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Background: A single nucleotide polymorphism (SNP) C-509T within the tumor growth factor β1 (TGFβ1) gene has been associated with atopic asthma and asthma severity. To further understand the mechanisms involved, the association of C-509T with allergy, T-lymphocyte proliferation and plasma TGFβ1 concentration has been explored in a case-control study with allergic and non-allergic subjects. Methods: The recruited subjects including allergic (n = 38) and nonallergic (n = 25) participants have been genotyped for C-509T using allele discrimination assay. Association of C-509T with allergy status was examined using logistic regression analysis in both dominant and recessive models. Association of C-509T with T-cell proliferation in control and antigen-stimulated peripheral blood mononuclear cells (PBMCs), plasma TGFβ1 and total IgE level were tested by multiple regression analysis. Results: Individuals with homozygous mutant TT genotype showed a higher risk of allergy (TT: odds ratio = 5.099, 95% confidence limit: 1.355–19.190, p = 0.016) after covariates were adjusted. A trend to increased plasma TGFβ1 in subjects with T allele has been discovered. In the meantime, the T allele is associated with lower T cell proliferation in controls and maximum response to above antigens. A low T-cell proliferation is correlated with higher plasma TGFβ1 concentration (p < 0.01). The in vitro studies confirmed the suppressing effect of TGFβ1 on T-cell proliferation at physiological range. A significant inhibitory effect on IL-4 production was also observed. Conclusions: A C to T base change in TGFβ1 SNP C-509T has been associated with a higher risk of allergy. The mechanisms are not clear. Elevated TGFβ1 levels associated with the C-509T polymorphism might suppress immune activation as well as Th2 cytokine production. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Inflammation in asthma extends into the small airways ( 2 mm. Therefore, inflammation in the small airways of patients with asthma may not be adequately treated with these preparations. Some inhaled corticosteroids, on the other hand, are compounded with alcohol, resulting in a solution producing an aerosol that has a mean particle diameter of p = 0.0214 and 0.0433, respectively), whereas forced expiratory flow over 25–75% of the vital capacity (FEF 25–75% ), forced expiratory volume in 1 second (FEV 1 ), and morning peak flow improved significantly ( p = 0.0014, 0.0184, and 0.0321). Improvements from baseline of CV, CV/VC, and postbronchodilator FEF 25–75% , were statistically significant in the HFA-BDP group compared with the CFC-FP group ( p = 0.0049, 0.0194, and 0.0355, respectively). These preliminary findings suggest that the addition of HFA-BDP, compared with CFC-FP in patients with poorly controlled asthma despite receiving moderate to high doses of inhaled steroids, has a greater effect on parameters reflecting small airway patency presumably secondary to reduction in inflammation. [ABSTRACT FROM AUTHOR]

Background: Biphasic anaphylaxis despite successful treatment has an incidence of 4-5% based on NIAID/FAAN criteria. Our study aimed to investigate the frequency and predictive factors associated with biphasic reactions within the emergency department (ED) at Siriraj Hospital., Methods: This observational study assessed medical records of anaphylaxis and anaphylactic shock patients at Siriraj Hospital's ED from January 2015 to December 2019. Of these, a random sample was reviewed and validated by allergists. Telephone interviews were performed to collect more data. Uni- or biphasic response were analyzed descriptively. Prediction modeling was performed., Results: Among 1888 ED anaphylaxis cases, 601 were randomly sampled; 239 patients completing interviews were analyzed. The incidence of biphasic reactions was 7.1% (17/239) of cases. Common triggers of biphasic responses were foods (57.7%), drugs (31%), other known allergens (5.9%). Shellfish, edible insects, and wheat were the leading food triggers. Biphasic responses were significantly associated with history of drug allergy, any allergic disease, allergic rhinitis, number of prior anaphylactic reactions, angioedema, less generalized erythema, less reaction to shellfish, reaction to NSAIDs, and no epinephrine giving at ED visit (all p < 0.1). From a 3-predictor prognostic model including drug/idiopathic reaction, duration from onset to first epinephrine > 60 minutes, and any cutaneous edema/angioedema with an area under the curve of 0.72 (95%CI 0.54, 0.90)., Conclusion: The incidence of biphasic response was 7.1%. Predictors of biphasic response were drug/idiopathic reac- tion, any cutaneous edema/angioedema, and time from onset to first epinephrine > 60 minutes.

Background: A maintenance oral corticosteroid (OCS) in addition to high-dose inhaled corticosteroids plus long-acting β 2 -agonists in patients with severe asthma leads to long-term adverse events. Oral corticosteroid-sparing agents are of high priority., Objective: This network meta-analysis assessed biologics' comparative efficacy and safety in OCS-dependent patients with asthma., Methods: We performed a systematic search through PubMed, Scopus, Embase, the Cochrane Center of Controlled Trials, and Google Scholar for randomized controlled trials that addressed the efficacy and safety of biologics compared with placebo in OCS-dependent patients with asthma from inception to July 2023. The primary outcome was an overall reduction in the OCS dose while asthma control was maintained., Results: We included seven randomized controlled trials involving 1,052 OCS-dependent patients with asthma. Compared with placebo, benralizumab every 8 weeks, benralizumab every 4 weeks, dupilumab, and mepolizumab were efficacious in achieving a reduction in the OCS dose with low to moderate confidence (odds ratio [95% CI]: 4.12 [2.22-7.64]; 4.09 [2.22-7.55]; 3.25 [1.90-5.55]; and 2.39 [1.25-4.57], respectively) whereas tralokinumab, tezepelumab, and subcutaneous reslizumab were ineffective. An indirect comparison found no significant differences among benralizumab, dupilumab, and mepolizumab. Efficacy in reducing exacerbations was consistent with the primary analysis. High baseline blood eosinophil counts benefit from anti-IL-5 therapies, whereas high FeNO levels favor dupilumab regardless of blood eosinophil counts. Adverse events between biologics and placebo were comparable, except for eosinophilia with dupilumab., Conclusions: In OCS-dependent patients with asthma, benralizumab, dupilumab, and mepolizumab were superior to placebo in reducing the OCS dose. Evaluating baseline biomarkers helps in choosing the proper biologics to maximize treatment effects., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Food allergy affects the patient's quality of life (QoL) and leads to anxiety and depression. In addition to routine treatment, QoL evaluation should also be performed in patients with food allergies. The validated Food Allergy Quality of Life Questionnaire - Adult Form (FAQLQ-AF) and Food Allergy Independent Measure - Adult Form (FAIM-AF) have been well accepted and available in many languages., Objective: Translate FAQLQ-AF and FAIM-AF into Thai and perform reliability and validity tests in Thai adult patients with food allergies., Methods: The translation process was performed according to the ISPOR Task Force for Translation and Cultural Adaptation. Participants 18 years or older and with physician-diagnosed food allergies were included in the study. Thai versions of FAQLQ-AF and FAIM-AF were administered to participants at baseline and after two weeks. The intraclass correlation coefficient and Cronbach's α coefficient were evaluated to demonstrate both questionnaires' test-retest reliability and internal consistency., Results: The study included 104 participants. The Thai version of FAQLQ-AF and FAIM-AF demonstrated good reliability, with intraclass correlation coefficients of 0.83 (95%CI 0.76, 0.88) and 0.85 (95%CI 0.79, 0.90), respectively. The validity was excellent, with Cronbach's α coefficient of 0.91 and 0.92, respectively. Both questionnaires were moderately correlated (r = 0.69, P < 0.001), but poorly correlated with the 36-Item Short Form Survey, which is usually used to evaluate general health status., Conclusions: To evaluate the QoL in adult patients with food allergies, the Thai versions of FAQLQ-AF and FAIM-AF are valid, reliable, and more suitable than the general questionnaire.

Background: IgE-mediated food allergy (FA) affects health-related quality of life, and may cause life-threatening reactions. Few studies characterizing adult FA patients have been reported, especially first ever reaction (FER) in adult-onset., Objective: We describe the characteristics of adult FA patients, especially FER and compare these characteristics between childhood- and adult-onset FA., Methods: A cross-sectional study of all adult patients visiting the Allergy Clinic, Siriraj Hospital at the outpatient department between January 2009 to December 2019 was conducted. Demographic, clinical data, and first reaction in life data were collected. Adult-onset was defined as ≥ 18 years old., Results: Of 711 patients visiting the clinic, 174 (24.4%) were FA with a median age of 31.0 years (interquartile range 24.0, 44.0 years); 29.3% were male. FA patients had significantly higher prevalence of sensitization to cockroach compared with non-FA patients (67.4% vs. 56.3%); p = 0.016). The three most common food triggers were shellfish (68.0%), wheat (28.7%), and fruit and vegetables (10.0%). Before diagnosis, 56.7% (97/171) experienced at least 1 food-related anaphylaxis. Of the 166 patients compared on age of onset, 127 (76.5%) were adult-onset. In FER, patients with adult-onset had significantly more reactions to fruit and vegetables, more respiratory system involvement, and more other systems involvement [OR 8.95 (1.13, 1157); p = 0.034; OR 3.15 (95%CI 1.30, 8.25), p = 0.011; OR 10.8 (1.35, 1404), p = 0.019, respectively]. In sensitivity analysis, the cardiovascular system involvement was also significantly more common [OR 2.78 (1.05, 9.15); p = 0.038]., Conclusions: Shellfish was the most common trigger foods in adult FA patients. In FER, anaphylaxis was common for adult-onset. Adult-onset FA patients also had more respiratory, cardiovascular, and other systems involvements than childhood-onset ones. FA awareness, early diagnosis, and proper management are encouraged. Further studies on the adult-onset food allergic patients are required.

Background: Perioperative immediate hypersensitivity reaction (POH) is an immediate hypersensitivity reaction during an anesthesiologist monitored procedure. We report data of clinically-suspected POH (csPOH) patients undergoing an allergist-performed unified diagnostic workup algorithm for POH., Objective: To describe the characteristics of patients with csPOH, POH events, and the POH outcomes of procedures after the unified diagnostic workup algorithm for POH., Methods: A prospective cohort was conducted in adult patients with csPOH at Siriraj Hospital, a tertiary hospital, in Thailand from January 2018 to August 2022. Diagnostic workup for POH by the allergist included an initial assessment, followed by comprehensive allergological evaluation. Patients were then follow-up for POH outcomes during subsequent anesthesia procedures., Results: Of 68 patients were csPOH, only 52 patients were diagnosed with POH by allergists. The incidence was 1:4,304 anesthetic procedures for POH, and 1:11,900 anesthetic procedures for at least grade III POH. Most patients had a grade III (51.2%) or II (46.4%) reaction. The leading identified causative agents were antibiotics (36.8%), antiseptics (21%), latex (13.1%), and morphine (13.1%). Cefazolin and chlorhexidine were the most common antibiotic and antiseptic, respectively. During a median follow-up time of 2.1 years, all 14 patients completing comprehensive allergological evaluation underwent subsequent anesthesia without recurrence of POH., Conclusions: The incidence of POH at our hospital was comparable to the global incidence. Antibiotics were the most common causative agent. Complete records, collaboration among the multidisciplinary team, and comprehensive evaluation of POH allow for safe subsequent procedures.

Background: Children with wheat anaphylaxis can present with a wide range of wheat-specific IgE (sIgE)., Objective: To identify differences in clinical features and predominant wheat allergens sensitized by these patients., Methods: Children with history of wheat anaphylaxis were recruited. Skin prick test (SPT) to wheat, sIgE to wheat, omega-5 gliadin (ω5G), lipid transfer protein (LTP) were investigated. Profiles of IgE-bound wheat allergens were studied to identify predominant wheat allergens., Results: Twenty-nine children (17 males) aged 1-18 years were enrolled. Sixteen patients (55.2%) had wheat-sIgE > 100 kUA/L (WAhi) and 13 patients (44.8%) had wheat-sIgE < 34 kUA/L (WAlo). The median of peak wheat-sIgE in WAhi and WAlo were 340.5 kUA/L (IQR 184.3, 564.5) and 12.2 kUA/L (IQR 1.4, 41.3), respectively. Oral food challenge test (OFC) was carried out in 12 of 13 patients in the WAlo group, all of which had positive results. Eight of these 12 patients developed anaphylaxis during OFC despite having wheat-sIgE less than 10 kUA/L. There were no differences in clinical characteristics and atopic history between WAhi vs. WAlo. Medium to low molecular weight gliadin (< 40 kDa) and glutenin (< 60 kDa) were commonly recognized by patients with WAhi. IgE immunoblot pattern among the WAlo group was more widely dispersed than those with WAhi., Conclusions: Wheat anaphylaxis can occur in patients with low wheat-sIgE. Predominant wheat allergens recognized by patients with WAlo were different than those with WAhi. Such difference could be responsible for anaphylaxis at even low levels of wheat-sIgE.

Background: Most patients with allergic rhinitis are polysensitized. The efficacy of house dust mite (HDM) allergen immunotherapy (AIT) compared between monosensitized and polysensitized patients remains limited., Objective: To systematically review the efficacy and safety of HDM AIT compared between monosensitized and polysensitized patients with allergic rhinitis., Methods: We searched PubMed/MEDLINE, Scopus, EMBASE, and the Cochrane central register of Controlled Trials (CENTRAL) until June 2022. The primary outcome was the changes from baseline in total nasal symptom score (TNSS). Secondary outcomes were changes from baseline in total medication score (TMS), combined symptom medication score (CSMS), visual analog scale (VAS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) score, immunological parameters, and adverse events (AEs)., Results: Of 13 eligible studies, 10 prospective cohorts, 2 retrospective cohorts, and 1 matched cohort, we identified 10 studies for quantitative synthesis. There were 1,113 patients with allergic rhinitis, 566 with HDM monosensitization and 547 with polysensitization to HDM and other allergens. There was no significant difference in the pooled mean changes of the 2 groups in TNSS (SMD -0.05, 95%CI: -0.22 to 0.11, p = 0.532) and VAS (SMD -0.20, 95%CI: -0.42 to 0.01, p = 0.060) with moderate certainty of evidence. The changes in TMS, CSMS, and RQLQ were similar between the 2 groups with very low certainty of evidence. The AEs were mild and comparable between the 2 groups. The immunological indices remained inconsistent and were not predictive of clinical responses., Conclusions: A single HDM AIT similarly improved clinical outcomes in monosensitized and polysensitized patients with allergic rhinitis.

Background: Cutaneous manifestations of chronic spontaneous urticaria (CSU) are identical to type 1 hypersensitivity reactions. The daily occurrence of rash from occupational allergy could be misinterpreted as CSU exacerbation., Objective: We aim to report a nurse with concomitant CSU suffering from latex-induced anaphylaxis., Methods: Skin tests, specific IgE using ImmunoCAP, and gloves challenge were performed., Results: A 27-year-old nurse with CSU suffered from several episodes of severe urticarial flare. H1-antihistamine up-dosing and oral corticosteroid burst were given. Unfortunately, she developed 3 episodes of anaphylaxis during her routine nursing care work on a medical ward, leading to allergist consultation. She had positive latex-specific IgE (6.86 kUA/L) and positive gloves challenge test., Conclusions: Concomitant CSU treatment might hinder the recognition of latex allergy by masking or delaying skin manifestations. IgE-mediated allergy should be suspected if there was a change in severity or frequency of previously controlled CSU or the presence of systemic symptoms.

Background: Shrimp allergy is considered a lifelong condition. The natural resolution of shrimp allergy is not well studied., Objective: To investigate the natural resolution of shrimp allergy among a cohort of patients diagnosed with shrimp allergy 10 years earlier by oral shrimp challenge., Methods: A prospective study recruited patients diagnosed with shrimp allergy to Penaeus monodon (Pm), Macrobrachium rosenbergii (Mr), or both from a study conducted during 2005-2006. The current oral shrimp challenges were conducted during 2015-2016. The negative oral shrimp challenge was designated 'resolved shrimp allergy' (RSA), with a positive challenge designated 'persistent shrimp allergy' (PSA). Skin prick and prick-to-prick testing to shrimp were used to determine sensitization., Results: Sixty patients who had positive shrimp challenge from the previous cohort were contacted. Patients who had previous anaphylactic reaction (8 subjects) or allergic reaction after shrimp ingestion within 6 months (6 subjects), were not included. Nine patients refused to participate and 20 patients could not be contacted. Seventeen patients were included. Three were previously diagnosed with allergy to Pm, 3 to Mr, and 11 to both species. RSA was observed in 1 patient with isolated Pm allergy, and in 3 patients with isolated Mr allergy. Three of 9 patients with dual allergy had RSA to both species. RSA patients had significantly smaller size of shrimp skin test than PSA patients at both diagnosis and follow-up., Conclusions: At ten years after diagnosis, 46% of patients had RSA. These patients had significantly smaller size of shrimp skin test than PSA patients.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.

Background: Universities in Thailand are preparing for Thailand's integration into the ASEAN Economic Community (AEC) by increasing the number of tests in English language. English language is not the native language of Thailand Differences in English language proficiency may affect scores among test-takers, even when subject knowledge among test-takers is comparable and may falsely represent the knowledge level of the test-taker., Objective: To study the impact of English language multiple choice test questions on test scores of medical students., Material and Method: The final examination of fourth-year medical students completing internal medicine rotation contains 120 multiple choice questions (MCQ). The languages used on the test are Thai and English at a ratio of 3:1. Individual scores of tests taken in both languages were collected and the effect of English language on MCQ was analyzed Individual MCQ scores were then compared with individual student English language proficiency and student grade point average (GPA)., Results: Two hundred ninety five fourth-year medical students were enrolled. The mean percentage of MCQ scores in Thai and English were significantly different (65.0 ± 8.4 and 56.5 ± 12.4, respectively, p < 0.001). The correlation between MCQ scores in Thai and English was fair (Spearman's correlation coefficient = 0.41, p < 0.001). Of 295 students, only 73 (24.7%) students scored higher when being tested in English than in Thai language. Students were classified into six grade categories (A, B+, B, C+, C, and D+), which cumulatively measured total internal medicine rotation performance score plus final examination score. MCQ scores from Thai language examination were more closely correlated with total course grades than were the scores from English language examination (Spearman's correlation coefficient = 0.73 (p < 0.001) and 0.53 (p < 0.001), respectively). The gap difference between MCQ scores in both languages was higher in borderline students than in the excellent student group (11.2 ± 11.2 and 7.1 ± 8.2, respectively, p < 0.001). Overall, average student English proficiency score was very high, at 3.71 ± 0.35 from a total of 4.00. Mean student GPA was 3.40 ± 0.33 from a possible 4.00. English language MCQ examination scores were more highly associated with GPA than with English language proficiency., Conclusion: The use of English language multiple choice question test may decrease scores of the fourth-year internal medicine post-rotation final examination, especially those of borderline students.

Background: The recommended drug for moderate to severe chronic rhinitis is intranasal steroids (INS). However, nasal congestion could be refractory and need additional treatments., Objective: We sought to explore the benefit of oxymetazoline (Oxymet) plus INS on nasal congestion without inducing rhinitis medicamentosa., Methods: We performed a 60-week, randomised, double-blind clinical trial in 50 patients, 18 years of age or greater, with chronic rhinitis who had used INS and cetirizine and still had nasal congestion. Subjects were randomised to receive 2 sprays of 0.05% Oxymet in each nostril twice daily or placebo for 4 weeks. All patients received 2 sprays of budesonide (100 μg/spray) in each nostril twice daily and 10 mg cetirizine once daily from entry throughout the study. Nasal symptom scores, nasal peak inspiratory flow (NPIF) and Rhinoconjunctivitis Quality of Life (Rcq) scores were measured., Results: Oxymet significantly reduced nasal congestion in subjects with chronic rhinitis compared with placebo on the day of 15-28 and 29-42. In subjects with allergic rhinitis, nasal congestion scores in the Oxymet group were significantly reduced compared with those in the placebo group on days 4-7, days 8-14, days 15-28 and days 29-42. In the Oxymet group, post hoc analysis showed that subjects with allergic rhinitis significantly improved their nasal congestion scores compared to non-allergic individuals (N, allergic/non-allergic = 18/7, p < 0.05). The combination of INS and Oxymet was not associated with rhinitis medicamentosa., Conclusions: The combination of INS and Oxymet provides additional benefit compared to INS monotherapy in relieving nasal congestion in subjects with chronic rhinitis and allergic rhinitis without developing rhinitis medicamentosa.

Objective: The present study was carried out in healthy Thai subjects to determine the types and concentrations of standard antigens used in delayed-type hypersensitivity (DTH) skin testing as an evaluation of cell-mediated immunity., Material and Method: One hundred subjects were tested with three antigens including tuberculin (purified protein derivative), tetanus toxoid, 1:10 and 1:100 dilutions, and Candida albicans, 1:10 and 1:100 dilutions., Results: We found that 92% of the subjects responded to tuberculin and/or tetanus toxoid at a 1:10 dilution, 77% responded to tetanus toxoid at a 1:10 dilution, and 35% responded to a 1:100 dilution. There was only one subject who responded to Candida albicans at a 1:10 dilution, and none to a 1:100 dilution. The size of tuberculin reactions varied from 5 mm to over 20 mm without any evidence of active tuberculosis., Conclusion: Tuberculin and tetanus toxoid at a 1:10 dilution are probably sufficient to be used in DTH skin testing to evaluate T-cell function.