Who diagnoses and treats nasal and ocular allergies in the US? Survey shows some surprises

Allergic rhinoconjunctivitis is managed by a number of health care professional specialties, whose practice styles may vary. This study included telephone surveys of randomly selected patients and health care professionals in the United States in 2012 (2,700 patients and 500 practitioners in 7 specialties).

Adult respondents to the patient survey reported that their allergies had been diagnosed most often by:

- physicians in family practice (46%)
- allergists/immunologists (17%)
- otolaryngologists, ENT (11%).

Children's allergies had been diagnosed most often by pediatricians (41%) and family practitioners (22%).

Most respondents with conditions diagnosed by an allergist/immunologist (95%) or otolaryngologist (63%) had been given an allergy test, but the test was not given to most patients with conditions diagnosed by family practitioners (61%) or pediatricians (65%).

Most patients (76%) were treating their allergies with over-the-counter medications, and 53% were taking prescription medications.

Allergen immunotherapy was being used by 33% (adult) or 28% (child) patients of allergist/immunologists, 25% (adult) or 24% (child) patients of otolaryngologists, and 8% and 10% of patients of family practitioners and pediatricians, respectively.

Treatment Options for 
Allergic Rhinitis (AR) and 
Non-Allergic Rhinitis (NAR) in 6 Steps (click to enlarge the image).


Diagnosis and treatment of nasal and ocular allergies: the Allergies, Immunotherapy, and RhinoconjunctivitiS (AIRS) surveys. Annals of Allergy, Asthma & Immunology, Volume 112, Issue 4 , Pages 322-328.e1, April 2014.

Image source: Wikipedia, Creative Commons license.

Game App For Asthma Education: Wellapets Virtual Pet

The Wellapets app has a fire breathing dragon. The pet is part of a video game that aims to help children with asthma.

When playing ‘Wellapets’ children must give their pet dragon a maintenance inhaler twice a day, just like many of them have to do in real-life. The game also aims to teach them to recognize symptoms and avoid asthma triggers like dust and smoke.

Asthma Treatment Options in 6 Steps (click to enlarge the image).

If the free asthma app is a success, the developers are looking at other games geared toward food allergies, diabetes, and childhood obesity.

The game looks like fun, but I'm not sure if the patients learn many useful skills, as the educational part is not really front and center, and that's by design. One of the founders said: "We initially made the mistake of building a game around educational objectives, rather than weaving educational objectives into a game, but through several rounds of testing and collaboration with industry veterans, we arrived at a more cohesive design." See for yourself how it all works in the video below:


Gamifying Asthma Education with Wellapets [INTERVIEW] http://buff.ly/1jaRV37
Boston Company Builds Gaming App For Children’s Health « CBS Boston http://buff.ly/1jaS2vJ

Sinusitis - top articles for April 2014

Here are my suggestions for some of the top articles about sinusitis for April 2014:

The united allergic airway: Connections between allergic rhinitis, asthma, and chronic sinusitis (free full text) http://goo.gl/m4O9b

Risk factors for chronic sinusitis in allergic rhinitis, from ENT perspective: infraorbital & frontal intersinus cells http://goo.gl/shthh

Left-sided maxillary sinusitis (absence of the air transparency of left maxillar sinus). Image source: Wikipedia, public domain.

The management of nasal polyps can be quite complex. There are no known "natural remedies." http://goo.gl/88dOU

Is nasal saline irrigation all it is cracked up to be? Small clinical benefit, with minimal side effects http://goo.gl/J44b5

European position paper on rhinosinusitis and nasal polyps 2012, full text PDF http://goo.gl/CVmjb

Uncontrolled allergic rhinitis and chronic rhinosinusitis - EAACI position paper http://buff.ly/Hv9YVm - The US approach is slightly different.

Former Guns n’ Roses bassist undergoes sinus surgery to remove scar tissue built up during years of cocaine abuse http://goo.gl/lb2dz

Polysaccharide nonresponsiveness in selective antibody deficiency can be classified into 4 phenotypes http://buff.ly/QHf9BY

Severe chronic upper airway disease (SCUAD): Uncontrolled allergic rhinitis and chronic rhinosinusitis http://buff.ly/PIVNdv

The united allergic airway: connections between allergic rhinitis, asthma, and chronic sinusitis http://buff.ly/QaASQQ

Nasal irrigation as an effective adjunctive treatment for acute sinusitis in atopic children (but no X-ray difference) http://buff.ly/R8ZuMV

Biologics and the treatment of chronic rhinosinusitis http://buff.ly/V5wZyR

Screening for primary immunodeficiency should be part of diagnostic workup of refractory chronic rhinosinusitis (CRS) http://buff.ly/XY5H0K

Premorbid diagnoses of patients with chronic rhinosinusitis: anxiety, headaches, GERD, sleep apnea. who are given a diagnosis of CRS have a higher premorbid prevalence of anxiety, headaches, gastroesophageal reflux disease, sleep apnea, and infections of the respiratory system and some nonrespiratory sites, which results in higher antibiotic, corticosteroid, and health care use. http://buff.ly/16vhQxc

Diagnostic Tools In Rhinology - EAACI position paper http://buff.ly/10xVPrT

The articles were selected from Twitter @Allergy and RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @Aller_MD @AllergyNet @IgECPD @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.

Please feel free to send suggestions for articles to allergycases AT gmail DOT com and you will receive an acknowledgement in the next edition of this publication.

Small airway involvement is present in all stages of asthmatic disease despite been referred to as 'silent zone'

This review provides an update on the importance of the peripheral, small airways in asthma. As the small airways account for less than 10% of total airway resistance, thus having little impact on standard lung function measures such as forced expiratory volume and peak flow, they have been referred to as the 'silent zone'.

Small airway involvement is present in all stages of asthmatic disease, and is related to important clinical phenotypes such:

- nocturnal asthma
- exercise-induced asthma
- difficult-to-control asthma
- patients with the risk of repeated asthma exacerbations

Uncontrolled small airway inflammation is related to airway remodeling and progression of the disease, with a more rapid decline in the lung function.

In order to control the disease, we need to target small airway inflammation, which is difficult to reach by standard inhaled medications. A better understanding of the role small airways are playing in asthma shows that the 'silent zone' is not silent at all.


The role of small airway disease in asthma. Bjermer L. Curr Opin Pulm Med. 2014 Jan;20(1):23-30. doi: 10.1097/MCP.0000000000000018.

Image source: Spirometry, from Wikipedia, the free encyclopedia, GNU Free Documentation License.

Uvular Angioedema Due to ACE Inhibitor - NEJM

Angioedema is a swelling that is similar to hives, but the swelling is under the skin instead of on the surface.

In this NEJM case report, treatment with 6.25 mg of captopril was started 6 hours after cardiac stent placement, and 30 minutes after administration the patient reported difficulty swallowing and throat pain. The uvula was markedly edematous and erythematous:

Uvular angioedema, or Quincke's disease, was diagnosed, and treatment with antihistamines and glucocorticoids was started. Improvement was rapid, and the edema completely resolved within 24 hours.

Isolated uvular angioedema is usually caused by an immediate (type I) hypersensitivity reaction. Mast-cell degranulation can occur after exposure to an immunologic or nonimmunologic stimulant, such as a drug, as was the case in this patient.

Angiotensin-converting–enzyme (ACE) inhibitors can cause isolated uvular angioedema, and although this response to ACE inhibitors is uncommon, it is important to be aware of it, since it can lead to obstructive respiratory distress.

Angioedema (AE) Classification (click to enlarge the image)


Isolated Uvular Angioedema — NEJM, 2014 http://buff.ly/1hnZqpO
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