IgE sensitization tests, such as skin prick testing and serum‐specific IgE, have been used to diagnose IgE‐mediated clinical allergy for many years. Their prime drawback is that they detect ...sensitization which is only loosely related to clinical allergy. Many patients therefore require provocation tests to make a definitive diagnosis; these are often expensive and potentially associated with severe reactions. The likelihood of clinical allergy can be semi‐quantified from an IgE sensitization test results. This relationship varies though according to the patients’ age, ethnicity, nature of the putative allergic reaction and coexisting clinical diseases such as eczema. The likelihood of clinical allergy can be more precisely estimated from an IgE sensitization test result, by taking into account the patient's presenting features (pretest probability). The presence of each of these patient‐specific factors may mean that a patient is more or less likely to have clinical allergy with a given test result (post‐test probability). We present two approaches to include pretest probabilities in the interpretation of results. These approaches are currently limited by a lack of data to allow us to derive pretest probabilities for diverse setting, regions and allergens. Also, cofactors, such as exercise, may be necessary for exposure to an allergen to result in an allergic reaction in specific IgE‐positive patients. The diagnosis of IgE‐mediated allergy is now being aided by the introduction of allergen component testing which may identify clinically relevant sensitization. Other approaches are in development with basophil activation testing being closest to clinical application.
Background
Kidney diseases, which have a prevalence of 3% in women of childbearing age, are increasingly encountered in pregnancy. Glomerulonephritis may develop or flare up in pregnancy, and a ...differential diagnosis with pre‐eclampsia may be impossible on clinical grounds. Use of kidney biopsy is controversial, but a systematic review has not been carried out to date.
Objectives
To review the literature on kidney biopsy in pregnancy, with a focus on indications, risks and timing.
Search strategy
Medline, Embase, CHINAL and the Cochrane Library were searched in September 2012, with ‘pregnancy’ and ‘kidney biopsy’ used as MESH and free terms, for the period 1980–2012. Results were filtered for ‘human’ if this option was available.
Selection criteria
Biopsies during pregnancy and within 2 months after delivery. Case reports (fewer than five cases) and kidney grafts were excluded. Paper selection was performed in duplicate.
Data collection and analysis
Data were extracted in duplicate. The high heterogeneity in study design necessitated that the review be narrative, except for data on adverse events, which were analysed with regard to the timing of kidney biopsy.
Main results
Of 949 references, 39 were selected, providing data on 243 biopsies in pregnancy and 1236 after delivery (timing was unclear in 106 women). The main aims of the studies were to define morphology in pre‐eclampsia (23 studies), to carry out a risk–benefit analysis of kidney biopsy (11 studies), and to investigate pregnancy‐related acute kidney injury (five studies). Four cases of major bleeding complications occurred at 23–26 weeks of gestation. Relevant complications were observed in 7% of women during pregnancy and 1% after delivery (P = 0.001). Kidney biopsy performed for the diagnosis of glomerulonephritis or pre‐eclampsia led to therapeutic changes in 66% of cases.
Authors’ conclusions
The evidence on kidney biopsy in pregnancy is heterogeneous, but a significantly higher risk of complications (relative to postpartum biopsy) was found, with a possible peak at around 25 gestational weeks.
Asthma, and severe asthma in particular, is often managed within a specialized field with allergists and clinical immunologists playing a leading role. In this respect, the National Scientific ...Society SIAAIC (Società Italiana di Allergologia, Asma ed Immunologia Clinica), structured in Regional and Inter-Regional sections, interviewed a large number of specialists involved in the management of this respiratory disease.
A survey entitled "Management of patients with asthma and severe asthma" based on 17 questions was conducted through the SIAAIC newsletter in 2019 thanks to the collaboration between GlaxoSmithKline S.p.A. and the Inter-Regional Section of SIAAIC of Central Italy.
Fifty-nine allergists and clinical immunologists participated to the survey, and 40 of them completed the entire questionnaire. Almost all of the specialists (88%) reported that asthma control was achieved in above 50% of their patients, even if only one third (32%) actually used validated clinical tools such as asthma control test (ACT). Poor adherence to inhaled therapy was recognized as the main cause of asthma control failure by 60% of respondents, and 2-5 min on average is dedicated to the patient inhaler technique training by two-thirds of the experts (65%). Maintenance and as-needed therapy (SMART/MART) is considered an appropriate approach in only a minority of the patients (25%) by one half of the respondents (52%). A high number of exacerbations despite the maximum inhalation therapy were recognized as highly suspicious of severe asthma. Patients eligible for biological therapies are 3-5% of the patients, and almost all the responders (95%) agreed that patients affected by severe asthma need to be managed in specialized centers with dedicated settings. Biological drugs are generally prescribed after 3-6 months from the initial access to the center, and once started, the follow-up is initially programmed monthly, and then every 3-6 months after the first year of treatment (96% of responders). After phenotyping and severity assessment, comorbidities (urticaria, chronic rhinosinusitis with or without nasal polyps, vasculitis, etc.) are the drivers of choice among the different biological drugs. In the management of severe asthma, general practitioners (GPs) should play a central role in selecting patients and referring them to specialized centers while Scientific Societies should train GPs to appropriately recognize difficult asthma and promote public disease awareness campaigns.
This survey which collects the point of view of allergists and clinical immunologists from Central Italy highlights that asthma control is still not measured with validated instruments. There is a general consensus that severe asthma should be managed only in dedicated centers and to this aim it is essential to encourage patient selection from a primary care setting and develop disease awareness campaigns for patients.
The prevalence of allergic disorders drastically increased over the last 50 years that today they can be considered epidemic. At present, allergen-specific immunotherapy (AIT) is the only therapy ...targeting the underlying cause of allergic disorders, and its superior evidence is based on accumulated data from clinical trials and observational studies demonstrating efficacy and safety. However, several aspects remain unsolved, such as harmonization and standardization of manufacturing and quantification procedures across manufacturers, homogeneous reporting of strength, and also the establishment of international reference standards for many allergens. This article discusses the issues related to the measurement of major allergen content in AIT extracts, raising the question of whether comparison of products by different manufacturers are appropriate as basis to choose among the different AIT products. Allergen standardization in immunotherapy products is critical to ensure quality and thereby safety and efficacy. However, lack of harmonization in manufacturing process, allergen quantification (methodologies and references), national regulatory differences, clinical practice, and labeling shows that the comparison of AIT products solely based on major allergen amounts is not rationale and, in fact, impossible. Moreover, further inherent characteristics of products and their clinical use such as their state of extract modification, addition of adjuvant or adjuvant-system, route of administration (sublingual/subcutaneous) and cumulative dose as per posology (including the volume per administration) need to be taken into account, when rating the information given for a specific product. Finally, only convincing clinical data can serve as the product-specific evaluation, or the basis for cross-product comparability, for individual products.
Introduction Le syndrome de Cushing est un syndrome rare, dont les étiologies sont variées. Observation Nous rapportons le cas d’une patiente de 40 ans, hospitalisée devant l’apparition d’un syndrome ...de Cushing d’évolution rapidement progressive. Au niveau hormonal, le cycle du cortisol était rompu, ne répondait pas au test de freinage minute à la dexaméthasone. Le cortisol libre urinaire ne s’élevait pas systématiquement, évoquant une sécrétion intermittente. L’ACTH était augmenté en faveur d’un syndrome de Cushing ACTH dépendant. Les tests dynamiques discordaient avec l’absence de freinage au test de freinage fort. Le cathétérisme des sinus pétreux étaient en faveur d’une sécrétion paranéoplasique d’ACTH. L’IRM hypophysaire ne retrouvait pas d’adénome et le scanner thoraco-abdomino-pelvien montrait une masse thymique, confirmée à l’octréoscanner, dont l’anatomopathologie s’est avérée être en faveur d’une tumeur neuroendocrine type carcinome thymique de haut grade (Ki67 15 %), invasive pT3, stade 3 de Masaoka. Elle a été traitée par chirurgie et radiothérapie adjuvante permettant une amélioration clinique et biologique. Discussion Les tumeurs neuroendocrine thymiques sont rares 1 , découvertes de façon fortuite, sur syndrome tumoral ou sur syndrome paranéoplasique dont le syndrome de Cushing 2 . Le caractère malin dépend du caractère invasif. Il s’agit d’une tumeur de mauvais pronostic avec 27 % de survie à 5 ans 3.
Introduction L’acromégalie est diagnostiquée de façon exceptionnelle pendant la grossesse. Observation Nous rapportons le cas d’une patiente de 34 ans, consultant à 12 semaines d’aménorrhée pour ...céphalées, baisse d’acuité visuelle à droite (1/10e ) avec quadranopsie bilatérale. L’IRM montrait un macro-adénome hypophysaire refoulant le chiasma optique. Cliniquement présence d’un syndrome dysmorphique franc. Biologiquement : IGF1 élevée à 573 ng/mL, GH moyenne à 28,67 ng/mL et hyperprolactinémie à 70 ng/mL. Analyse génétique négative. Un traitement médicamenteux a été instauré (Sandostatine LP 30 mg mensuel, Dostinex 0,5 mg hebdomadaire) permettant une amélioration de l’acuité visuelle de 1/10 à 9/10e en 2 semaines. Au 2e trimestre devant une aggravation des troubles visuels, une exérèse chirurgicale a été réalisée avec normalisation de l’IGF1 à 166,8 ng/mL et GH moyenne < 1 ng/mL. L’enfant est né en bonne santé. Discussion Moins de 150 grossesses ont été rapportées chez les patientes acromégales 1 . L’acromégalie est fréquemment associée à une infertilité par insuffisance gonadotrope, hyperprolactinémie ou dysfonction ovarienne 2,3 . En cas de macro-adénome, la surveillance visuelle doit être mensuelle devant un risque d’augmentation en taille de l’adénome 2,3 . Peu d’effets indésirables ont été décrits avec les traitements médicamenteux, cela permet de temporiser si possible la chirurgie jusqu’à la meilleure fenêtre thérapeutique du 2e trimestre 2,3.
Introduction Le somatostatinome est une tumeur neuroendocrine rare. Observation Nous rapportons le cas d’une patiente de 32 ans avec découverte au cours d’une grossesse d’un diabète initialement ...étiqueté de type 1 devant des Ac anti-GAD faiblement positif. Devant une cholestase modérée, l’imagerie abdominale a mis en évidence une lésion de la queue du pancréas avec envahissement hépatique secondaire de 25–50 %. L’anatomopathologie sur biopsie d’une métastase montrait une tumeur neuroendocrine bien différenciée de grade 1 selon la classification OMS 2010 1 . Aucune fixation n’était retrouvée à l’octréoscanner. Le bilan hormonal a permis le diagnostic de somatostatinome devant une somatostatine plasmatique élevée à 620 pmol/l ( n < 20). La recherche d’un syndrome de prédisposition génétique était négative. La patiente a bénéficié d’un traitement par thérapie ciblée (Everolimus), puis chimio-embolisation hépatique devant une progression de la maladie. Discussion L’hyperglycémie fait partie des signes fonctionnels du somatostatinome associée, non systématiquement, à des diarrhées et lithiases biliaires 2 . Face à la découverte d’un diabète atypique, chez le sujet jeune, la recherche d’un diabète secondaire doit être envisagée et discutée.
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