Current Management of Moderate-to-Severe Atopic Dermatitis: A Survey of Allergists, Pediatric Allergists and Dermatologists in Korea

염혜영,김현희,김현정,김우경,이소연,이갑숙,이동훈,The KAAACI Work Group on Severe/Recalcitrant Atopic Dermatitis 대한천식알레르기학회 2018 Allergy, Asthma & Immunology Research Vol.10 No.3

Purpose: There is an unmet need for the treatment of moderate-to-severe atopic dermatitis (AD), leading to variation in management strategies. To investigate distinct features and treatment modalities according to physicians’ specialties, we collected data on the current treatment approach to moderate-to-severe AD among allergists, pediatric allergists and dermatologists in Korea. Methods: This questionnaire-based study was administered to physicians from the Korean Academy of Asthma, Allergy and Clinical Immunology (KAAACI), Korean Academy of Pediatric Allergy and Respiratory Disease (KAPARD), and Korean Atopic Dermatitis Association (KADA). Results: A total of 93 physicians participated in the study; 64.5% were pediatric allergists and 31.2% were dermatologists. The major patient age groups were “less than 5 years” for 100% of pediatric allergists and “6-12 years old” for 38% of dermatologists. The proportion of patients with moderate-to-severe AD was higher for dermatologists and allergists compared to pediatric allergists. Physicians agreed on the necessity of education including demonstration of basic skin care and application of topical therapies (88.2%), nutritional consultation (83.9%) and psychological counseling (75.3%). However, less than half were able to educate and counsel their patients in real practice. There were noticeable differences in first-line treatment among physician groups. For pediatric allergists, the order of preferred systemic treatment was wet wrap therapy, systemic corticosteroids and oral cyclosporin. Dermatologists ranked cyclosporin, phototherapy, and systemic corticosteroids as first-line treatment regimens. Major reported barriers to proper management were steroid phobia, unproven complementary and alternative medicine, lack of education, and the unreasonable insurance system. Conclusions: Our findings suggest there are distinct differences in moderate-to-severe AD treatment according to physicians’ specialties. Medical policy changes along with governmental supports are required in order to implement the ideal approach in real practice. For moderate-to-severe AD, a consensus on the approach to optimal management should be reached for the best outcomes, based on further randomized controlled trials.

소아 천식의 예후와 폐기능

염혜영 대한 소아알레르기 호흡기학회 2008 Allergy Asthma & Respiratory Disease Vol.18 No.2

소아 농흉 원인균에 대한 다기관 연구(1999. 9-2004. 8)

염혜영,김우경,김진택,김현희,나영호,박용민,손명현,안강모,이수영,홍수종,이혜란 대한소아청소년과학회 2007 Clinical and Experimental Pediatrics (CEP) Vol.50 No.1

Purpose : In spite of medical advances, empyema is a serious complication of pneumonia in children. Vaccination practices and antibiotic prescribing practices promote the change of clinical manifestations of empyema and causative organisms. So we made a nationwide clinical observation of 122 cases of empyema in children from 32 hospitals during the 5 year period from September 1999 to August 2004. Methods : Demographic data, and clinical information on the course and management of empyema patients were collected retrospectively from medical records in secondary and tertiary hospitals in Korea. Results : One hundred twenty two patients were enrolled from 35 hospitals. The most frequent age group was 1-3 years, accounting for 48 percent of all cases. The male to female sex ratio was 1.2:1. The main symptoms were cough, fever, respiratory difficulty, lethargy and chest pain in order of frequency. Hematologic findings on admission revealed decreased hemoglobin levels (10.4±1.6 g/dL) and increased leukocyte counts (16,234.3±10,601.8/ L). Pleural fluid obtained from patients showed high leukocyte counts (30,365.8±64,073.0/ L), high protein levels (522.3±1582.3 g/dL), and low glucose levels (88.1±523.5 mg/dL). Findings from pleural fluid cultures were positive in 80 cases(65.6 percent). The most common causative agent was Streptococcus pneumoniae. The majority of patients were treated with antibiotics and closed drainage. Some patients needed open drainage (16.4 percent) or decortication (3.3 percent). The mean duration of hospitalization was 28.6±15.3 days. Conclusion : We analyzed childhood empyema patients during a period of 5 years in Korean children. The most frequent age group was 1-3 years and the most common causative agent was Streptococcus pneumoniaeiae. The majority of patients were treated with antibiotics and close drainage. 목 적 : 농흉은 세균성 폐렴의 주요 합병증으로 소아과 영역의 중요 질환이며 새로운 백신의 개발과 광범위 항생제의 사용으로 농흉의 임상 양상과 원인균주의 변화가 예상된다. 본 연구는 최근 5년간의 전국의 2, 3차 병원에서 농흉으로 진단, 치료를 받은 환아들을 대상으로 그 임상 양상과 원인균주에 대한 분석을 하여 보고하는 바이다. 방 법 : 1999.9.1-2004.8.31까지 만 5년간 2, 3차 병원에 내원한 소아연령의 농흉 환자들의 임상기록을 검토하여 임상 양상 및 검사실 소견, 치료 및 경과를 후향적으로 조사하였다. 결 과 : 전국 35개 2, 3차 병원의 122명의 환자가 선정되었다. 이중 1세에서 3세미만이 가장 많아 48명(39.3%)였다. 주증상은 기침과 발열, 호흡곤란, 기면, 흉통, 복통, 구토, 과민, 복부 팽창, 청색증 등의 순서로 관찰되었다. 흉강 천자 결과 육안으로 보았을 때 황색을 보인 경우가 58례(47.5%)로 가장 많았다. 흉막액의 백혈구 수는 평균 30,365.8±64,073.0/ g였고 단백량은 522.3±1,582.3 g/dL였다. 전체 환자 중 80례(65.6%)에서 원인균이 배양되었다. 흉막액 배양에서 균이 동정된 증례 중 45명(36.9%)에서 S. pneumoniae가 검출되었고 Group A Streptococcus, coagulase negative staphylococcus, S. aureus 순서로 동정되었다. 혈액배양에서 양성을 보인 경우는 15례(12.3%)로 S. pneumoniae, S. aureus, coagulase negative staphylococcus, H. influenzae type b, Enterobacter cloacae의 순서로 나타났다. 107명(87.7%)의 환자에서 폐렴이 동반되었다. 그 외에 기흉, 패혈증, 뇌성마비, 무기폐, hyper IgE 증후군, X-linked agammaglobulinemia, 기관식도누출관, 철분 결핍성 빈혈, 유미흉, 폐쇄 항문 등이 동반되었다. 좌우측을 명시한 단순 흉부 방사선 소견을 조사한 결과 좌측의 병변이 42례(34.4%), 우측의 병변이 75례(61.5%)였고 양측 모두에 농흉이 있던 경우가 1례였다. 전 환자에서 항생제를 투여하였고 75례(61.5%)에서 폐쇄성 배농을 시행하였다. 이 중 8례는 흉관을 통해 urokinase를 투여하였다. 27례(22.1%)에서는 항생제만을 투여하였고 16례(13.1%)에서는 개방성 배농을 시행하고 4례(3.3%)에서 겉질제거를 시행하였다. 투여한 항생제는 vancomycin 46례(36.6%), cefotaxime 44례(36.1%), ampicillin with clavulinic acid 38례(31.1%), ceftriaxone 36례(29.5%), teicoplanin 6례(4.9%)의 순서로 사용되었다. 평균 입원기간은 28.6±15.3일 이었다. 21-30일간 입원한 환자가 37례(30.3%)로 가장 많았다. 사망 1례는 Hyper IgE 증후군을 가진 9세 남아로서 우측 페의 농흉이 있던 증례로 폐출혈과 호흡부전으로 사망하였다. 결 론 : 1999. 9. 1-2004. 8. 31까지 만 5년간 2, 3차 병원에 내원한의 122명의 소아 농흉 환자를 대상으로 임상양상을 분석한 결과 1985년 이전의 국내 보고와 달리 1세에서 3세 미만의 연령에서 호발하고 주원인균은 S. pneumoniae, Group A Streptococcus, coagulase negative staphylococcus, S. aureus 순서로 동정되었다. 항생제로는 vancomycin과 2, 3세대 세팔로스파린을 가장 많이 투여하였으며 폐쇄성 배농을 주로 시행하고 일부에서 개방성 배농과 fibrinolysis를 시행하였다. 폐구균 백신의 사용과 항생제 내성균의 출현에 따른 원인균주의 변화 및 항생제 감수성에 대한 지속적 연구가 요구된다.

쌀과 저항원성 쌀 및 유전자 재조합 쌀의알레르기 항원성의 비교

염혜영,이경은,최성연,양혜선,손명현,이상일,박혜경,박선희,이순호,이우영,김규언 대한 소아알레르기 호흡기학회 2005 Allergy Asthma & Respiratory Disease Vol.15 No.2

목 적 : 본 연구에서는 국내산 쌀의 산지와 도정의 정도, 유전자 재조합 여부 및 조리의 형태에 따른 항원성의 변화를 관찰하고 일본에서 생산된 여러 가지 저항원성 쌀의 항원성과 비교해 보고자 하였다. 방 법 : 다양한 쌀을 조항원으로 제조하여 SDS-PAGE를 통해 그 단백분포를 비교하고 알레르기 환자를 대상으로 시행한 CAP test를 토대로 쌀 항원에 감작된 환자의 혈청을 수집하여 immunoblot을 시행하여 특이 IgE 결합능을 비교해 보았다.결 과 : 산지와 도정의 정도에 따른 단백의 분포에는 변화가 없었고 조리 후에는 대부분의 단백이 변성되어 그 분포를 관찰할 수 없었으며 IgE immunoblot의 결과 국내산 일반미와 저항원성 일본산 쌀 사이에는 특이한 IgE 결합능의 차이가 없었다. 순수 쌀과 유전자 재조합 쌀의 Ig E immunoblot의 결과 유의한 차이는 관찰되지 않았다.결 론:다양한 형태의 쌀의 알레르기 항원성을 연구한 결과 다중 식품알레르기 환자의 제한식과 영유아 이유식으로 이용되는 조리된 쌀의 경우 그 항원성이 대부분 소실되는 것을 알 수 있었다. 저항원성 쌀 및 유전자 재조합 쌀의 알레르기 유발성 검증을 위해서는 지속적인 쌀 알레르기 혈청의 수집과 임상 연구가 지속되어야 할 것으로 사료된다. Purpose : Rice is the main cereal produced and consumed in large quantities in Asian countries including Korea. Several reports have suggested a role of IgE-mediated hypersensitivity in asthma and eczema associated with ingestion or inhalation of rice. In Japan, hypoallergenic rices are used as substitutes for rice in some atopic patients. We performed this study to identify major the allergens of rice and the different allergenicity in cooked rice and hypoallergenic rices. Methods : We made crude extracts from rice of various origins : polished rice, cooked rice, hypoallergenic rice from Japan and GMO rice, and performed SDS-PAGE. Based on uni, CAP test and skin prick tests we got pooled sera, then IgE immunoblots were undertaken. We performed ELISA inhibition to rule out nonspecific binding. Results : There was no difference of protein distribution between the origins of the various rices, and their “polishment”. After cooking, it was difficult to see any protein distribution of rice. With the results of IgE immunoblots it was impossible to differentiate between wild and hypoallergenic rices by IgE binding itself. Even in hypoallergenic rice, there was still a binding of IgE with remaining allergen. Conclusion : Boiling degenerates almost all protein in rice IgE binding activities remain in hypoallergenic rice produced in Japan was no difference between wild and GMO rice in SDS-PAGE and IgE immunoblot using sensitized pooled sera. Further studies with more sensitive sera are necessary for the identification of major allergens and the development of hypoallergenic rice.

Oral food challenges in children

염혜영,편복양,양현종,김경원,송태원,Woo Kyung Kim,김정희,안강모,김현희,이수영 대한소아청소년과학회 2011 Clinical and Experimental Pediatrics (CEP) Vol.54 No.1

Many patients assume that allergic reactions against foods are responsible for triggering or worsening their allergic symptoms. Therefore, it is important to identify patients who would benefit from an elimination diet, while avoiding unnecessary dietary restrictions. The diagnosis of food allergy depends on the thorough review of the patients's medical history, results of supplemented trials of dietary elimination, and in vivo and in vitro tests for measuring specific IgE levels. However, in some cases the reliability of such procedures is suboptimal. Oral food challenges are procedures employed for making an accurate diagnosis of immediate and occasionally delayed adverse reactions to foods. The timing and type of the challenge, preparation of patients, foods to be tested, and dosing schedule should be determined on the basis of the patient's history, age, and experience. Although double-blind, placebo-controlled food challenges(DBPCFC) are used to establish definitively if a food is the cause of adverse reactions,they are time-consuming, expensive and troublesome for physician and patients. In practice, An open challenge controlled by trained personnel is sufficient especially in infants and young children. The interpretation of the results and follow-up after a challenge are also important. Since theses challenges are relatively safe and informative,controlled oral food challenges could become the measure of choice in children.

세균성 폐렴과 항생제 선택

염혜영 대한소아청소년과학회 2009 Clinical and Experimental Pediatrics (CEP) Vol.52 No.3

Pneumonia remains the leading cause of mortality in children. Diagnosis depends on a combination of factors, including clinical assessment, radiological and laboratory findings. Although Streptococcus pneumoniae remains the most important cause of childhood bacterial pneumonia, the great majority of cases of community-acquired pneumonia (CAP) are of viral etiology. A new, rapid, and inexpensive test that differentiates viral from bacterial pneumonia is needed to decide empiric antibiotic treatment. Antibiotics effective against the expected bacterial pathogens should be instituted where necessary. The role of emerging pathogens and the effect of pneumococcal resistance and heptavalent conjugate pneumococcal vaccines are to be considered in practice. There are reports supporting the valid and highly efficacious use of penicillin as a first-line drug for treating CAP. This review raises the issue of the overuse of unnecessary antibiotics in viral CAPs and the use of second or third-line antibiotics for non-complicated pneumonias in most clinical settings.

Mucosal Immunotherapy : the Action Mechanism and Clinical Effects

염혜영 대한 소아알레르기 호흡기학회(구 대한소아알레르기 및 호흡기학회) 2000 Supplement Vol.10 No.1

천식의 만성기도개형에서 섬유아세포성장인자와 그 수용체의 역할

염혜영 대한 소아알레르기 호흡기학회 2006 Allergy Asthma & Respiratory Disease Vol.16 No.4

천식환자에서 나타나는 기도의 다양한 구조적 변화는 기도 상피와 하부 세포외기질 간의 작용에 의한 결과로 생각되고 있으며 여기에는 손상된 상피의 이상 복구과정에서 분비되는 여러 성장인자들이 관여한다. 여러 임상 연구, 동물 연구 및 세포주를 이용한 실험 연구의 결과 bFGF와 FGFR의 신호에 의해 섬유모세포, 평활근 세포, 내피 세포의 증식에 영향을 미칠 것으로 보인다. 천식환자의 기도에서 bFGF의 표현에 영향을 미치는 다른 성장인자나 사이토카인과 주 표현세포, 그리고 그 분비에 관련된 신호 전달에 대한 연구 및 그 수용체의 분포와 작용에 대한 연구들이 요구된다. 또한 T세포와 관련된 염증반응을 목표로 한 현재의 천식치료가 기도개형에 미치는 영향을 알기 위해서 상피 기질 간 상호작용에 관여하는 여러 성장인자들을 조절하는 치료법의 고안이 필요할 것으로 생각된다. A number of structural changes occur in the airway wall in asthma. The most characteristic is thickening of the subepithelial lamina reticularis which is observed in bronchial tissue even in patients with mild disease. This pathophysiological change which was the result of deposition of interstitial collagens by increased numbers of myofibroblasts is likely to be directed by growth factors having fibropoliferative and profibrotic effect. The acivation of the epithelial-mesenchymal unit involves reciprocal activities of growth factors belonging to the fibroblast growth (FGF), epidermal growth factor (EGF), and transforming growth factor-β families. Among them FGF is a member of family of heparin binding growth factors that affect the growth and differentiation of a large number of cell types. Especially basic FGF involved in morphogenesis, wound repair, inflammation, angiogenesis, and tumor growth and invasion, and require the glycosaminoglycan side chains of heparan sulphate, proteoglycans for high affinity binding to their specific receptors. Few studies suggested bFGF would be an important regulator of airway remodeling by means of paracrine control of bronchial myofibroblasts in response to cell damage and repair.

알레르기 질환과 모유수유

염혜영 대한 소아알레르기 호흡기학회 2009 Allergy Asthma & Respiratory Disease Vol.19 No.4

우리나라에 서식하고 있는 모기(Culex pipiens)의 항원 추출과 항원성 분석

염혜영,김규언,류정우,정병주,이기영,전성후,이한일,이기선,이수영 대한천식 및 알레르기학회 ( 구 대한알레르기학회 ) 1999 춘계학술대회 초록집 Vol.1999 No.-