CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 35, No 3 September 2022
- Autonomy vs beneficence
- Truth in transition – can clinical guidelines carry the load?
- Relationships between health professionals and the pharmaceutical industry
- The unexplored possibilities, perceptions and ethical implications of gene-editing allergic disease
- How I found a rare solution to a rare disease
- Spray-painters and occupational contact dermatitis
Authors: Sharon Kling
Abstract: It is my privilege to guest edit this issue of Current Allergy and Clinical Immunology, themed ‘Ethics and Allergy’. I wish to express my sincere thanks to the editors, Professor Eugene Weinberg and Dr Di Hawarden, for entrusting me with this task, and to Mrs Robyn Marais, the production editor of the journal, for her enduring patience and her professionalism during the finalisation of this issue.
ALLSA 2022: ALLERGIES – BEHIND THE MASK
Author: Jonny Peter
Abstract: No area of our professional or personal lives has been left untouched by the COVID-19 pandemic. In South Africa, high levels of natural immunity – hard-earned through hundreds of thousands of lives lost – combined with vaccine-derived immunity has allowed us to emerge slowly from behind our masks in 2022. Our reemergence has given us a new appreciation of smiling faces, in-person meetings, and the ability to travel for connection and learning at local and international meetings. We hope that as you read this congress edition of our journal, you are also feeling welcomed and inspired by ALLSA 2022.
TRIBUTE TO PROFESSOR EUGENE WEINBERG
Author: Sharon Kling, Di Hawarden, Robyn Marais, Emeritus Professor Paul Potter, Dilys Berman, Professor Matthias Haus, Pete White, Professor Heather J Zar, Claudia Gray, John O Warner, Shaunagh Emanuel, Ahmed Ismail Manjra, André van Niekerk
Abstract: When Di Hawarden suggested that the issue of Current Allergy and Clinical Immunology for which I am the guest editor should also serve as a tribute for Eugene Weinberg, I thought it was a brilliant idea. All of us in the field of allergy in South Africa credit Eugene with being the father of Allergology in this country – although, with typical modesty, he says this accolade belongs to Dr Lorne Shore.
AUTONOMY VS BENEFICENCE: SHARED DECISION-MAKING IN ALLERGY
Author: John O Warner
Abstract: Understanding the principles of ethical clinical practice is fundamental to making appropriate decisions. While ethical practice is a regulatory and legal obligation, it more importantly improves clinical judgement and the delivery of effective care. Traditionally, there are four principles: autonomy (giving choice to the patient); beneficence (paternalism); nonmaleficence (do no harm); and justice (confidentiality and equality). However, a fifth principle, fidelity, which constitutes fairness, truthfulness and advocacy, must be included. Balancing between autonomy and beneficence is like walking on a tight-rope, particularly when dealing with children and young people. However, competence to make sensible autonomous decisions is not linearly related to age. Adults sometimes make bad decisions and do not necessarily understand the long-term consequences of their actions. Nevertheless, whereas children are not, adults are legally considered to have autonomous rights. Irrespective of age, generating an accord between clinician and patient through empathetic consultation has the best chance of achieving favourable patient experience and consequent optimal clinical outcomes. In most situations honesty and full disclosure should be the rule; but, very occasionally, it may be necessary to modify approaches to avoid adverse consequences. The five principles are discussed and illustrated with case scenarios. It is not always possible to achieve consensus and sometimes there are no correct answers to ethical dilemmas. But discussion with colleagues, ethicists, patients and their representatives will improve ethical clinical practice.
Keywords: autonomy, beneficence, ethical clinical practice
TRUTH IN TRANSITION – CAN CLINICAL GUIDELINES CARRY THE LOAD?
Authors: Marc Blockman, Andy Parrish
Abstract: A few decades ago, clinicians were led to believe that it was beneficial to prescribe encainide and flecainide to patients experiencing ventricular extrasystoles after a myocardial infarction. Estimates of harm vary widely but range from 50 000 excess deaths. Similarly, prescribing corticosteroids to head-injured patients was reasoned to be safe and possibly beneficial until the large CRASH-1 trial proved harm, again with an estimated 10 000 unnecessary deaths associated with that belief. Peri-operative beta-blockade is a third example, with widely ranging estimates of harm (from 10 000 annual iatrogenic deaths in the United Kingdom) to a later review which failed to substantiate any increased mortality from this practice. The first two examples – there are many others – date back some decades and highlight the importance of careful evidence accumulation and scrutiny prior to widespread implementation of new strategies. The erroneous thinking ‘it may do some good, and it can’t do much harm’ is a lesson that clinicians continue to ignore. We need to trust evidence of both safety and efficacy before prescribing, and society trusts us to have made that assessment scrupulously. When we have not and people die, we are responsible. The third example highlights the potential clinical impact of guideline recommendations on healthcare outcomes and demonstrates that more than a decade after a major trial enrolling more than 8 000 patients, it is still unclear what to recommend. The evidence space was muddied by trial fraud in the DECREASE trial stable and by patient selection issues.
Keywords: clinical guidelines, careful evidence accumulation, evidence-based medicine
RELATIONSHIPS BETWEEN HEALTH PROFESSIONALS AND THE PHARMACEUTICAL INDUSTRY: ACHIEVING A BALANCE
Authors: Sharon Kling, Matthias Haus
Abstract: Health professionals and the pharmaceutical and medical-device industry have had a long and often problematic relationship. The interaction between for-profit companies trying to promote and market their products and the prescribers of those products has come under increasing scrutiny. Most of the current regulation is from the industry’s side; health professionals and professional medical associations are taking much longer to disentangle themselves from this often unethical relationship.
Keywords: health professionals, pharmaceutical industry, conflict of interest, professional medical associations
THE UNEXPLORED POSSIBILITIES, PERCEPTIONS AND ETHICAL IMPLICATIONS OF GENE-EDITING ALLERGIC DISEASE: ENGAGING STAKEHOLDERS IN SOUTH AFRICA
Author: Camille Castelyn
Abstract: Clinically approved cell and gene therapies are opening up future possibilities to treat and prevent myriad diseases, which may include allergic diseases. In South Africa, this could help alleviate the high disease burden and economic cost of treating such diseases. However, even if viable gene-editing options to treat, cure and prevent allergic diseases become safe, effective and affordable for the South African market within the next few decades, the ethical implications and challenges of perceptions, regulation and oversight to ensure safety and equitable access remain. It would be important for all stakeholders involved, including the public and physicians, clinicians and ethicists on clinical and research ethics committees, to be informed about the possibilities, to engage in discussions with one another and to redress any gaps in knowledge. It would be especially important to determine whether cases for gene-editing aimed at allergy would be applied for therapeutic purposes or for enhancement. Much research and discussion remain to be embarked upon; however, it is imperative that research and engagement are expanded and prioritised.
Keywords: allergic disease, gene-editing, enhancement, therapeutic, equitable access
INVITED GUEST ARTICLE
HOW I FOUND A RARE SOLUTION TO A RARE DISEASE
Author: Shamaa Sheik
Abstract: Severe combined immunodeficiency (SCID) is a group of rare disorders caused by mutations in different genes involved in the development and functioning of infection-fighting immune cells. Infants with SCID appear healthy at birth but are highly susceptible to severe infections. The condition is fatal, usually within the first year or two of life, unless infants receive immune-restoring treatments such as transplants of blood-forming stem cells, gene therapy or enzyme therapy. More than 80 per cent of SCID infants do not have a family history of the condition. However, the development of a screening test for newborns has made it possible to detect SCID before symptoms appear, which helps to ensure that affected infants receive life-saving treatments.
Keywords: severe combined immunodeficiency, rare disorders, mutations, genes
ALLERGIES IN THE WORKPLACE
SPRAY-PAINTERS AND OCCUPATIONAL CONTACT DERMATITIS
Authors: Phinias Mfune, Shahieda Adams
Abstract: Introduction: Spray-painting is associated with exposure to certain chemicals such as resins, amines, isocyanates and diluents that are important causes of occupational contact dermatitis (OCD). A thorough assessment of causative agents by a specific skin-patch test with workplace substances is an important part of the diagnosis, treatment and prevention of OCD in the workplace.
Case report: We present a case of two spray-painters from the same company who developed OCD after exposure to paints containing amines, epoxy and isocyanates.
Discussion: OCD can have a wide range of causes. Isolation of the actual cause is therefore important for effective management. Workplace visits and specific skin-patch testing play a role in identifying the cause of OCD in the workplace.
Conclusion: Thorough assessment of workplace substances is needed to identify the causes of OCD. A workplace visit and skin-patch testing of specific workplace substances plays an important role too. Avoidance of contact with the offending substances through substitution and/or elimination is core to the management of OCD.
Keywords: occupational contact dermatitis, allergic contact dermatitis, occupational skin diseases, spray-paint-induced dermatitis, specific skin-patch testing
DR SPUR’S MYSTERY CASE
THE CASE OF ’WHAT NOW?’
Authors: Sylvia van den Berg, Cathy van Rooyen, André van Niekerk
Abstract: Dear Dr Rodriques. It is important to recognise a patient with an immunodeficiency in order to manage the patient appropriately and initiate treatment timeously. It cannot be emphasised enough that a high index of suspicion should always be maintained for possible immunodeficiencies, as untreated immunodeficiencies are lifethreatening. Primary immunodeficiencies now form part of the disease group known as ‘inborn errors of immunity’. These two terms are often used interchangeably.
ABC OF ALLERGIES
Authors: Shaunagh Emanuel, Di Hawarden
Abstract: Dr Do-a-lot and her students have an informal discussion about allergy prevention in neonates. As she leaves the tutorial room, she notices a doodle on a sheet of paper which a student has left on the chair … the student has highlighted the following aspects of their chat: Allergy is on the rise. Perhaps there are factors in the perinatal period that contribute to this trend. It appears that complex interactions between genes, the environment, lifestyle, nutrition and microbial diversity may lead to epigenetic adjustments which in turn result in a shift in the balance between the development of immune tolerance and the development of allergy. These shifts may occur before, during and/or after birth.
CONGRESS ABSTRACTS 2022
EPIDEMIOLOGY AND MANAGEMENT OF ACUTE ANGIOEDEMA ACROSS TERTIARY AND DISTRICT-LEVEL SOUTH AFRICAN EMERGENCY ROOMS
Authors: Cascia Day, Janet van der Walt, Kenneth Crombie, Clint Hendrikse, Jonny Peter
Abstract: Angioedema (AE) is the most common acute allergic presentation in emergency rooms (ER), with hospitalisation rates increasing in high-income countries. AE can complicate with life-threatening laryngeal obstruction. There are no local data; therefore we aimed to characterise acute AE cases presenting to ER.