverse milieu of bacteria, fungi, viruses, bacteriophages, and archaeal communities. The application of culture-independent approaches has revolutionized the characterization of the skin microbiome and have revealed a previously underappreciated phylogenetic and functional granularity of skin-associated microbes in both health and disease states. Recent findings The physiology of a given skin-niche drives the site-specific differences in bacterial phyla composition of healthy skin. Changes in the skin microbiome have consistently been associated with atopic dermatitis. In particular, Staphylococcus aureus overgrowth with concomitant decline in Staphylococcus epidermidis is a general feature associated with atopic dermatitis and is not restricted to eczematous lesions. Changes in fungal species are now also being described. Changes in the composition and metabolic activity of the gut microbiota are associated with skin health. Summary We are now beginning to appreciate the intimate and intricate interactions between microbes and skin health. Multiple studies are currently focused on the manipulation of the skin or gut microbiome to explore their therapeutic potential in the prevention and treatment of skin inflammation. Correspondence to Liam O'Mahony, Office 450, 4th Floor Food Science and Technology Building, University College Cork, Cork, Ireland. Tel.: +353 21 4901316;. e-mail: liam.omahony@ucc.ie Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Recombinant allergens for immunotherapy: state of the art Purpose of review More than 30 years ago, the first molecular structures of allergens were elucidated and defined recombinant allergens became available. We review the state of the art regarding molecular AIT with the goal to understand why progress in this field has been slow, although there is huge potential for treatment and allergen-specific prevention. Recent findings On the basis of allergen structures, several AIT strategies have been developed and were advanced into clinical evaluation. In clinical AIT trials, promising results were obtained with recombinant and synthetic allergen derivatives inducing allergen-specific IgG antibodies, which interfered with allergen recognition by IgE whereas clinical efficacy could not yet be demonstrated for approaches targeting only allergen-specific T-cell responses. Available data suggest that molecular AIT strategies have many advantages over allergen extract-based AIT. Summary Clinical studies indicate that recombinant allergen-based AIT vaccines, which are superior to existing allergen extract-based AIT can be developed for respiratory, food and venom allergy. Allergen-specific preventive strategies based on recombinant allergen-based vaccine approaches and induction of T-cell tolerance are on the horizon and hold promise that allergy can be prevented. However, progress is limited by lack of resources needed for clinical studies, which are necessary for the development of these innovative strategies. Correspondence to Rudolf Valenta, MD, Division of Immunopathology, Department of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria. Tel: +43 140400 51080; e-mail: Rudolf.valenta@meduniwien.ac.at Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Use of biologics in chronic sinusitis with nasal polyps Purpose of review Chronic rhinosinusitis with nasal polyps (CRSwNP) is a heterogeneous inflammatory condition with different endotypes between patients from eastern or western countries. Targeted biologics are currently used to treat CRSwNP, but the outcomes widely vary. This review focuses on the present use of biologics for treating CRSwNP. Recent findings Monoclonal biologics have been used as an innovative therapy for multiple allergic diseases and comorbid allergic conditions. Over the past several decades, numerous biomarkers have been investigated and were found to be closely correlated with CRSwNP, improving the understanding of inflammatory patterns and endotype classifications for CRSwNP and prompting discussion regarding the use of biologics in CRSwNP. Efficacies vary in reports of different research groups, but it has been found that patients with TH-2-driven inflammatory patterns respond better to the use of biologics than those with non-TH-2-driven CRSwNP. These findings suggest the importance and urgency of developing criteria for biologics in CRSwNP. Summary Precisely determining patient criteria, identifying treatment biomarkers based on endotyping for CRSwNP and determinations of contraindications for long-term utilization may be useful for optimizing treatment strategies and improving the therapeutic efficacy of biologics to achieve long-term control starting at early stages. Correspondence to Luo Zhang, MD, PhD, Beijing TongRen Hospital, Capital Medical University, No. 1, DongJiaoMinXiang, DongCheng District, Beijing, China. Tel: +86 13910830399; e-mail: dr.luozhang@139.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Therapeutic approach of anaphylaxis Purpose of review Anaphylaxis is a recognized cause of death in all ages, which requires prompt recognition and treatment. We here propose to review the current and new pharmacological treatment of anaphylaxis in the view of the new knowledge in the field that can support the quality practice and empower allergists and health professionals with new tools that can be used to treat symptoms and prevent anaphylaxis. Recent findings The recent description of phenotypes provides new insight and understanding into the mechanisms and causes of anaphylaxis through a better understanding of endotypes and application of precision medicine. Several biologic therapies and new devices are emerging as potential preventive treatment for anaphylaxis. Summary Adrenaline (epinephrine) is still the first-line treatment for any type of anaphylaxis and is recognized as the only medication documented to prevent hospitalizations, hypoxic sequelae and fatalities. β2-adrenergic agonists and glucagon remains as the second-line treatment of anaphylaxis, meanwhile glucocorticoids and antihistamines should be used only as third-line treatment. Their administration should never delay adrenaline injection in anaphylaxis. More intuitive adrenaline autoinjectors design and features are required as well as a worldwide availability of adrenaline autoinjectors. Biological drugs, such as omalizumab, have been used as therapeutic adjuvants as a preventive treatment of anaphylaxis, but cost-effectiveness should be considered individually. Understanding the specifications of underlying mechanisms can potentially support improvements in the patients' allergological work-up and open the opportunity of developments of potential new drugs, such as biological agents. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among healthcare providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality. Correspondence to Luciana Kase Tanno, MD, PhD, Department of Pulmonology, Division of Allergy, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud 34295, Montpellier Cedex 5, France. Tel: +33 467336107; fax: +33 467633645; e-mail: luciana.tanno@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Eosinophilic esophagitis during sublingual and oral allergen immunotherapy Purpose of review The aim of this review is to discuss the current evidence regarding the development of eosinophilic esophagitis (EoE) in individuals undergoing oral and sublingual immunotherapy (SLIT) for both food and environmental allergens. Cumulative incidence of EoE in patients on allergen immunotherapy for peanut, milk, and egg is estimated. Recent findings De novo development of EoE in patients undergoing oral and SLIT has been demonstrated on the scale of case reports and prospective randomized trials. However, few individuals with EoE-like symptoms during immunotherapy undergo endoscopy, and the long-term outcomes of immunotherapy-associated EoE are unknown. Summary Evidence exists to suggest that allergen immunotherapy could place individuals at risk for the development of EoE, the true incidence of which may vary depending on antigen exposure and methods used to define the condition. Correspondence to Jonathan M. Spergel, MD, PhD, Division of Allergy and Immunology, Children's Hospital of Philadelphia, The Wood Building, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA. Tel: +1 215 590 2549; fax: +1 215 590 6849; e-mail: spergel@email.chop.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

ALEXANDROS SFAKIANAKIS ANAPAFSEOS 5 AGIOS NIKOLAOS CRETE 72100 GREECE +306932607174 +302841026182