Best wishes for a Happy New Year! It is great pleasure to celebrate the 10th anniversary of Asia Pacific Allergy, the official journal of Asia Pacific Association of Allergy, Asthma, and Clinical Immunology (APAAACI)! This year Asia Pacific Allergy will have new collaborations: position papers, review papers, original articles from the various committees of APAAACI. In this issue, readers will find very nice review articles: APAAACI white paper 2020 on climate change, air pollution, and biodiversity, and a review article on drug hypersensitivity reactions that highlight important regional issues and challenges [1, 2]. With industrialization, air pollutants are present everywhere - outdoors and indoors which affect allergic diseases such as asthma, allergic rhinitis, and atopic dermatitis. Outdoor air pollutants such as sulfur dioxide, CO, NO2, ozone, particulate matter (PM), and diesel exhaust come from many sources. Natural sources include wildfires, volcanoes, biologic decay, and dust storms. Man-made air pollutants from motor vehicles, biomass burning, power plants, manufacturing facilities, and waste incineration are of more concern. Especially PM with a diameter of 10 μm or less (PM10), PM with a diameter of 2.5 μm or less (PM2.5) and even PM with a diameter of 0.1 μm or less (ultrafine particles) have been dramatically increasing in our region, and causing major health problems. Indoor air pollutants include volatile organic compound, PM, and combustion pollutants such as sulfur dioxide, CO, and NO2. Indoor air pollutants come from various sources: environmental tobacco smoke, furniture, combustion products such as stoves and gas ranges, building materials, and biological agents from mold and animals. Readers will enjoy the overview of important issues in climate change, air pollution, biodiversity, and allergic diseases. Drug hypersensitivity reactions are also major health problems causing morbidity and even mortality both in adults and children. In this issue, Thong et al. [2] highlight important regional issues and challenges focusing on 5 aspects of drug hypersensitivity reactions: beta-lactam allergy, severe cutaneous adverse drug reactions, antituberculosis drug allergy, nonsteroidal anti-inflammatory drug hypersensitivity reactions, and radiocontrast media hypersensitivity. Readers will find important discoveries and issues in drug hypersensitivity reactions from our region through this nice overview from the drug allergy committee of APAAACI. This issue also contains a very interesting case report suggesting altered T cell and monocyte subsets in prolonged immune reconstitution inflammatory syndrome related with drug reaction with eosinophilia and systemic symptoms [3]. Asthma is a chronic inflammatory disease of airway that can be exacerbated by various triggering factors. Which tests can predict the loss of asthma control? In this issue, Kreetapirom et al. [4] and Kang et al. [5] shares their experience with forced oscillator technique, a noninvasive objective measurement of lung physiology, and spirometric parameters such as forced expiratory volume in 1 second/forced vital capacity with fractional exhaled nitric oxide. Fruit allergy is an interesting area. Most patients have oral allergy syndrome. However, some patients have very severe allergic reactions such as anaphylaxis. This issue contains interesting articles on banana-induced anaphylaxis from Thailand [6], and the association between fruit and vegetable allergies and pollen-food allergy in Japanese children [7]. This issue also contains unique articles on 5-year experience of peanut allergy in the largest pediatric hospital in Singapore [8] and differences in omega-5-gliadin allergy, wheat dependent exercise induced anaphylaxis, from Hong Kong and UK [9]. Proper diagnosis and management of anaphylaxis is very critical in the Emergency Department. De Vera and Tagaro [10] emphasize the importance again in the article from the Philippines. Educations not only for patients and their care givers, but also for medical students, physicians, nurses, nurseries, kindergartens, schools, and emergency rescue teams are very important to increase the awareness on anaphylaxis [11121314]. In this January, there has been lots of difficulties such as Taal volcano eruption in the Philippines (I was in Silang near Taal with medical students for a medical volunteer program at the time of eruption), and 2019-nCoV, a novel corona virus, outbreak. As the Editor-in-Chief, I deeply appreciate those who contributed for this issue in times of difficulty. Our mission is to publish your work, and to introduce you and your work to the world. Please note that Japanese Society of Allergology/ World Allergy Organization Joint Congress (WAC 2020) conjoint with the APAAACI/APAPARI 2020 Congress will be held in Kyoto on September 17-20 this year. It is also the official APAAACI congress. Hope many of you can join us. Please save the dates! Conflict of Interest: The author has no financial conflicts of interest.

1Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. 2Department of Allergology, Institution of Internal Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden. 3Respiratory Research Group, University of Hull, Hull York Medical School, Castle Hill Hospital, Cottingham, East Yorkshire, United Kingdom. Correspondence to Woo-Jung Song. Department of Allergy and Clinical Immunology, Airway Sensation and Cough Research Laboratory, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3288, e-mail; [email protected] Received October 13, 2019; Accepted October 15, 2019; previously published online October 25, 2019

Clinical and experimental studies have shown that the heart and especially the coronary arteries constitute the primary targets of anaphylactic inflammatory mediators [1] which could induce coronary injury with increased cardiac troponin and mast cell tryptase levels. The elevated tryptase levels document anaphylactic reaction while the increased troponin levels combined with ischemic changes document acute myocardial injury. Whereas other studies have shown that tryptase is elevated in acute coronary events of nonanaphylactic etiology [2] and that troponin could also increase in allergic reactions [3]. This confirms our findings of a common pathway for coronary events in both allergic and nonallergic reactions [4]. Beyond anaphylaxis, the main concept lies to myocardial damage and ventricular dysfunction, which can lead to shock and cardiovascular collapse. It is commonly believed that the depression of cardiac output due to coronary hypoperfusion from systemic vasodilation associated with leakage of plasma and volume loss due to increased vascular permeability, and the following reduced venous return, constitute the main causes of cardiovascular collapse encountered in anaphylactic shock. Indeed, during anaphylactic shock circulating blood volume may decrease by as much as 35% within 10 minutes due to transfer of intravascular fluid to extravascular space [5]. In the very important paper published Asian Pacific Allergy [6], the authors, showed, for the first time, that cardiac dysfunction may develop during anaphylactic reaction independent of the severity of reaction and with suitable treatment may resolve after recovery from anaphylaxis. They used the QLAB-CMQ software program of Speckle tracking echocardiography and measured the global longitudinal strain (GLS) via apical chambers (4 chambers, 3 chambers, 2 chambers) through at least 4 consecutive cardiac cycles. They found that the GLS value was lower shortly after the anaphylaxis than those measured 6 weeks later in 50% of the patients and was also lower during the reaction in the anaphylaxis group than in the urticaria. Furthermore, the lower GLS has been recently associated with a higher long-term risk of cardiovascular morbidity and mortality in a low-risk general population [78]. This report raises important issues as far as the heart and especially the coronary arteries acting as primary targets of anaphylaxis is concerned. It comes to corroborate the following experimental and clinical findings that seem to have clinical, pathophysiologic, and therapeutic repercussions. Indeed, experiments, with ovalbumin sensitized guinea pigs anaphylaxis model, have shown that within 3-minute post ovalbumin administration the followings cardiac events have occured [9]: (1) cardiac output decrease by 90%; (2) left ventricular end diastolic pressure significant increase by 35%, indicating pump failure; (3) arterial blood pressure increases significantly by 35% and starts declining steadily after 4 minutes; (4) concurrent electrocardiographic changes reveal signs of acute myocardial ischemia. The conclusion was: “the idea that the registered anaphylactic damage might be due to peripheral vasodilatation can be definitely excluded.” In a recent experimental model with anaphylaxis, that was induced by ovalbumin antigen injection into open-chest of artificially ventilated sensitized mice the followings were found [10]: (1) Aortic blood flow and mean arterial pressure progressively decreased after an initial transient increase. (2) Total peripheral resistance reduction was not observed while pulmonary artery pressure showed initially a transient increase up to 18.5±0.5 mmHg along with pulmonary vascular resistance increment. (3) Aortic blood flow and the mean arterial pressure decrease were attenuated by pretreatment with either a platelet-activating factor receptor antagonist, or by histamine H1 receptor antagonist, -diphenhydramine-, and further were abolished by their combination. The authors again concluded that mice anaphylactic hypotension could be only attributed to cardiac output reduction via platelet activating factor and histamine actions and not to vasodilation. In a recent clinical study [3] of 31 patients admitted to the Emergency Department suffering from anaphylaxis, angioedema, urticaria and urticaria angioedema it was found, for the first time, a significantly increase of cardiac troponin I concentration compared to 125 healthy controls. In the subgroup of anaphylaxis, the cardiac troponin I levels were higher than those of patients with milder allergic reactions. The authors suggested systematic troponin measurement in patients with acute allergic reactions in order to detect and treat potential myocardial injury. Indeed, these findings might have profound clinical, therapeutic and pathophysiologic implications as far as anaphylaxis, myocardial injury and Kounis anaphylaxis-associated acute coronary syndrome are concerned. In another recent study [11] concerning 300 patients with anaphylactic reactions, who were assessed by electrocardiography, echocardiography and troponin measurements, myocardial injury was observed in 22 patients (7.3%). Cardiomyopathies, such as Kounis syndrome and Takotsubo cardiomyopathy were present in patients with myocardial injury. No mortality was observed in myocardial injury group, but there were 9 patients with documented cardiac arrest. One patient died due to multiple organ failure. The authors concluded that further prospective studies are required to investigate the prognosis of cardiac injury in patients with anaphylaxis. Furthermore, in an atopic patient allergic to milk protein, with eczema and bronchial asthma, anaphylactic reaction induced hemodynamic collapse and myocardial stunning leading to reduced cardiac output. The condition did not respond to intravenous Ringer acetate, antiallergic treatment with adrenaline and corticosteroids. Whereas her condition was complicated by pulmonary edema and decompensated heart failure, the patient responded satisfactorily and recovered only after myocardial infarction protocol treatment [12]. All above together with the new findings of Demir et al. [6] show that anaphylaxis affects the heart and especially the coronary arteries inducing cardiac dysfunction independent of the severity of reaction and with suitable treatment may resolve after recovery from anaphylaxis. In anaphylaxis myocardial involvement due to vasospasm-induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered [1]. Clinically, combined treatment targeting the primary cause of anaphylaxis together with protection of cardiac tissue seems to be of paramount importance. Conflict of Interest: The authors have no financial conflicts of interest.

BackgroundPrevious studies have reported that exposure to paraben (Pb) and triclosan (TCS) is associated with allergies. However, Pb and TCS exposure in the Japanese population is not fully understood.ObjectivesThe present study was aimed to examine such exposure among Japanese individuals with allergic diseases.MethodsThis cross-sectional study included the International Study of Asthma and Allergies in Childhood questionnaire survey to evaluate allergic outcomes and the collection of urine samples to examine Pb and TCS exposure.ResultsPb containing daily commodities was used in 84.8% children. Pb use was positively associated with current atopic dermatitis (adjusted odds ratio, 4.61; 95% confidence interval, 1.23–17.3). Urinary Pb concentrations were increased significantly in those with current atopic dermatitis (AD) (median, 4.58 vs. 0; p < 0.0001), and showed an increased tendency in those with current wheeze (median, 3.45 vs. 1.81; p = 0.0535) in participants ≤15 years old. Urinary TCS concentration was under the limit of detection in all children.ConclusionUrinary levels of Pb were associated with current AD in children. We should pay more attention about Pb and TCS.

BackgroundPeanut allergy is an increasing problem in Singapore and strict avoidance is difficult as peanut is ubiquitous in Asian cuisine.ObjectiveWe aimed to assess the efficacy and safety of peanut oral immunotherapy (OIT) in children with obvious peanut allergy in Singapore.MethodsThis was an open-label study of peanut OIT in children living in Singapore, with 2 weekly dose escalation until final maintenance dose of 3,000 mg of peanut protein and a maintenance phase of 12 months. An oral food challenge was performed at 6 months to assess for desensitisation and at 4 weeks after discontinuation of OIT having completed 12 months of maintenance therapy to assess for possible sustained unresponsiveness. The adverse events were monitored using the symptom diaries.ResultsNine subjects were started on OIT, with 7 managing to complete maintenance phase of therapy. Of these 7, all were able to tolerate at least 3,000 mg of peanut protein by 6 months of maintenance therapy, showing that the OIT was effective. Of these 7, 3 patients complied with the 4-week abstinence period after completion of OIT before another peanut challenge; 2 of the 3 subjects showed a significant decrease from the initial ability to tolerate 3,000 mg of peanut protein. Side effects were mainly gastrointestinal in nature and were more common during the updosing phase than the maintenance phase. No episodes of anaphylaxis were observed in this study.ConclusionPeanut OIT seemed to be effective and safe in our cohort of Singaporean children.

Most of temporal arteritis occurs in the older patient over 50 years old, and the histopathologic finding shows a granulomatous inflammation, so this called giant cell arteritis. However, the young patients also present with a nodular lesion in their temple, and juvenile temporal arteritis (JTA) should be considered as one of the differential diagnosis, although it is very rare. For both diagnosis and treatment of JTA, excisional biopsy is essential. The pathologic finding of the temporal artery shows panarteritis with lymphoeosinophilic infiltrates, but no giant cell or granulomatous lesion. JTA is a localized disease with low level of systemic inflammatory marker, so the symptom is usually relieved by excision of affected lesion. Peripheral blood eosinophilia present in some cases of JTA, but its relation with clinical course and prognosis is not yet been known. Herein, we report the case of a 24-year-old man diagnosed with concurrent JTA and hypereosinophilic syndrome. We also reviewed the literature of JTA focusing on the impact of combined peripheral eosinophilia on the course of the disease. Combined peripheral eosinophilia may increase the risk of recurrence of JTA after local treatment such as excision only.

BackgroundNasal polyposis is a chronic disease presenting with nasal obstruction as the most frequent complaint. It has been documented that nasal polyposis results in deterioration of quality of life and disturbances of sleep. However, remarkable consequences of nasal polyposis such as psychological and cognitive outcomes are relatively poorly studied.ObjectiveThe aim of the present study was to evaluate whether there is an impairment of concentration and attention in nasal polyposis patients due to hypoxia caused by nasal obstruction.MethodsThis cross-sectional, case-control study was carried out on 30 male patients with nasal polyps and 30 healthy subjects serving as controls. Participant ages were 41.6 ± 10.2 years in the nasal polyps group and 41.3 ± 6.2 in the control group. All participants underwent systemic, neurological, and otorhinolaryngological examinations together with routine hematological and biochemical tests. Patients with nasal polyposis had bilateral complete obstruction of nasal cavity. P300 component of electroencephalography-derived event related potentials were used to monitor concentration and attention. Nasal polyposis and control groups were compared in terms of amplitude and latency of P300.ResultsThere were significant differences between control and nasal polyposis groups in terms of latency of P300 (p < 0.001). Nasal polyposis patient latencies in P300 were longer than controls (345.8 ± 16.6 msec, 309.3 ± 16.6 msec, respectively). However, there were no significant differences between control and nasal polyposis groups in terms of amplitude of P300 (p > 0.05).ConclusionResults of the current study indicate that hypoxia due to complete nasal obstruction may result in impairment of attention and concentration in nasal polyposis patients. Assessment of patients with P300 latency subcomponent can be a useful diagnostic tool to detect cognitive and psychological consequences.

BackgroundAlthough many risk factors are known to be associated with poor asthma outcomes in the elderly, the literature on the effect of risk factor control on asthma outcomes in the elderly is very sparse.ObjectiveTo evaluate the role of multifaceted interventions in reducing acute exacerbations in elderly asthmatics.MethodsA total of 100 subjects were randomly selected from our prospective cohort of elderly asthmatics aged 65 years or older and were provided multifaceted intervention for 1 year. Our multifaceted interventions included repeated education on asthma and inhaler technique for patients and their caregivers, provision of an action plan to cope with acute exacerbations, short message service to prevent follow-up losses, and oral replacement of magnesium. The primary outcome was an acute asthma exacerbation rate compared to the previous year.ResultsNinety-two subjects completed this study, although only 58 subjects continued to take magnesium. Compared to the previous year, the acute asthma exacerbation rate showed a significant reduction from 67% to 50% (p = 0001) and significant improvement was observed in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) (p = 0.04, p = 0.036 for each). Interestingly, a subgroup analysis revealed that predicted value of FEV1 increased significantly in subjects who continued to take magnesium from 79.6% to 87.1% (p = 0.008).ConclusionTo reduce acute exacerbations in elderly asthmatics, a multifaceted approach in increase medical awareness, proficiency and adherence to inhaler, assistance of caregivers and correction of micronutrients deficiency is likely to be effective. In addition, a continuous oral replacement of magnesium may increase FEV1 in elderly asthmatics.

BackgroundAsthma and allergic rhinitis are a global health burden. Inhalant allergens worsen the symptoms and clinical manifestations of asthma and allergic rhinitis. Skin prick test is the gold standard for diagnosing allergen sensitization but is associated with some limitations. In contrast, in vitro serum-specific immunoglobulin E (SSIgE) test is convenient and is not associated with an anaphylactic risk.ObjectiveThe present study compared the accuracy of the SSIgE test by using microfluidic array enzyme-linked immunosorbent assay (ELISA) with that of the skin prick test for diagnosing inhalant allergen sensitization in patients with asthma and/or allergic rhinitis.MethodsThis diagnostic study included patients with asthma and/or allergic rhinitis. Of these, 100 patients underwent the SSIgE test for diagnosing sensitization to house dust mites (Dermatophagoides pteronyssinus, Dermatophagoides farinae, and Blomia tropicalis), dog dander, cat dander, and cockroach allergen. All the patients also underwent the skin prick test for diagnosing allergen sensitization. The sensitivity, specificity, predictive value, and likelihood ratio (LR) of the SSIgE test were evaluated for each allergen.ResultsSensitivity of the SSIgE test for diagnosing house dust mite sensitization was 48%–77%, with the highest sensitivity (77%) observed for diagnosing D. farinae sensitization. Specificity of the SSIgE test for diagnosing house dust mite sensitization was 64%–95%, with the highest specificity (95%) observed for diagnosing B. tropicalis sensitization. Although the SSIgE test showed high specificity and LR+ for diagnosing cockroach allergen sensitization, it showed low sensitivity (12%). Moreover, the SSIgE test showed high specificity (89%) but low sensitivity (3%) for diagnosing dog dander sensitization and high specificity (88%) but low sensitivity (10%) for diagnosing cat dander sensitization.ConclusionThe SSIgE test using microfluidic array ELISA shows moderate accuracy for diagnosing house dust mite sensitization and low accuracy for diagnosing cockroach allergen and dog and cat dander sensitization.

BackgroundAtopic dermatitis (AD) is a common skin condition among Asians. Recent studies have shown that Asian AD has a unique clinical and immunologic phenotype compared with European/American AD.ObjectiveThe Asian Academy of Dermatology and Venereology Expert Panel on Atopic Dermatitis developed this reference guide to provide a holistic and evidence-based approach in managing AD among Asians.MethodsElectronic searches were performed to retrieve relevant systematic reviews and guidelines on AD. Recommendations were appraised for level of evidence and strength of recommendation based on the U.K. National Institute for Health and Care Excellence and Scottish Intercollegiate Guidelines Network guidelines. These practice points were based on the consensus recommendations discussed during the Asia Pacific Meeting of Experts in Dermatology held in Bali, Indonesia in October 2016 and April 2017.ResultsThe Expert Panel recommends an approach to treatment based on disease severity. The use of moisturizers is recommended across all levels of AD severity, while topical steroids are recommended only for flares not controlled by conventional skin care and moisturizers. Causes of waning efficacy must be explored before using topical corticosteroids of higher potency. Topical calcineurin inhibitors are recommended for patients who have become recalcitrant to steroid, in chronic uninterrupted use, and when there is steroid atrophy, or when there is a need to treat sensitive areas and pediatric patients. Systemic steroids have a limited role in AD treatment and should be avoided if possible. Educational programs that allow a patient-centered approach in AD management are recommended as an adjunct to conventional therapies. Recommendations on the use of phototherapy, systemic drugs, and emerging treatments are also included.ConclusionThe management of AD among Asians requires a holistic approach, integrating evidence-based treatments while considering accessibility and cultural acceptability.