Orathai Jirapongsananuruk’s research while affiliated with Mahidol University and other places

Background: Visual analog scale (VAS) correlates well with total nasal symptom score (TNSS) but negatively correlates with peak nasal inspiratory flow (PNIF) in adults with allergic rhinitis (AR). Small children may not rate VAS properly and parents usually help assess their child's symptoms. Data on the correlations among parent-assessed VAS (P-VAS), VAS, TNSS, and PNIF in children with AR was limited. Objective: To assess correlations among P-VAS, VAS, TNSS, and PNIF in children and adolescents with perennial AR (PAR). Methods: Patients with PAR aged 6-18 years and their parents were instructed to record daily VAS, TNSS, PNIF, and P-VAS in an electronic diary for 8 weeks. Results: 2387 records from 46 patients (56.5% male) were obtained. VAS and P-VAS showed a strong correlation (rs = 0.82, p < 0.001). Moderate correlations were found between VAS vs TNSS (rs = 0.53, p < 0.001) and between P-VAS vs TNSS (rs = 0.48, p < 0.001). There was a weak negative correlation between PNIF vs VAS, PNIF vs TNSS, and PNIF vs P-VAS (rs = -0.20, rs = -0.22, rs = -0.18, p < 0.001 respectively). In addition, a weak negative correlation was found between nasal congestion and PNIF (rs = -0.26, p < 0.001). The overall inter-rater agreement between VAS and TNSS was fair (Kappa = 0.37, p < 0.001). Higher inter-rater agreement was found in moderate-severe than in the mild PAR group (Kappa = 0.50 vs 0.17) and in adolescents than in the children group (Kappa = 0.44 vs 0.26). Conclusion: In small children, P-VAS was a reliable tool to assess nasal symptoms. Both subjective and objective measurements provided complementary information for symptom monitoring in patients with AR.

Background: During the COVID-19 pandemic, national lockdowns were implemented worldwide. Asthma control was reported to have improved. However, some patients lost follow-up from the clinic because they intended to avoid crowds at the hospital. Objective: To evaluate the level of asthma control during the COVID-19 pandemic and explore factors influencing asthma outcomes. Methods: Subjects 8-18 years old from our previous study in 2019 were recruited. The data during the pandemic period were collected between June 2021 - May 2023. The level of asthma control was compared before and during the pandemic. We also evaluated inhaled corticosteroid (ICS) adherence and factors related to poor asthma control during the COVID-19 pandemic. Results: One hundred and three subjects were enrolled. Asthma control levels remained relatively stable during the pandemic. However, an asthma exacerbation was significantly decreased from 36 (36.3%) in 2019 to 19 (19.2%)and 15 (15.1%) in 2021 and 2022 (p = 0.012, p < 0.001), respectively. Spirometry results demonstrated improved pre-bronchodilator FEV1 (89.91 ± 11.02 vs. 101.91 ± 14.11, p < 0.001). The factors related to the poor asthma outcome were not wearing a face mask (aOR = 8.52, 95%CI 1.26-57.79) and previously poor-controlled by the ACT score (aOR = 2.55, 95%CI 1.41-4.63). The median adherence rate during the pandemic was 85%. The main reasons for poor adherence were hectic lifestyle and misunderstandings of disease. Conclusion: Asthma exacerbation was significantly decreased during the lockdown. Not wearing a face mask and previously poorly controlled by the ACT score are related to poor asthma outcomes.

Background: Food allergy (FA) has been reported in one-third of children with moderate-to-severe atopic dermatitis (AD). Objective: To identify factor associated with food allergy among preschool children with AD, and to compare AD resolution between preschool children with and without FA. Methods: A cross-sectional study using database registry and questionnaire interview was conducted at Siriraj Hospital(Bangkok, Thailand) during 2022, and physician-diagnosed AD children aged ≤ 6 years were enrolled. Results: A total of 110 children (60.9% male, median age: 2.3 years) were included. Of those, 53 and 57 children had AD with and without FA, respectively. Very early-onset AD (≤ 3 months) and moderate-to-severe AD at onset were reported in 43.9% and 26.3% of AD without FA, and in 35.8% and 45.3% of AD with FA, respectively. The most commonly reported FAs were hen's egg, cow's milk, and wheat. Moderate-to-severe AD at onset was found significant associated with FA (aOR: 2.50; p = 0.037). Thirty-one (28.2%) patients experienced completed resolution of AD by 5 years of age. Of those, 19 had AD without FA, and 12 had AD with FA (p = 0.213). The median age at AD resolution was 18 months and 22.5 months in the without and with FA groups, respectively. AD with FA showed a strong trend toward a significantly longer duration to achieving AD resolution after adjusting for onset and severity of AD (aHR: 0.46, p = 0.050). Conclusion: Preschool AD children with FA were found to have significantly greater AD severity at AD onset and a longer duration to AD resolution compared to AD children without FA.

Background: Factors associated with wheat oral immunotherapy (OIT) difficulties in patients with IgE-mediated wheat allergy have not been well studied. Objective: We aimed to assess factors associated with difficulties in wheat OIT. Methods: We retrospectively collected data from children under 18 years of age with history of IgE-mediated wheat allergy who underwent wheat OIT. The initial specific IgE (sIgE) of wheat and omega-5-gliadin, wheat skin prick test (SPT) sizes, eliciting doses, and adverse reactions during the OIT were evaluated. Results: A total of 81 children were enrolled, with a mean age of 7.0 ± 2.7 years at the initiation of wheat OIT. The median follow-up duration was 2 years (IQR 1.2 -3.0 years). Difficulties in wheat OIT included patients who experienced frequent reactions (at least grade 2 or exercise-induced reactions) or deviated from the up-dosing protocol, which we defined as 'Complicated cases.' Twenty-six patients (32.1%) were complicated cases. Initial wheat-sIgEs were significantly higher in complicated cases than in noncomplicated cases (median of 192.3 kUA/L (IQR 30.4-590.0) vs 6.9 kUA/L (IQR 1.9-100.0) (p = 0.001)). Initial omega-5-gliadin-sIgEs in the complicated group were also significantly higher, with a median of 15.0 kUA/L (IQR 6.3-69.8) vs 1.6 kUA/L (IQR 0.2-11.4) (p < 0.001). The risk factors for complicated cases include higher omega-5-gliadin-sIgEs and anaphylaxis during the oral food challenge test (aOR 1.035 and 5.684, respectively). Conclusion: The initial wheat and omega-5-gliadin-sIgEs were significant risk factors for complicated OIT patients and could be used to monitor these patients carefully during the OIT period.

Background: The commercial wheat extract for skin prick test (SPT) provides less sensitivity to predict wheat allergy, compared to in-house gliadin extracts. SPT is a preferred method to study extract stability as it is the aim of developing extract. The role of cell degranulation assay, a functional assay with the same mechanism as SPT, is not widely used to determine extract stability. Objective: To study the stability of in-house gliadin extracts stored at different periods, by using protein analysis, SPT and degranulation assay of humanized rat basophilic-leukemia (RBL-SX38) cells. Methods: Patients with a history of wheat allergy and positive SPT to wheat, were recruited. The gliadin extracts stored for 1, 6, 9, and 12 months at 2-8°C were used in SDS-PAGE, SPT and cell degranulation assay. The cell degranulation was determined by β-hexosaminidase release. AR patients. Results: Forty children were recruited. The gliadin extract stored for 9 and 12 months provided lighter protein bands than 1 and 6 months. However, the wheal diameters from SPT using extracts stored at different periods, were not significantly different (p = 0.09). There were also no significant differences of the β-hexosaminidase released using 0.1 and 1 μg/mL of gliadin extracts stored at different periods (p > 0.05). The 10 μg/mL of gliadin extracts stored at longer periods, significantly stimulated higher β-hexosaminidase release (p = 0.01). The extracts were sterile at all storage times. Conclusions: To determine the stability of in-house gliadin extracts, SPT or cell degranulation assay provided additional information to SDS-PAGE. The extracts were stable for up to 12 months.

Background: Despite nebulized budesonide being identified by the Global Initiative for Asthma report as a viable alternative to inhaled corticosteroids (ICS) delivered by pressurized metered-dose inhalers (pMDIs) with spacers, practical guidance on nebulized corticosteroid use in the pediatric population remains scarce. Objective: To review the current literature and provide practical recommendations for nebulized budesonide use in children aged ≤ 5 years with a diagnosis of asthma. Methods: A group of 15 expert pediatricians in the respiratory and allergy fields in Thailand developed Delphi consensus recommendations on nebulized budesonide use based on their clinical expertise and a review of the published literature. Studies that evaluated the efficacy (effectiveness) and/or safety of nebulized budesonide in children aged ≤ 5 years with asthma were assessed. AR patients. Results: Overall, 24 clinical studies published between 1993 and 2020 met the inclusion criteria for review. Overall, results demonstrated that nebulized budesonide significantly improved symptom control and reduced exacerbations, asthma-related hospitalizations, and the requirement for oral corticosteroids compared with placebo or active controls. Nebulized budesonide was well tolerated, with no severe or drug-related adverse events reported. Following a review of the published evidence and group consensus, a treatment algorithm as per the Thai Pediatric Asthma 2020 Guidelines was proposed, based on the availability of medications in Thailand, to include nebulized budesonide as the initial treatment option alongside ICS delivered by pMDIs with spacers in children aged ≤ 5 years. Conclusions: ThNebulized budesonide is an effective and well-tolerated treatment option in children aged ≤ 5 years with asthma.

Background: Non-allergic rhinitis (NAR) is characterized by symptoms of nasal inflammation without allergic sensitization. The long-term outcome of NAR in children is poorly defined. Objective: To determine the natural history of childhood-onset NAR and the development of allergic rhinitis (AR) in these children. Methods: NAR patients who were followed for more than 10 years were evaluated at 3-5 years (E2) and 9-12 years (E3) after the first evaluation (E1). Nasal symptoms, disease severity, comorbidities, medication used, and aeroallergen sensitization were assessed. Results: Eighty-two NAR patients (58.5% male) completed all 3 evaluations. The age at onset was 2.0 (range 2.0-4.0) years. The follow-up period was 13.6 (range 12.3-14.3) years. At E2, 37.8% of patients developed AR. At E3, the patients were classified into four groups based on results of skin prick tests in E2 and E3 (group I: NAR→NAR→NAR, 39.0%, group II: NAR→NAR→AR, 23.2%, group III: NAR→AR→NAR, 12.2% and group IV: NAR→AR→AR, 25.6%). The most common aeroallergen sensitization was house dust mite. The family history of atopy, asthma and allergic rhinitis were higher in group III and IV than other groups (p < 0.05). The atopic dermatitis, obstructive sleep apnea and adenotonsillar hypertrophy at E1 and E2 were predominantly found in group IV (p < 0.05). At E2, group III and IV patients had higher proportion of exposure to house dust, animal dander and smoking compared to other groups (p < 0.05). The overall remission rate was 14.6%. Conclusions: Children with NAR should be reevaluated periodically to determine aeroallergen sensitization for the appropriate diagnosis and management.

Background: Food-dependent exercise-induced allergic reactions can manifest with wheals, angioedema, and anaphylaxis, alone or in combination. Objective: To systematically review the clinical manifestation, culprit foods and exercise, augmenting factors, comorbidities, and treatment options of each phenotype. Methods: Using predefined search terms, we assessed and analyzed the relevant literature until June 2021. Preferred Reporting Items for Systematic Reviews and Meta-analysis recommendations were applied to this systematic review. Results: A total of 231 studies with 722 patients were included. The most common phenotype was anaphylaxis with wheals, angioedema, or both, reported in 80% of patients. This was associated with a higher number of anaphylactic episodes, augmenting factors, and use of on-demand antihistamine compared to the least common phenotype, anaphylaxis without wheals or angioedema, reported in 4% of patients. Anaphylaxis with wheals/angioedema was also associated with distinct characteristics compared to stand-alone wheals, angioedema, or both, in 17% of patients: Patients with anaphylaxis were older at the time of disease onset, less often had history of atopy, showed more positive results in response to food and exercise provocation tests, had a more restricted spectrum of culprit foods, and more often used on-demand epinephrine. Conclusions: The three phenotypes of allergic reactions to food and exercise differ in their clinical characteristics, triggers, and response to treatment. Knowledge of these differences may help with patient education and counseling, as well as disease management.