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Medical Journal Review

December 2018

WAO Reviews – Editors' Choice

The Editors select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible they seek articles that everyone can access freely. The Editors’ Choice comes to you from Juan Carlos Ivancevich, MD, WAO Web Managing Editor, and summary author, John J. Oppenheimer, MD, FACAAI, FAAAAI, WAO Reviews Editor.

Recent advances in clinical allergy and immunology
Simon D
International Archives of Allergy and Immunology 2018;177(4):324-333. DOI:10.1159/000494931

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This is an excellent review of recent advances in clinical allergy and immunology, stressing new data regarding both genetic and environmental risk factors of atopic/allergic diseases. The authors note that application of new technologies such as “omics” has allowed a better understanding of the pathogenesis and has helped in the identification of therapeutic targets – especially in asthma and urticaria. Much of the recent efforts have focused on biomarkers to help to classify patients, identify their potential responsiveness to specific therapies, and monitor disease severity. In the case of food allergy and drug hypersensitivity, recent research has focused on novel strategies for diagnostics, allergen avoidance, and induction of tolerance.

Association of fatality risk with value-based drug pricing of epinephrine autoinjectors for children with peanut allergy: A cost-effective analysis
Shaker M and Greenhawt M
JAMA Network Open 2018;1(7):e184728. DOI:10.1001/jamanetworkopen.2018.4728

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There is concern that the high cost of self-injectable epinephrine autoinjectors may represent a barrier to community anaphylaxis management. The authors explore value-based pricing to provide a benchmark for rational epinephrine autoinjector costs by undertaking an economic evaluation study using a cost-effectiveness birth cohort model over an extended 80-year time horizon and Markov simulations of children with peanut allergy, to determine cost ceilings for value-based epinephrine prices in peanut allergy. Cohorts of children with peanut allergy prescribed epinephrine autoinjectors were compared with those not receiving personal epinephrine prescriptions assuming lack of autoinjectors resulted in a 10-fold to 100-fold increase in fatality risk.

A total of 100,000 simulated infants with peanut allergy entered each strategy, with two-thirds of the group receiving annual personal epinephrine prescriptions and using those devices appropriately when indicated. Over this time horizon, the cost of anaphylaxis preparedness and treatment in those with epinephrine devices was $25,478 (95% CI, $25,399-$25,557) compared with $654 (95% CI, $645-$663) for those without personal epinephrine, resulting in an average food allergy fatality of 0.00056 (95% CI, 0.000414-0.000706) per patient prescribed self-injectable epinephrine and 0.00148 (95% CI, 0.001242-0.001718) in those not prescribed self-injectable epinephrine. The value-based price (incremental cost-effectiveness ratio, $100,000 per quality-adjusted life-year) for personal epinephrine based on 10-fold fatality risk difference was $24, while if the hypothetical fatality risk protection from personal epinephrine was modeled at 100-fold, the value-based price ceiling for a personal autoinjector was $264.

Perivascular dendritic cells elicit anaphylaxis by relaying allergens to mast cells via microvesicles
Choi HW, Suwanpradid J, Kim IH, Staats HF, Haniffa M et al
Science 2018;9:362(6415). DOI:10.1126/science.aao0666

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In this study, Choi and colleagues explore how IgE sensitized mast cells (MCs) are indirectly activated by blood-born allergens. They found that CD301b+ dermal dendritic cells (DCs), through extrusion of dendrites, can sample blood within luminal space and then present antigen through microvesicles to neighboring MCs. Thus, perivascular DCs are continuously sampling blood and can initiate /enhance the immune response through their discharge of antigen-bearing macrovesicles to surrounding MCs.

Vaccination and allergic sensitization in early childhood – The ALADDIN Birth Cohort
Swartz J, Aronsson B, Lindblad F, Järnbert-Pettersson H, Scheynius A et al.
eClinicalMedicine 2018; published online before print. DOI:10.1016/j.eclinm.2018.10.005

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In trying to explain the increased incidence of allergic disease, some postulate this may be the consequence of vaccination. To answer this question, Swartz and colleagues mined the ALADDIN prospective birth cohort study data, which included one group from an anthroposophic community, with restrictive attitudes concerning vaccinations, and two other groups of age-matched children with more conventional parental lifestyles. They followed 466 children from birth to 5 years of age. Detailed vaccination data and blood samples were collected at 6 months, 1, 2, and 5 years and were compared with the outcome variable of allergic sensitization (defined as allergen-specific serum IgE levels ≥ 0.35 kUA/L to foods and aeroallergens).  From this analysis they found no support for an association between vaccination (including: age at first vaccination; total sum of vaccine injections and of vaccines; MMR vaccination) and allergic sensitization.

Addressing health-related misinformation on social media
Chou WS, Oh A, Klein WMP
JAMA 2018; published online ahead of print (Nov 14). DOI:10.1001/jama.2018.16865

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In this recent viewpoint, the authors note that social media can greatly impact the field of medicine.  Through its inappropriate use, false, inaccurate and incomplete information about health can occur.  They suggest that social media platforms should develop and implement mechanisms for vetting and validating the credibility of information presented on their platforms; if not, their transmission of misinformation has the potential to undermine progress in medicine/healthcare. Furthermore, they stress that curbing potential misinformation requires a proactive examination of its prevalence and potential influence and should not be labeled as a fad or passively wished away.