No abstract

Penicillin P enicillin allergy remains the most common drug allergy reported, with a prevalence of ϳ8 -12% depending on the specific population evaluated. 1-3Higher rates are noted in individuals receiving more health care, including female patients and with increasing age.2,3 Symptoms associated with reported penicillin allergy classically include rash and/or itching, nausea, vomiting, shortness of breath, and anaphylaxis. However, often reported symptoms are either classified as unknown or representative of non-IgE-mediated reactions, such as nonurticarial rashes resulting from underlying viral illnesses. 4 The Choosing Wisely campaign recommends appropriate evaluation of patients with a history of penicillin allergy rather than avoidance or use of alternative antibiotics that can increase medical costs, patient morbidity, and potentially contribute to further antibiotic resistance.5,6 After a complete evaluation, up to 90% of individuals with a history of penicillin allergy are able to tolerate penicillins.1 Despite these favorable statistics, drug allergies are very rarely confirmed or removed from the medical record, and penicillin allergy is overdiagnosed with the antibiotic class avoided as part of a "safe rather than sorry" approach. 2,4,7 It is therefore important to study the epidemiology of penicillin allergy, because it may help practitioners better identify the patients at risk for true drug allergy. Relatively few studies have examined the characteristics of penicillin allergy in various patient populations. A 20-year retrospective study published by Ponvert et al. is the largest to report on ␤-lactam allergy in children. They showed that a history of severe skin symptoms such as acute generalized Stevens-Johnson Syndrome (SJS), serum sickness-like reactions, and anaphylaxis were risk factors for ␤-lactam allergy, although age, gender, and a history of atopy were not contributing factors. 8 In contrast, the largest retrospective study of both children and adults with self-reported antibiotic allergy by Macy et al. found that female gender and older age were associated with a higher rate of self-reported allergy, albeit without confirmation by skin and challenge testing.2 Despite these reports, there are still few published data on the epidemiology of penicillin allergy in the outpatient population of the United States.

For patients with significant antibody deficiencies, immunoglobulin therapy is the mainstay of treatment as it significantly reduces both the frequency and severity of infections. The formulations and delivery methods of immunoglobulin have evolved over time, and continued improvements have allowed for increased access to this effective medication. This review is an update on the current status of immunoglobulin therapy in immunodeficiency disorders, and discusses the mechanisms, forms and dosing, and indications for immunoglobulin replacement.

With the emergence of food allergy as an important public health problem, it has become clear that there is an unmet need in regard to treatment. In particular, IgE-mediated food allergy that is associated with risk of fatal anaphylaxis has been the subject of multiple studies in the past decade. The growing body of evidence derived from multiple centres and various study designs indicates that for IgE-mediated food allergy, immunomodulation through food immunotherapy is possible; however, the extent of protection afforded by such treatment is highly variable. At this time, the capacity for food immunotherapy to restore permanent tolerance to food has not been demonstrated conclusively. This review will discuss these topics as they apply to the most important studies of food oral immunotherapy.

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Here we present a secondary analysis from a parent database of 97 acutely injured participants enrolled in a prospective inception cohort study of whiplash recovery after motor vehicle collision (MVC). The purpose was to investigate the deep and superficial neck extensor muscles with peri-traumatic computed tomography (CT) and longitudinal measures of magnetic resonance imaging (MRI) in participants with varying levels of whiplash-related disability. Thirty-six underwent standard care imaging of the cervical spine with CT at a level-1 trauma designated emergency department. All 36 participants were assessed with MRI of the cervical spine at <1-week, 2-weeks, 3-, and 12-months post-injury and classified into three groups using initial pain severity and percentage scores on the Neck Disability Index (recovered (NDI of 0-8%), mild (NDI of 10-28%), or severe (NDI � 30%)) at 3-months post MVC. CT muscle attenuation values were significantly correlated to muscle fat infiltration (MFI) on MRI at one-week post MVC. There was no significant difference in muscle attenuation across groups at the time of enrollment. A trend of lower muscle attenuation in the deep compared to the superficial extensors was observed in the severe group. MFI values in the deep muscles on MRI were significantly higher in the severe group when compared to the mild group at 1-year post MVC. This study provides further evidence that the magnitude of 1) deep MFI appears unique to those at risk of and eventually transitioning to chronic WAD and that 2) pre-or peri-traumatic muscular health, determined by CT muscle attenuation, may be contribute to our understanding of long-term recovery.

No abstract

Previous preliminary work mapped the distribution of neck muscle fat infiltration (MFI) in the deep cervical extensor muscles (multifidus and semispinalis cervicis) in a small cohort of participants with chronic whiplash associated disorders (WAD), recovered, and healthy controls. While MFI was reported to be concentrated in the medial portion of the muscles in all participants, the magnitude was significantly greater in those with chronic WAD. This study aims to confirm these results in a prospective fashion with a larger cohort and compare the findings across a population of patients with varying levels of WAD-related disability one-year following the motor vehicle collision. Sixtyone participants enrolled in a longitudinal study: Recovered (n = 25), Mild (n = 26) and Severe WAD (n = 10) were studied using Fat/Water magnetic resonance imaging, 12-months post injury. Bilateral measures of MFI in four quartiles (Q1-Q4; medial to lateral) at cervical levels C4 through C7 were included. A linear mixed model was performed, controlling for covariates (age, sex, body mass index), examining interaction effects, and comparing MFI distribution between groups. The recovered group had significantly less MFI in Q1 compared to the two symptomatic groups. Group differences were not found in the more lateral quartiles. Results at 12 months are consistent with the preliminary study, indicating that MFI is spatially concentrated in the medial portions of the deep cervical extensors regardless of WAD recovery, but the magnitude of MFI in the medial portions of the muscles is significantly larger in those with severe chronic WAD. Various investigations across three continents (United States 1-3 , Australia 2,4-6 , and Sweden 7,8) have used similar manual segmentation methods with magnetic resonance imaging (MRI) to demonstrate widespread fatty infiltrates in the neck muscles of individuals with acute and chronic whiplash associated disorders (WAD). Comparably high levels of muscle fat infiltration (MFI) were not identified in individuals who (i) had recovered or reported lower levels of WAD-related disability 1,3,4,7,8 , (2) had chronic non-traumatic neck pain 9 , or (3) those without a history of neck disorders 10. Knowledge of a precise mechanism for MFI expression and distribution (e.g. extra-or intra-fascicular MFI) would provide a target for clinical remediation of any adverse symptoms; but this is largely unknown. There remains conjecture in the literature about what constitutes extra-or intra-fascicular MFI, which likely centres on our ability to reliably distinguish the epimysium/perimysium and associated muscle fascicles on MRI. Some have proposed standardised, anatomical definitions of regions of interest in quantifying spinal muscle composition 11,12 , which we concede can be difficult for the cervical spine (eg transversospinal muscles like multifidus).