This article continues the comprehensive international consensus (ICON) statement on allergen immunotherapy (AIT). The initial article also recently appeared in the Journal . The conclusions below ...focus on key mechanisms of AIT-triggered tolerance, requirements in allergen standardization, AIT cost-effectiveness, and regulatory guidance. Potential barriers to and facilitators of the use of AIT are described in addition to future directions. International allergy specialists representing the European Academy of Allergy and Clinical Immunology; the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma and Immunology; and the World Allergy Organization critically reviewed the existing literature and prepared this summary of recommendations for best AIT practice. The authors contributed equally and reached consensus on the statements presented herein.
The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single ...individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Chief Editors Linda Cox, MD Department of Medicine Nova Southeastern University College of Osteopathic Medicine Davie, Florida Richard Lockey, MD Division of Allergy and Immunology Department of Internal Medicine University of South Florida College of Medicine and James A. Haley Veterans' Hospital Tampa, Florida Harold Nelson, MD Department of Medicine National Jewish Health Denver, Colorado Work Group Members Christopher Calabria, MD Glen Burnie, Maryland Thomas Chacko, MD Roswell, Georgia Ira Finegold, MD New York, New York Michael Nelson, MD, PhD Washington, DC Richard Weber, MD Denver, Colorado Joint Task Force Reviewers David Bernstein, MD Department of Medicine and Environmental Health University of Cincinnati College of Medicine Cincinnati, Ohio David A. Khan, MD Department of Internal Medicine University of Texas Southwestern Medical Center Dallas, Texas Joann Blessing-Moore, MD Departments of Medicine and Pediatrics Stanford University Medical Center Department of Immunology Palo Alto, California David M. Lang, MD Allergy/Immunology Section Division of Medicine Allergy and Immunology Fellowship Training Program Cleveland Clinic Foundation Cleveland, Ohio Richard A. Nicklas, MD Department of Medicine George Washington Medical Center Washington, DC John Oppenheimer, MD Department of Internal Medicine New Jersey Medical School Pulmonary and Allergy Associates Morristown, New Jersey Jay M. Portnoy, MD Section of Allergy, Asthma & Immunology The Children's Mercy Hospital Department of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, Missouri Christopher Randolph, MD Yale University New Haven, Connecticut Diane E. Schuller, MD Department of Pediatrics Pennsylvania State University Milton S. Hershey Medical College Hershey, Pennsylvania Sheldon L. Spector, MD Department of Medicine UCLA School of Medicine Los Angeles, California Stephen A. Tilles, MD Department of Medicine University of Washington School of Medicine Redmond, Washington Dana V. Wallace, MD Department of Medicine Nova Southeastern University Davie, Florida Invited Reviewers Don Aaronson, MD, JD, MPH Chicago, Illinois Desiree Larenas-Linnemann, MD Mexico city, Mexico Bryan Leatherman, MD Gulfport, Mississippi Sandra Y. Lin, MD Johns Hopkins Department of Otolaryngology-Head & Neck Surgery Baltimore, Maryland Oral and sublingual immunotherapy for food hypersensitivity Wesley Burkes, MD Duke University Raleigh, North Carolina Venom hypersensitivity David Golden, MD Baltimore, Maryland Theodore M. Freeman, MD Helotes, Texas Allergen extract section Derek Constable, PhD Spokane, Washington Robert Esch, PhD Lenoir, North Carolina Larry Garner, CPT, BA Spokane, Washington Richard Lankow, PhD Round Rock, Texas Greg Plunkett, PhD Round Rock, Texas Ronald Rabin, MD Rockville, Maryland Assigned Reviewers Paul Greenberger, MD Northwestern University Feinberg School of Medicine Chicago, Illinois Bryan Martin, DO Ohio State University Columbus, Ohio Preface This document was developed by the Joint Task Force on Practice Parameters, which represents the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology (JCAAI).
It is difficult to predict adverse patient outcomes associated with transvenous lead extraction (TLE) procedures.
The purpose of this study was to examine the safety and efficacy of chronic ...endovascular pacemaker and implantable cardioverter-defibrillator (ICD) lead extraction and risk factors associated with adverse patient outcomes.
Consecutive patients undergoing TLE at the Cleveland Clinic between August 1996 and August 2011 were included in the analysis. Univariate and multivariable logistic regression analyses were performed to evaluate for associations with outcomes. Continuous data are given as median (25th, 75th percentile). Categorical data are given as number (percentage).
In total, 5521 leads (4137 74.9% pacemaker, 1384 25.1% ICD) were extracted during 2999 TLE procedures (patient age 67.2 55.2, 76.2 years, 30.2% female). Lead implant duration was 4.7 (2.4, 8.3) years, and 2.0 (1.0, 2.0) leads were extracted per procedure. Powered sheaths were used in 74.9% of procedures. Overall, there was 95.1% complete procedural success, 98.9% clinical success, and 1.1% failure, with 3.6% minor complications and 1.8% major complications. All-cause mortality within 30 days of TLE was 2.2%. Multivariable predictors of major complications included cerebrovascular disease, ejection fraction ≤15%, lower platelet count, international normalized ratio ≥1.2, mechanical sheaths, and powered sheaths. Multivariable predictors of all-cause mortality within 30 days of TLE included body mass index <25 kg/m(2), end-stage renal disease, higher New York Heart Association functional class, lower hemoglobin, higher international normalized ratio, lead extraction for infection, and extraction of a dual-coil ICD lead.
TLE in this single-center experience was highly successful. Risk factors associated with adverse patient outcomes were identified.
Cough features a complex peripheral and central neuronal network. The function of the chemosensitive and stretch (afferent) cough receptors is well described but partly understood. It is speculated ...that chronic cough reflects a neurogenic inflammation of the cough reflex, which becomes hypersensitive. This is mediated by neuromediators, cytokines, inflammatory cells, and a differential expression of neuronal (chemo/stretch) receptors, such as transient receptor potential (TRP) and purinergic P2X ion channels; yet the overall interaction of these mediators in neurogenic inflammation of cough pathways remains unclear.
The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on neuroanatomy and pathophysiology of chronic cough. The role of TRP ion channels in pathogenic mechanisms of the hypersensitive cough reflex was also examined.
Chemoreceptors are better studied in cough neuronal pathways compared to stretch receptors, likely due to their anatomical overabundance in the respiratory tract, but also their distinctive functional properties. Central pathways are important in suppressive mechanisms and behavioral/affective aspects of chronic cough. Current evidence strongly suggests neurogenic inflammation induces a hypersensitive cough reflex marked by increased expression of neuromediators, mast cells, and eosinophils, among others. TRP ion channels, mainly TRP V1/A1, are important in the pathogenesis of chronic cough due to their role in mediating chemosensitivity to various endogenous and exogenous triggers, as well as a crosstalk between neurogenic and inflammatory pathways in cough-associated airways diseases.
Comparative safety and efficacy associated with transvenous lead extraction (TLE) of recalled and non-recalled implantable cardioverter-defibrillator (ICD) leads has not been well characterized.
To ...compare the indications, techniques, and procedural outcomes of recalled vs non-recalled ICD lead extraction procedures.
TLE procedures performed at our institution from June 2002 to June 2012 in which Riata, Sprint Fidelis, or non-recalled ICD leads were extracted were included in the analysis.
ICD lead extraction procedures were performed in 1079 patients, including 430 patients with recalled leads (121 Riata, 308 Sprint Fidelis, and 1 Riata and Sprint Fidelis) and 649 patients with non-recalled ICD leads. A total of 2056 chronic endovascular leads were extracted, of which 1215 (59.1%) were ICD leads. Overall, there was 96.8% complete procedural success, 99.1% clinical success, and 0.9% failure, with 3.9% minor complications and 1.5% major complications. Procedural outcomes for Riata and Sprint Fidelis TLE procedures were no different. Lead implant duration was significantly less in recalled than in non-recalled ICD lead TLE procedures. Complete procedural success was higher in recalled (424 of 430 98.6%) than in non-recalled (621 of 649 95.7%; P = .007) ICD lead TLE procedures. Minor complications were lower in recalled (10 of 430 2.3%) than in non-recalled (32 of 649 5.0%; P = .030) ICD lead TLE procedures. Rates of clinical success, failure, and major complications were no different in the recalled and non-recalled ICD lead TLE procedures.
In our experience, recalled ICD leads were extracted with safety and efficacy comparable to that of non-recalled ICD leads.
In patients with chronic systolic heart failure who undergo cardiac resynchronization therapy (CRT), improvements in left ventricular ejection fraction (LVEF) and reductions in left ventricular ...volume are generally modest. A minority of patients experience a dramatic response to CRT (super-responders), but the attributes associated with these patients have not been fully characterized.
The purpose of this study was to identify baseline clinical attributes of super-responders and to assess the survival benefit associated with this response.
We reviewed clinical, echocardiographic, and ECG data from a cohort of 233 patients undergoing new implantation of a CRT device between December 2001 and November 2006. All patients had a baseline LVEF < or =40% and New York Heart Association class II to IV symptoms on standard medical therapy. Patients whose absolute LVEF improved by > or =20% were termed super-responders. A multivariate model was constructed to determine factors predictive of super-response, and an assessment of mortality was made.
In this cohort of 233 patients, 32 (13.7%) met criteria for super-response. In univariate analysis, super-responders were more likely to be female and have a native left bundle branch block, lower preimplant brain natriuretic peptide and red cell distribution width levels, and smaller baseline left ventricular volumes with trends toward having more nonischemic cardiomyopathy and midventricular lead positions. In multivariate analysis, only left bundle branch block remained significantly associated with super-response. Super-responders had a considerably lower incidence of mortality compared to non-super-responders (9.4% vs 43.2%, P = .006) at mean follow-up of 5.5 +/- 1.2 years.
Baseline left bundle branch block is strongly associated with super-response to CRT. Super-responders derive better long-term outcomes with CRT than do non-super-responders.
OBJECTIVES:
Traumatic brain injury is associated with coagulopathy that increases mortality risk. Viscoelastic hemostatic assays such as thromboelastography (Haemonetics SA, Signy, Switzerland) ...provide rapid coagulopathy assessment and may be particularly useful for goal-directed treatment of traumatic brain injury patients. We conducted a systematic review to assess thromboelastography in the evaluation and management of coagulopathy in traumatic brain injury patients.
DATA SOURCES:
MEDLINE, PubMed Central, Embase, and CENTRAL.
STUDY SELECTION:
Clinical studies of adult patients with traumatic brain injury (isolated or polytrauma) who were assessed by either standard thromboelastography or thromboelastography with platelet mapping plus either conventional coagulation assays or platelet function assays from January 1999 to June 2021.
DATA EXTRACTION:
Demographics, injury mechanism and severity, diagnostic, laboratory data, therapies, and outcome data were extracted for analysis and comparison.
DATA SYNTHESIS:
Database search revealed 1,169 sources; eight additional articles were identified by the authors. After review, 31 publications were used for qualitative analysis, and of these, 16 were used for quantitative analysis. Qualitative and quantitative analysis found unique patterns of thromboelastography and thromboelastography with platelet mapping parameters in traumatic brain injury patients. Patterns were distinct compared with healthy controls, nontraumatic brain injury trauma patients, and traumatic brain injury subpopulations including those with severe traumatic brain injury or penetrating traumatic brain injury. Abnormal thromboelastography K-time and adenosine diphosphate % inhibition on thromboelastography with platelet mapping are associated with decreased survival after traumatic brain injury. Subgroup meta-analysis of severe traumatic brain injury patients from two randomized controlled trials demonstrated improved survival when using a viscoelastic hemostatic assay-guided resuscitation strategy (odds ratio, 0.39; 95% CI, 0.17–0.91;
p
= 0.030).
CONCLUSIONS:
Thromboelastography and thromboelastography with platelet mapping characterize coagulopathy patterns in traumatic brain injury patients. Abnormal thromboelastography profiles are associated with poor outcomes. Conversely, treatment protocols designed to normalize abnormal parameters may be associated with improved traumatic brain injury patient outcomes. Current quality of evidence in this population is low; so future efforts should evaluate viscoelastic hemostatic assay-guided hemostatic resuscitation in larger numbers of traumatic brain injury patients with specific focus on those with traumatic brain injury-associated coagulopathy.
Conclusions It is important for pediatric providers to educate peanut- and tree nut-allergic individuals and their caregivers on avoidance measures for peanuts and tree nuts including the ability to ...properly identify them.
Chronic cough can be triggered by respiratory and non-respiratory tract illnesses originating mainly from the upper and lower airways, and the GI tract (ie, reflux). Recent findings suggest it can ...also be a prominent feature in obstructive sleep apnea (OSA), laryngeal hyperresponsiveness, and COVID-19. The classification of chronic cough is constantly updated but lacks clear definition. Epidemiological data on the prevalence of chronic cough are informative but highly variable. The underlying mechanism of chronic cough is a neurogenic inflammation of the cough reflex which becomes hypersensitive, thus the term hypersensitive cough reflex (HCR). A current challenge is to decipher how various infectious and inflammatory airway diseases and esophageal reflux, among others, modulate HCR.
The World Allergy Organization/Allergic Rhinitis and its Impact on Asthma (WAO/ARIA) Joint Committee on Chronic Cough reviewed the current literature on classification, epidemiology, presenting features, and mechanistic pathways of chronic cough in airway- and reflux-related cough phenotypes, OSA, and COVID-19. The interplay of cough reflex sensitivity with other pathogenic mechanisms inherent to airway and reflux-related inflammatory conditions was also analyzed.
Currently, it is difficult to clearly ascertain true prevalence rates in epidemiological studies of chronic cough phenotypes. This is likely due to lack of standardized objective measures needed for cough classification and frequent coexistence of multi-organ cough origins. Notwithstanding, we emphasize the important role of HCR as a mechanistic trigger in airway- and reflux-related cough phenotypes. Other concomitant mechanisms can also modulate HCR, including type2/Th1/Th2 inflammation, presence or absence of deep inspiration-bronchoprotective reflex (lower airways), tissue remodeling, and likely cough plasticity, among others.
An arteriovenous (AV) fistula is an infrequently reported complication of transvenous lead extraction (TLE), but may be under-recognized.
To determine the incidence, management, and outcomes of the ...AV fistula complicating TLE.
All TLE procedures from July 2001 to December 2012 were reviewed.
Of 2471 patients who underwent TLE, the AV fistula occurred in 8 (0.3%; 6 pacemaker and 2 implantable cardioverter-defibrillator) procedures. Patients who developed an AV fistula had longer lead implant duration (11.8 interquartile range 7.7 vs 5.2 interquartile range 7.0 years) and were more likely to have required a powered sheath (8 of 8 100% vs 1392 of 2463 56.5%) compared to those who did not. Other procedural and demographic details did not discriminate. All patients had a continuous bruit along the anterior chest wall. Catheter angiography was more sensitive (100%) than computed tomography (75%) or ultrasound (25%) for confirming the diagnosis and identifying the vessels involved. One fistula closed spontaneously, while others were closed with covered stents (4) or surgical glue (1). One attempt at closure failed, and one was diagnosed postmortem. Mortality related to the AV fistula was 3 of 8 (37.5%). Patients who died all had structural heart disease. In the 5 patients with normal hearts, the AV fistula was well tolerated for up to 2 years.
An AV fistula is an infrequent, though possibly under-recognized, complication of TLE. It requires a high index of suspicion for early diagnosis, may present late, and may be associated with significant morbidity and mortality in patients with structural heart disease.
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