Course Of Systemic Corticosteroids Research Articles

Prevalence of chronic rhinosinusitis without/with nasal polyps according to severity in Spain.

The worldwide prevalence range of chronic rhinosinusitis (CRS) is 5-12%; from this, 20 % have nasal polyps. Due to the little epidemiological data about CRS in the Spanish population, this study analyses the prevalence and severity of CRS with (CRSwNP) or without (CRSsNP) nasal polyps, and their connection with other coexisting type 2 inflammatory diseases in Spain. This is a retrospective, large-scale, nationwide, epidemiological study based on the electronic medical records from the BIG-PAC® database. Patients diagnosed of CRSsNP and CRSwNP were identified using specific disease codes. The severe form of the disease was defined as patients who received at least a long course of antibiotics in CRSsNP or ≥2 short courses of systemic corticosteroids in CRSwNP in ≤12 months during the last 2 years, and/or had previous sinus surgery. Physician-diagnosed prevalence, sociodemographic and clinical characteristics, and disease severity were assessed. Out of a cohort of 1,012,257 patients (≥18 years old), 42,863 and 7,550 patients with diagnosed CRSsNP and CRSwNP, respectively, were analysed. The overall prevalence of diagnosed CRS was 5.1%, being 4.3% and 0.8% for CRSsNP and CRSwNP, respectively. Patients with CRSwNP and severe forms of the disease were older and had higher levels of type 2 inflammatory biomarkers than CRSsNP patients and non-severe disease. Although CRSsNP was more prevalent than CRSwNP, the severe forms of CRS were more frequent in patients with CRSwNP. In addition, CRSwNP patients had a higher incidence of coexisting type 2 inflammatory diseases.

Surgery for chronic rhinosinusitis with nasal polyps: An update

This update aimed to evaluate surgical indications in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). It was conducted and reported according to the criteria stipulated by the Synthesis Without Meta-analysis (SwiM) guidelines. From the PubMed-National Library of Medicine database, 1098 articles were identified for the period 2006–2021 using the key words “nasal polyps” and “surgery”. After screening and analysis, 39 publications were selected. The efficacy of surgery on functional improvement in CRSwNP, measured by the specific quality-of-life score SNOT-22, is established, and improvement in olfactory function is expected in 50% of patients. The rate of surgical revision is at least 10–15% at 4 years, but the disease can be controlled for several years, with the interval between primary surgery and symptomatic recurrence exceeding 10 years in some cases. The criteria for surgery are not clearly defined in the literature. However, several authors consider failure of ≥ 8 weeks’ well-conducted local medical treatment and use of more than 2 courses of systemic corticosteroids as a reliable indication. No studies or meta-analyses are currently available to determine the superiority of one surgical technique over another.

Impact of Post-Visit Outreach on Inhaled Corticosteroid Refill Persistence in Children and Young Adults With Asthma.

Inhaled corticosteroids (ICSs) are a fundamental pillar of most regimens for long-term control of persistent asthma. Poor adherence to ICS medication is a common problem in the asthma population that can lead to poor asthma control. We hypothesized that conducting a follow-up telephone call after general pediatric clinic visits for asthma would improve refill persistence. We conducted a prospective cohort analysis of pediatric and young adult subjects followed in our pediatric primary care clinic for asthma on ICS medication found to have poor ICS refill persistence. This cohort received a follow-up telephone outreach call 5-8 weeks after the clinic visit. The primary outcome measure was refill persistence with regard to ICS therapy. There were 289 subjects who met the inclusion criteria and did not meet any exclusion criteria for the study (n = 131 in the primary cohort, n = 158 in the post-COVID cohort). The mean ICS refill persistence increased significantly for subjects in the primary cohort (39.4 ± 30.8% post intervention vs 32.4 ± 19.7% pre intervention) (P = .02) but not in the post-COVID cohort (36.4 ± 25.6% post intervention vs 38.9 ± 21.0% pre intervention) (P = .26). There was not a statistically significant change in hospitalizations after the intervention in either the primary or the post-COVID cohorts (P = .08 and .07, respectively). Systemic corticosteroid courses and emergency department visits decreased significantly post intervention (P = .01 and P = .004, respectively) in the primary group but not in the post-COVID group (P = .75 and P = .16, respectively). These results suggest that telephone outreach after out-patient clinic visits for asthma may have short-term benefit in ICS refill persistence; however, the effect size was small.

Is there a difference in treatment outcomes between short (seven days or less) and long (greater than seven days) courses of systemic corticosteroids in patients with an acute exacerbation of COPD?

Tripler Army Medical Center, Honolulu, HI The corresponding author is Savannah Smith; [email protected]. The authors declare no conflicts of interest. The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the US Army Medical Department, the Army at large, or the Department of Defense.

Autosomal dominant NFKB1 haploinsufficiency and family planning

BackgroundThe nuclear factor kappa B subunit 1 (NFKB1) gene encodes a pleiotropic transcription factor involved in a vast array of biological processes including inflammation, immunity, differentiation, and tumorigenesis. Deleterious variants in NFKB1 have highly variable penetrance, but heterozygosity can lead to autosomal dominant (AD) haploinsufficiency resulting in intrinsic B cell disorders and late-onset antibody deficiencies.Case Description: A 33-year-old woman presented for an initial evaluation of recurrent autoimmune cytopenias and sinopulmonary infections. Her medical history was remarkable for pneumococcal sepsis, recurrent sinopulmonary infections, Evan’s syndrome, neutropenia, splenomegaly, recurrent oral and genital ulcers, and autoimmune alopecia. She required multiple and prolonged courses of systemic corticosteroids for the management of refractory autoimmune cytopenias. Imaging studies were significant for splenomegaly (28 cm). Laboratory workup prior to starting Ig replacement therapy showed normal total IgG with low IgG2, undetectable IgA, and high IgM. She had an impaired response to polysaccharide antigens and did not make IgG antibodies against the SARS-COV2 spike protein after COVID-19 immunization. She had leukopenia, neutropenia, normocytic anemia, and thrombocytopenia despite treatment with Ig replacement therapy and systemic corticosteroids. Lymphocyte immunophenotyping in peripheral blood revealed decreased CD19+ B cell counts (5/uL). Targeted genetic testing for inborn errors of immunity revealed that she is heterozygous for a pathogenic variant in NFKB1 (c.896del, p.Gly299Glufs*133). She expressed interest in having a child but her autoimmune cytopenias were not well controlled. Therapeutic options were discussed with the patient and an interdisciplinary team. Sirolimus, which is contraindicated in pregnancy, was recommended for the management of refractory autoimmune cytopenias as well as in vitro fertilization with pre-implantation genetic testing and surrogacy. Conclusiongenetic testing for inborn errors of immunity in patients with antibody deficiency and autoimmunity can be a valuable tool in family planning.

Дисфункція дрібних дихальних шляхів та можливості її корекції при астмі

Abstract. Background. Although randomized controlled trials have shown that asthma control is an achievable goal, real-life studies over the past 20 years have shown that asthma remains poorly controlled in a significant proportion of patients, even among those receiving treatment at asthma specialist, and in patients with mild asthma who regularly take inhaled corticosteroids. Even when asthma control is achieved, it is not optimal on all GINA steps. The small airways have been recognized as the primary site of airflow limitation in asthma. The aim of the work: to study, according to the literature, the peculiarities of the dysfunction of the small airways in asthma and to evaluate the possibilities of its treatment. Materials and methods. Scientific articles that covered the pathophysiology of small airways disorders, their impact on asthma control, diagnostic methods, and pharmacological treatment methods were analyzed. The results. Airways with an internal diameter < 2 mm, which do not contain cartilage in their walls and extend from the 8th generation of the airways to the periphery of the lung, are collectively called “small airways”. They are called the QUIET ZONE because they are difficult to assess and treat in patients with asthma who are not optimally controlled but have relatively normal FEV1 and disproportionate small airways dysfunction (SAD). Predominant in patients at all stages of treatment, associated with poor disease control. The ATLANTIS study showed that up to 91 % of patients with asthma have. The small airways have a high density of corticosteroid and β2-adrenoceptors, which means that they can be influenced. The main task is that the drugs should reach these small airways. Conventional inhalers that generate particles larger than 2 μm do not address the problem of SAD in patients with asthma. Inhaler devices that produce ultrafine particles of inhaled corticosteroids alone or in combination with long-acting β-agonists with a diameter of less than 2 μm have the potential to improve long-term asthma control along with a corresponding improvement in small airway function. The fixed combination of beclomethasone dipropionate with formoterol has optimal deposition in the respiratory tract — central pulmonary deposition accounts for 66 %, and peripheral — 34 % of the dose, thus the drug is delivered to both the central and peripheral respiratory tracts and affects inflammation and bronchoconstriction throughout the lungs. This is facilitated by MODULITE technology. The effectiveness and safety of the use of the BDP/F combination (Foster) in MART regimen is confirmed by a significant evidence base, which guaranteed its place in the Track1 treatment of asthma. Conclusions: Patients with asthma have a serious inflammatory process in the peripheral airways, which makes them the main site of obstruction in asthma; SAD predominates in patients at all stages of asthma, is associated with poor disease control, is responsible for air trapping, correlates with poor asthma control1, and predicts an increased risk of exacerbations in patients. The fixed combination of beclamethasone/formoterol in one inhaler (Foster) is the only extrafinely dispersed fixed combination of ICS/LABA that reaches the small airways; the fixed combination of BDP/Formoterol in the MART regimen provides a significant reduction in the frequency of severe complications, hospitalizations, emergency calls, and reduces the number of courses of systemic corticosteroids.

Clinical experience of a specialized urticaria outpatient clinic from a Portuguese UCARE.

Background. Chronic urticaria (CU) is a frequent disease, with a prevalence of at least 1%. It is characterized by pruritic wheals, angioedema or both for a period longer than 6 weeks. Objective. Identify the demographic, clinical, laboratory and therapeutic profile of patients treated in a Portuguese Urticaria Center of Reference and Excellence (UCARE) and compare it with international series. Methods. Retrospective analysis of database of patients observed in a specialized urticaria outpatient clinic, from January 2017 through September 2019, of a UCARE center in Portugal. Demographic and clinical features, laboratory findings and pharmacological treatment were obtained from the records. Descriptive analyses were performed for all variables. Chi square and fisher's exact tests were applied to analyze the independence of variables and the fit of distribution. P less than 0.05 was considered significant. Results. During this period, 477 patients were observed, of whom 429 (90%) were diagnosed with chronic urticaria. Mean age (years) at the onset of symptoms was 43.7 (standard deviation (SD) 17.6, range 6-88) and at diagnosis 46.7 (SD 17.8, range 6-88) resulting in an average diagnostic delay of 3 years (range 0-25). Median follow-up period since first attendance in the specialized outpatient clinic was 1.7 years (interquartile range (IQR) 0.79, range 0.1-2.75) . Concerning the whole group of CU patients, 347 (81%) had chronic spontaneous urticaria (CSU) - 79% female, 39 (9%) had isolated chronic inducible urticaria (CIndU) and 43 (10%) had CSU with CIndU. Autologous serum skin test (ASST) was done in 76 patients (positive in 24 (32%)) and basophil activation test (BAT) was done in 38 (positive in 13 (34%)). At the moment of study, 204 (48%) of CU patients were medicated with a second-generation H1-antihistamine (sgAH) daily (first-line therapy), 99 (23%) with sgAH up to four times the standard dose (second-line therapy) and 126 (29%) with omalizumab (third-line therapy). Additionally, 7 (2%) patients were completing a short course of systemic corticosteroids for management of disease exacerbation. Disease control was achieved in 316 of CSU patients (81%). Conclusions. Referral to a specialized urticaria outpatient clinic is important for a proper assessment of the disease and adequately symptom control.

TREATMENT OF DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS (DRESS) WITH MEPOLIZUMAB

<h3>Introduction</h3> The standard treatment for DRESS involves stopping the culprit drug and often a prolonged course of systemic corticosteroids. Long-term systemic corticosteroids can have major adverse effects. We present a case of DRESS successfully managed with mepolizumab, an interleukin-5-antagonist, to decrease systemic corticosteroids. <h3>Case Description</h3> A 53-year-old male with a history of poorly controlled type 2 diabetes complicated by foot osteomyelitis was treated with vancomycin, ertapenem, and gabapentin. In three weeks, his absolute eosinophil count (AEC) increased to 1100/µL from a baseline of 300/µL. One week later he developed a diffuse morbilliform eruption, facial swelling, AEC of 2200/µL, and acute renal injury. He was diagnosed with DRESS. Vancomycin, ertapenem, and gabapentin were stopped, and he was treated with intravenous methylprednisolone. Vancomycin was presumed to be the likely culprit. By day 7 of hospitalization, his rash and creatinine improved and AEC decreased to 300/µL. He was discharged on oral prednisone 60mg and an adjusted insulin regimen due to elevated blood glucose. Two days post-discharge, his AEC increased to 3700/µL and he had persistent pruritus but improving rash. He was given mepolizumab 100mg and an oral corticosteroid taper. Within a week, AEC was zero. He was given a second dose of mepolizumab 100mg six weeks after the first dose as AEC increased to 900/µL. Three months post-discharge after a 7-week taper of steroids, he has not had recurrence of DRESS, AEC is ≤ 500/µL, and HbA1C remains within goal. <h3>Discussion</h3> Mepolizumab shows promise as a novel and safe steroid-sparing treatment for DRESS.

Recurrent Multiple Evanescent White Dot Syndrome (MEWDS) Following First Dose and Booster of the mRNA-1273 COVID-19 Vaccine: Case Report and Review of Literature

To report a rare case of a patient with two recurrent episodes of Multiple Evanescent White Dot Syndrome (MEWDS) associated with the second dose and second booster of the mRNA-1273 COVID-19 vaccine (Moderna), and to perform a literature review on COVID-19-vaccine-associated MEWDS. Case Report: A 31-year-old female was evaluated for a temporal scotoma and photopsias that started two weeks after the second dose of the Moderna COVID-19 vaccine. Dilated fundus findings were remarkable for unilateral, small whitish-yellow dots scattered around posterior pole of the left eye, consistent with a diagnosis of MEWDS. The symptoms resolved three months later without treatment. Approximately one year after the first vaccine, the patient received the second Moderna COVID-19 vaccine booster and experienced a recurrence of symptoms with an enlarged scotoma and similar examination findings. The patient was treated with a course of systemic corticosteroids with subsequent clinical improvement. Conclusion: Although uveitis following COVID-19 vaccines is rare, our case highlights a need for increased awareness amongst practitioners regarding COVID-19-vaccine-associated onset or recurrence of ocular inflammatory diseases.

Systemic corticosteroids for radicular and non-radicular low back pain.

Corticosteroids are medications with anti-inflammatory and immunosuppressant properties. Systemic corticosteroids administered through the oral, intravenous, or intramuscular routes have been used to treat various types of low back pain, including radicular back pain (not due to spinal stenosis), non-radicular back pain, and spinal stenosis. However, there is uncertainty about the benefits and harms of systemic corticosteroids for low back pain. To evaluate the benefits and harms of systemic corticosteroids versus placebo or no corticosteroid for radicular low back pain, non-radicular low back pain, and symptomatic spinal stenosis in adults. We used standard, extensive Cochrane search methods. The latest search date was September 2021. We included randomized and quasi-randomized trials in adults of systematic corticosteroids versus placebo or no corticosteroid. We used standard Cochrane methods. The major outcomes were pain, function, need for surgery, serious adverse effect, and presence of hyperglycemia. The minor outcomes were quality of life, successful outcomes, non-serious adverse events, and withdrawal due to adverse events. We used GRADE to assess the certainty of evidence for each outcome. Thirteen trials (1047 participants) met the inclusion criteria. Nine trials included participants with radicular low back pain, two trial with low back pain, and two trials with spinal stenosis. All trials blinded participants to receipt of systemic corticosteroids. Seven trials were at low risk of bias, five at unclear risk, and one at high risk of selection bias. Two trials were at high risk of attrition bias. Doses and duration of systemic corticosteroid therapy varied. Radicular low back pain For radicular low back pain, moderate-certainty evidence indicated that systemic corticosteroids probably slightly decrease pain versus placebo at short-term follow-up (mean difference (MD) 0.56 points better, 95% confidence interval (CI) 1.08 to 0.04 on a 0 to 10 scale) and may slightly increase the likelihood of experiencing improvement in pain at short-term follow-up (risk ratio (RR) 1.21, 95% CI 0.88 to 1.66; absolute effect 5% better (95% CI 5% worse to 15% better). Systemic corticosteroids may not improve function at short-term follow-up (standardized mean difference (SMD) 0.14 better; range 0.49 better to 0.21 worse) and probably increase the likelihood of improvement in function at short-term follow-up (RR 1.52, 95% CI 1.22 to 1.91; absolute effect 19% better, 95% CI 8% better to 30% better). Systemic corticosteroids were associated with greater improvement in function versus placebo at long-term follow-up (MD -7.40, 95% CI -12.55 to -2.25 on the 0 to 100 Oswestry Disability Index) and greater likelihood of functional improvement (RR 1.29, 95% CI 1.06 to 1.56), based on a single trial. There was no difference in likelihood of surgery (RR 1.00, 95% CI 0.68 to 1.47). Evidence indicated that systemic corticosteroids (administered as a single dose or as a short course of therapy) are not associated with increased risk of any adverse event, serious adverse events, withdrawal due to adverse events, or hyperglycemia, but estimates were imprecise as some trials did not report harms, and harms reporting was suboptimal in trials that did provide data. Limitations included variability across trials in interventions (e.g. corticosteroid used, dose and duration of treatment), clinical settings, and participants (e.g. duration of symptoms, methods for diagnosis); limited utility of subgroup analyses due to small numbers of trials; methodologic limitations or suboptimal reporting of methods by some trials; and too few trials to formally assess for publication bias using graphical or statistical tests for small sample effects. Non-radicular low back pain Evidence on systemic corticosteroids versus placebo for non-radicular pain was limited and suggested that systemic corticosteroids may be associated with slightly worse short-term pain but slightly better function. Spinal stenosis For spinal stenosis, limited evidence indicated that systemic corticosteroids are probably no more effective than placebo for short-term pain or function. Systemic corticosteroids appear to be slightly effective at improving short-term pain and function in people with radicular low back pain not due to spinal stenosis, and might slightly improve long-term function. The effects of systemic corticosteroids in people with non-radicular low back pain are unclear and systemic corticosteroids are probably ineffective for spinal stenosis. A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harms, but evidence is limited.

A 4-Year Retrospective Claims Analysis of Oral Corticosteroid Use and Health Conditions in Newly Diagnosed Medicare FFS Patients with COPD.

PurposeWe analyzed population-level administrative claims data for Medicare fee-for-service (FFS) beneficiaries to provide insights on systemic oral corticosteroid (OCS) use patterns and associated health conditions and acute events among patients newly diagnosed with chronic obstructive pulmonary disease (COPD).BackgroundCOPD is a progressive inflammatory disease of the lungs, characterized by acute exacerbations that may lead to increased mortality. Short courses of systemic corticosteroids (SCS) are recommended to reduce recovery time from exacerbations, although SCS use has been associated with increased risk of adverse events.MethodsThis study used 2013–2019 Medicare 100% FFS research identifiable files, which contain all Medicare Parts A, B, and D paid claims incurred by 100% of Medicare FFS beneficiaries. Descriptive statistics for patients newly diagnosed with COPD were analyzed, including OCS use, select health conditions and acute events, and COPD exacerbations. Statistical models were used to analyze the relationship between the incidence of select health conditions and events and cumulative OCS dosage.ResultsOf Medicare FFS patients newly diagnosed with COPD, 36% received OCS in the 48 months following diagnosis, and 38% of OCS episodes lasted longer than the recommended 5–7 days. Patients had a variety of health conditions or acute events in the 24-month period prior to new COPD diagnosis, such as hypertension, depression/anxiety, type 2 diabetes, or osteoporosis, that could heighten the risks of OCS use. Patients treated with >1000 mg of prednisolone equivalent OCS in the 48 months following COPD diagnosis had a higher incidence of new conditions or events, including cardiovascular disease, heart failure, hypertension, obesity, dyspepsia, infections, and depression/anxiety, than patients with no OCS use.ConclusionThese results highlight the potential risks of OCS in COPD treatment, including prolonged use among complex Medicare patients, and reinforce the importance of preventive treatment strategies and therapy optimization early in the disease course.

Systemic Corticosteroids in the Management of Pediatric Cystic Fibrosis Pulmonary Exacerbations.

Rationale: Pulmonary exacerbation (PEx) events contribute to lung function decline in people with cystic fibrosis (CF). CF Foundation PEx guidelines note that a short course of systemic corticosteroids may offer benefit without contributing to long-term adverse effects. However, insufficient evidence exists to recommend systemic corticosteroids for PEx treatment. Objectives: To determine if systemic corticosteroids for the treatment of in-hospital pediatric PEx are associated with improved clinical outcomes compared with treatment without systemic corticosteroids. Methods: We conducted a retrospective cohort study using the CF Foundation Patient Registry-Pediatric Health Information System linked database. People with CF were included if hospitalized for a PEx between 2006 and 2018 and were 6-21 years of age. Time to next PEx was assessed by Cox proportional hazards regression. Lung function outcomes were assessed by linear mixed-effect modeling and generalized estimating equations. To address confounding by indication, inverse probability treatment weighting was used. Results: A total of 3,471 people with CF contributed 9,787 PEx for analysis. Systemic corticosteroids were used in 15% of all PEx. In our primary analysis, systemic corticosteroids were not associated with better pre- to post-PEx percent predicted forced expiratory volume in 1 second responses (mean difference, -0.36; 95% confidence interval [CI], -1.14, 0.42; P = 0.4) or a higher odds of returning to lung function baseline (odds ratio, 0.97; 95% CI, 0.84-1.12; P = 0.7) but were associated with a reduced chance of future PEx requiring intravenous antibiotics (hazard ratio, 0.91; 95% CI, 0.85-0.96; P = 0.002). When restricting the analysis to one PEx per person, lung function outcomes remained no different among PEx treated with or without systemic corticosteroids, but, in contrast to our primary analysis, the use of systemic corticosteroids was no longer associated with a reduced chance of having a future PEx requiring intravenous antibiotics (hazard ratio, 0.96; 95% CI, 0.86, 1.07; P = 0.42). Conclusions: Systemic corticosteroid treatment for in-hospital pediatric PEx was not associated with improved lung function outcomes. Prospective trials are needed to better evaluate the risks and benefits of systemic corticosteroid use for PEx treatment in children with CF.

More Than Asthma: A Case Report of Eosinophilic Bronchiolitis

Eosinophilic bronchiolitis (EB) is a rare disease that may mimic or coexist with asthma, but EB typically fails to improve with guideline-based asthma treatments. A 52-year-old man presented with wheezing and shortness of breath for 5 months. He was found to have elevated peripheral blood eosinophils and moderately severe airflow obstruction but did not improve with high-dose inhaled corticosteroids in combination with long-acting beta2-agonist and long-acting muscarinic antagonist. Computed tomography revealed diffuse and widespread “tree-in-bud” changes. Transbronchial lung biopsy demonstrated eosinophilic bronchiolitis. The patient improved with a prolonged course of systemic corticosteroids. EB is distinguished from eosinophilic asthma by the presence of florid bronchiolitis on radiologic imaging or histopathology. The mainstay of treatment is systemic corticosteroids, with a possible role for biologics.

Гостра кропив'янка — актуальна мультидисциплінарна проблема

Abstract. The article is devoted to an actual multidisciplinary problem — etiology, pathogenesis, diagnosis and treatment of acute urticaria (AU). It belongs to the 20 most common skin diseases, and it is faced not only by allergists and dermatologists, but also by therapists, pediatricians and other doctors. In therapeutic and especially pediatric practice, AU is of particular interest, which is associated with significant diagnostic and therapeutic difficulties. The prevalence of AU ranges from 1 to 5% in the population, and among the child population, the incidence of AU reaches 6.7 %. The most common triggers for AU are drugs (38.1 %), infectious agents (35.2 %), stress (24.7 %), and food (17.8 %). AU pathogenesis is based on degranulation and release of mediators from mast cells. Their activation during AU can be caused by both immunological factors mediated by specific receptors on cell membranes and non-immunological factors. The diagnostic process begins with the collection of complaints, anamnesis data and physical examination. The volume of laboratory and instrumental examination of patients with AU is determined by the intensity of clinical manifestations, duration of the disease, response to therapy, as well as external symptoms. There are no routine indications for laboratory testing in AU. If an allergic genesis of AU is suspected, specific allergy diagnostics are indicated. Antihistamines of the second generation remain the basis of treatment for patients with urticaria, and in case of their insufficient effectiveness, omalizumab and cyclosporine are added to the treatment regimen. Short courses of systemic corticosteroids may be prescribed in rare cases of severe disease. Key words: acute urticaria, etiology, pathogenesis, diagnosis, treatment.

Should Steroid Dosing in COPD Exacerbations Be Individualized

Evidence suggests that shorter courses of systemic corticosteroids are preferable for patients hospitalized with acute exacerbations of chronic

Impact of type 2 targeting biologics on acute exacerbations of chronic rhinosinusitis.

Background: Acute exacerbations of chronic rhinosinusitis (AECRS) are associated with significant morbidity and decreased quality of life. There are sparse data assessing the real-world impact of biologics on AECRS. Objectives: We sought to determine the impact of type 2-targeting biologics on the frequency of medication use for AECRS episodes. Methods: Antibiotic and/or systemic corticosteroid courses for AECRS were identified in a retrospective study from November 2015 to February 2020, at a single academic health system. The estimated yearly rates for antibiotic and corticosteroid courses were evaluated before and after initiation of type 2 biologics. Results: One-hundred and sixty-five patients with chronic rhinosinusitis (CRS) had received either omalizumab (n = 12), mepolizumab (n = 42), benralizumab (n = 44), dupilumab (n = 61), or reslizumab (n = 6). Seventy percent had CRS with nasal polyps, and 30% had CRS without nasal polyps. All the patients had asthma. When all the biologics were combined, the estimated yearly rate for antibiotics for AECRS decreased from 1.34 (95% confidence interval [CI], 1.12-1.59) to 0.68 (95% CI, 0.52-0.88) with biologic use (49% reduction, p < 0.001). Those with frequent AECRS (three or more courses of antibiotics in the 1 year before biologic use) had a larger degree of reduction, with an estimated yearly rate of 4.15 (95% CI, 3.79-4.55) to 1.58 (95% CI, 1.06-2.35) with biologic use (n = 27; 62% reduction; p < 0.001). Within the total cohort, the estimated yearly rate for systemic corticosteroids for AECRS decreased from 1.69 (95% CI, 1.42-2.02) to 0.68 (95% CI, 0.53-0.88) with biologic use (60% reduction; p < 0.001). Conclusion: Type 2-targeting biologics reduced medication use for AECRS. This suggested that biologics may be a therapeutic option for patients with frequent AECRS.

The Burden of Coronavirus Disease 2019 and Its Complications in Patients With Atopic Dermatitis-A Nested Case-Control Study.

The burden of coronavirus disease 2019 (COVID-19) among patients with atopic dermatitis (AD) is poorly understood. The aims of the study were to characterize a large cohort of COVID-19-positive adult patients with AD and to identify predictors of COVID-19-associated hospitalization and mortality. A population-based nested case-control study was performed. Multivariable logistic regression was used to evaluate odds ratios and 95% confidence intervals of predictors for COVID-19-associated hospitalization and mortality. Of 78,073 adult patients with AD, 3618 (4.6%) tested positive for COVID-19. Subclinical COVID-19 infection occurred in 3368 (93.1%) of COVID-19-positive patients, whereas 123 (3.4%), 46 (1.3%), 55 (1.5%), and 26 (0.7%) patients developed a mild, moderate, severe, and critical disease, respectively. Altogether, 250 patients (6.0%) were hospitalized, and 40 patients (1.1%) died because of COVID-19 complications. Coronavirus disease 2019-associated hospitalization was independently associated with the intake of extended courses of systemic corticosteroids (adjusted odds ratio, 1.96; 95% confidence interval, 1.23-3.14; P = 0.005). None of AD-related variables independently predicted COVID-19-associated mortality. The presence of comorbid metabolic syndrome, chronic obstructive pulmonary disease, chronic renal failure, and depression projected both COVID-19-associated hospitalization and mortality. Prolonged systemic corticosteroids during the pandemic are associated with increased odds of COVID-19-associated hospitalization and should be avoided in patients with AD.

Multidisciplinary consensus on a stepwise treatment algorithm for management of chronic rhinosinusitis with nasal polyps.

Multidisciplinary consensus on a stepwise treatment algorithm for management of chronic rhinosinusitis with nasal polyps.

COVID-19 in a series of patients with aspirin-exacerbated respiratory disease

COVID-19 in a series of patients with aspirin-exacerbated respiratory disease

Steroid-refractory dermatologic and pulmonary toxicity in a patient on rituximab treated with pembrolizumab for progressive urothelial carcinoma: a case report

BackgroundIncreasingly widespread use of programmed cell death protein 1 (PD-1) immune checkpoint inhibitors (ICIs) for treatment of a variety of progressive malignancies continues to reveal a range of immune-related adverse events (irAEs), necessitating immunosuppressive therapy for management. While a single course of systemic corticosteroids may be sufficient for many irAEs, no clear standard-of-care guidelines exist for steroid-refractory cases. We present an unusual case of a patient who developed several steroid-refractory novel irAEs on pembrolizumab despite ongoing B cell-directed immunosuppressive therapy with rituximab, who ultimately noted resolution of symptoms with tacrolimus, a T-cell-directed immunosuppressant.Case presentationThis 72-year-old Caucasian man with Waldenstrom’s macroglobulinemia and myelin-associated glycoprotein (MAG) immunoglobulin M (IgM) antibody-associated neuropathy was being treated with maintenance rituximab and intravenous immunoglobulin when he was started on pembrolizumab (2.26 mg/kg) for metastatic urothelial cancer 31 months after surgery and adjuvant chemotherapy. After his third dose of pembrolizumab, he developed a painful blistering papular rash of the distal extremities. He received two more doses of pembrolizumab before he also developed diarrhea, and it was held; he was initiated on 1 mg/kg prednisone for presumed ICI-induced dermatitis and colitis. Skin biopsy 10 weeks after cessation of pembrolizumab and taper of steroids to 20 mg daily revealed a unique bullous erythema multiforme. He was then admitted with dyspnea and imaging concerning for necrotizing pneumonia, but did not respond to antibiotic therapy. Bronchoscopy and biopsy revealed acute fibrinous organizing pneumonia. His symptoms failed to fully respond to multiple courses of high-dose systemic corticosteroids and a trial of azathioprine, but pneumonia, diarrhea, and skin rash all improved markedly with tacrolimus. The patient has since completed his therapy for tacrolimus, continues off of ICI, and has not experienced a recurrence of any irAEs, though has more recently experienced progression of his cancer.ConclusionDespite immunosuppression with rituximab and intravenous immunoglobulin, two immunomodulators targeting B cells, ICI cessation, and systemic corticosteroid therapy, our patient developed two high-grade unusual irAEs, bullous erythema multiforme and acute fibrinous organizing pneumonia. Our patient’s improvement with tacrolimus can offer critical insight into the pathophysiology of steroid-refractory irAEs.