Allergy and Immunology News of the Day

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Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

• Baths With Diluted Bleach May Help Kids With Atopic Dermatitis. 90% of people with atopic dermatitis have Staph on their skin, compared to about 25% of general population http://bit.ly/QMq4b
  
  
• In Depth Report from Forbes.com: America's Most Polluted Cities http://bit.ly/34XGL
  
  
• California cities some of the most polluted in the U.S., air quality likely damaging the health of millions of people http://bit.ly/wm6LV
  
  
• Omega 3 and 6 oils unlikely to play an important role for primary prevention of allergic disease http://bit.ly/Gc5qK
  
  
• Impaired TLR-2 expression may contribute to susceptibility to skin infections with S. aureus in atopic dermatitis http://bit.ly/OPaNX
  
  
• Adolescents with asthma ask "Why bother with our meds?"- 20% think meds unnecessary, another 18% not sure about benefit http://bit.ly/122noq
  
  
• Heterogeneity of asthma according to blood inflammatory patterns - difference between eos. and neutrophil patterns http://bit.ly/8DTHW
  
  
• Genes DPP10/ADAM33 increase asthma risk but genotyping of multiple polymorphisms in many genes will be needed to define a full genetic profile for asthma risk http://bit.ly/XOUxm
  
  
• HIV-infected infants have a normal immune response to childhood vaccines if HAART is started in the first year of life http://is.gd/vuPx
  
  
• "Rota and Pneumococcus Vaccine Success Stories: Pediatric Emergency Practitioners Wonder “Where Have the Kids Gone?” http://is.gd/qje0

Image source: OpenClipArt.org, public domain.

Durham, NC: Seasonal Allergies Last Longer In The South

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From Durham County:

"It actually is worse here than anywhere else," he said. "Nothing dies here, the weather's too good."

In the spring, Dr. Lugar said the biggest allergens are tree pollens, like elm, maple and oak. Unlike pine pollen, which is visible in the trees and in the yellow film it leaves on cars and windows, the most problematic allergens are too small to see.

"And tree pollen, for example, can travel for miles. So even if you assume that you are surrounded by concrete buildings, the pollen that's been produced miles away will reach your nose."

Mnemonic for the pollen calendar: TGR MI

Tree pollen - spring
Grass pollen - summer
Ragweed and weeds - fall

Mold
Indoor allergens are year-round


Pollen-producing plants (weeds and trees) in Omaha, Nebraska. V. Dimov, M.D.

References:
Seasonal Allergies Last Longer In The South. Durham County Story, 2009.
Pollen Role in Allergy and Asthma
Image source: Southern United States, Wikipedia, GNU Free Documentation License.

New Test for Respiratory and Asthma Control in pre-school Kids, aged 2-5 (TRACK) and "3S" Mnemonic

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A validated questionnaire is needed to monitor respiratory control in preschool-aged children.

The Test for Respiratory and Asthma Control in Kids (TRACK) includes 5 items:

- frequency of respiratory symptoms (wheeze, cough, shortness of breath)
- activity limitation
- nighttime awakenings in the past 4 weeks
- rescue medication use in the past 3 months
- oral corticosteroid use in the previous year

Reliability was greater than 0.70. The control status was correctly classified in 81% and 78% of cases. Changes in TRACK scores of 10 or more points represent clinically meaningful changes in respiratory control status.

Compare TRACK (age 2-5 years) to C-ACT (age 4-11 years)

Test for respiratory and asthma control in kids (TRACK) is a caregiver-completed questionnaire for preschool-aged children. Childhood Asthma Control Test (C-ACT) is a mix between children and caregiver-completed questionnaire.

TRACK includes 5 questions. C-ACT includes 7 questions with a 1-4 scale (http://www.asthmacontrol.com/child.html).

TRACK mnemonics

5
5 questions
5 year-old or younger (2-5 years)

Test for respiratory and asthma control in kids (TRACK) - mnemonic: 3S

Symptoms (3 questions)
SABA use
Steroid use

Test for respiratory and asthma control in kids (TRACK) - complete mnemonic: 3S

Symptoms - SPA: Symptoms - how often, Play, At night, past 4 weeks
SABA use, past 12 weeks (3 months)
Steroid use, past 12 months (1 year)

Time frame of TRACK:

Symptoms - 4 weeks (1 month)
SABA use - 12 weeks (3 months), quarter
Steroid use - 12 months (1 year)

Abbreviations:
SABA, Short Acting Beta Agonist
C-ACT, Childhood Asthma Control Test

The authors concluded that TRACK was a valid, easy-to-administer, caregiver-completed questionnaire of respiratory control in preschool-aged children with symptoms consistent with asthma.

References:

Test for Respiratory and Asthma Control in Kids (TRACK): A caregiver-completed questionnaire for preschool-aged children. Kevin R. Murphy et al. JACI. Volume 123, Issue 4, Pages 833-839.e9 (April 2009).

Test for Respiratory and Asthma Control in Kids (TRACK): Clinically meaningful changes in score. J Allergy Clin Immunol. 2011 Sep 7. [Epub ahead of print]

ACQ scores ≥ 1.50 and ACT scores ≤ 19 are suitable to indicate uncontrolled asthma http://goo.gl/l9Sl5

Validated tools to assess asthma control - ACT, ATAQ, LASS, ACQ, ACSS, TRACK and more. AAAAI, 2011.

Image source: picturestation.net, free license.

Textile Dermatitis Associated With Contact Allergy to Disperse Dyes

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Textile dermatitis, i.e. skin manifestations due to clothing and other textiles, can be caused by irritant reactions to textile fibres or by contact allergy to textile dyes and finishing chemicals.

Disperse dyes were developed for the dyeing of cellulose acetate, and are water insoluble. The dyes are finely ground in the presence of a dispersing agent and then sold as a paste, or spray-dried and sold as a powder. Their main use is to dye polyester but they can also be used to dye nylon, cellulose triacetate, and acrylic fibres. The very fine particle size gives a large surface area that aids dissolution to allow uptake by the fibre.

Disperse dyes (DDs) are the most common sensitizers among textile dyes. Contact allergy to DDs is quite common in Sweden, with 1.5% of 3325 consecutively patch tested patients reacting positively to a textile dye mix (TDM) consisting of eight DDs: Disperse Blue (DB) 35, 106 and 124; Disperse Yellow (DY) 3; Disperse Orange (DO) 1 and 3; and Disperse Red (DR) 1 and 17.

A questionnaire on textile-related skin problems was answered by 858 of 982 consecutively patch tested patients in Sweden and Belgium.

Para-phenylenediamine (PPD), which historically has been considered to be a screening allergen for textile dye dermatitis, is included in most baseline patch test series.

The patch testing was supplemented with a textile dye mix (TDM) consisting of the eight DDs and with the separate dyes.

18% of the patients suspected textiles as a cause of their skin problems.

Synthetic materials were the most common textiles to give skin problems.

A significant association was found between self-reported textile-related skin problems and contact allergy to para-phenylenediamine (PPD). A similar, but more imprecise, relationship was found for TDM.

Contact allergy to PPD was a more prevalent indicator for skin reactions to textiles than the TDM used in this study.

References:
Contact Allergy to Disperse Dyes and Related Substances Associated With Textile Dermatitis? Medscape, 2009.

Post-Traumatic Basal Cell Carcinoma Associated With Patch Testing - with strongly positive reaction to gold. Actas Dermo-Sifiliográficas (English Edition), 2009.
Dye, from Wikipedia, the free encyclopedia.
Image source: Close-up of a polyester shirt, Wikipedia, GNU Free Documentation License.

Beta 2-AR polymorphism (homozygous arginine 16) associated with higher IgE in children with asthma

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Beta 2-adrenergic receptor (AR) polymorphisms occurring at amino acid positions 16 (arginine/glycine) and 27 (glutamine/glutamic acid) are known to be functionally relevant.


The mechanism of adrenergic receptors. β receptors couple to Gs, and increases intracellular cAMP activity, resulting in e.g. heart muscle contraction, smooth muscle relaxation and glycogenolysis. Image source: Wikipedia, GNU Free Documentation License.

In this Argentinean study, beta 2-Adrenergic receptor polymorphisms and total serum IgE levels were analyzed in 124 white asthmatic children using polymerase chain reaction during a 3-year period.

Serum levels of IgE were 4.3-fold higher than age-adjusted normal values in the study population.

No association was found in regard to asthma severity.

A significant difference of IgE serum levels was observed among polymorphisms at position 16, with the highest IgE level in the arginine/arginine group (P = 0.04).

The authors concluded that beta 2-adrenergic receptor polymorphisms, especially homozygous arginine 16, were associated with higher serum IgE levels in children with asthma.

References:
Beta 2-Adrenergic polymorphisms and total serum IgE levels in children with asthma from Argentina. Verónica Giubergia MD; Marta Zelazko MD; Adriana Roy MSc; Luis P. Gravina MSc; Hebe Gonzalez Pena MD; Lilien Chertkoff PhD. Annals of Allergy, Asthma and Immunology, 2009, vol. 102, no. 4, pp. 308 - 313.

Acupuncture for allergic rhinitis: evidence for effectiveness is mixed

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7 RCTs met the inclusion criteria for this systematic review.

3 RCTs failed to show superiority of acupuncture for treating or preventing symptoms for seasonal allergic rhinitis (AR) compared with placebo acupuncture.

For perennial AR, 1 study reported favorable effects of acupuncture on a rhinitis symptoms score and 1 found positive results for a nasal symptoms score compared with placebo acupuncture (n = 152; P = .006)

2 RCTs compared acupuncture with oral pharmacologic medications. Their results were in favor of acupuncture.

The authors concluded that the evidence for the effectiveness of acupuncture for the symptomatic treatment or prevention of AR is mixed.

The results for seasonal AR failed to show specific effects of acupuncture. For perennial AR, results provide suggestive evidence of the effectiveness of acupuncture.

References:
Acupuncture for allergic rhinitis: a systematic review. Myeong S. Lee PhD; Max H. Pittler MD, PhD; Byung-Cheul Shin OMD, PhD; Jong-In Kim OMD, PhD; Edzard Ernst MD, PhD, FRCP, FRCPEd. Annals of Allergy, Asthma and Immunology, 2009, vol. 102, no. 4, pp. 269 - 279.
Acupuncture for treatment of allergic rhinitis

Allergy Sufferers Turn To Alternative Treatments - Acupuncture - WLKY Louisville.
Image source: Needles being inserted into a patient's skin, Wikipedia, public domain.

Unintentional injection of epinephrine from autoinjectors: demographics and treatment modalities

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From 26 reports of an unintentional injection of epinephrine from an autoinjector published during the past 20 years:

- 69 people were affected
- 68% were reported in the past 6 years
- 58% were female
- 42% were injured in the home
- 91% sustained injury to a finger or thumb
- 65% were evaluated in an emergency department

Treatment an unintentional injection of epinephrine from an autoinjector:

- warming of the injured part was used in 25%
- nitroglycerin paste application in 9%
- local injections of phentolamine and/or lidocaine in 22%

No permanent sequelae were reported.

(Click here for Figure 1. Treatment of adrenaline induced digital ischaemia caused by auto-injector devices, for example, EpiPen. Emergency Medicine Journal 2004;21:387-388.)

The authors concluded that occurrences of unintentional injection of epinephrine from autoinjectors may be increasing.

People at risk for anaphylaxis need regular coaching in how to use epinephrine autoinjectors correctly and safely. Improved autoinjector design may be needed.

References:
Hazards of unintentional injection of epinephrine from autoinjectors: a systematic review. F Estelle R. Simons MD; Phillip L. Lieberman MD; Edward J. Read Jr MD; Eric S. Edwards BS. Annals of Allergy, Asthma and Immunology. 2009, vol. 102, no. 4, pp. 282 - 287.
Image source: EpiPen, Wikipedia, GNU Free Documentation License.

Related:
Figure 1. Treatment of adrenaline induced digital ischaemia caused by auto-injector devices, for example, EpiPen. Emergency Medicine Journal 2004;21:387-388.
Management of adrenaline (epinephrine) induced digital ischaemia in children after accidental injection from an EpiPen. I Velissariou, S Cottrell, K Berry, B Wilson. Emergency Medicine Journal 2004;21:387-388; doi:10.1136/emj.2003.005462.
Treatment of accidental digital injection of adrenaline from an auto-injector device. S J McGovern. J Accid Emerg Med. 1997 November; 14(6): 379–380.
Finger Injection with High-Dose (1:1,000) Epinephrine: Does it Cause Finger Necrosis and Should it be Treated? Colleen Fitzcharles-Bowe1, Keith Denkler2 and Don Lalonde. Hand, Volume 2, Number 1 / March, 2007.
Management options for accidental injection of epinephrine from an autoinjector: a case report. Christian Mathez, Bernard Favrat and Philippe Staeger. Journal of Medical Case Reports 2009, 3:7268.
Another Ordinary Day. Sean Donahue, DO.

Updated: 08/31/2009

Intralymphatic immunization with allergens induced 10-fold higher IgG2a with 100-fold lower allergen doses than SCIT (in mice)

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IgE-mediated allergy can be treated by subcutaneous allergen-specific immunotherapy (SCIT). However, the percentage of allergic patients undergoing SCIT is low, mainly due to the long duration of the therapy and the risk of systemic allergic reactions associated with SCIT.

To improve the safety and attractiveness of SIT for patients, alternative routes of allergen administration are being explored:

- sublingual (SLIT)
- oral

The present study (done in mice, not humans) evaluated direct intralymphatic allergen administration with bee venom and cat fur allergens.


A lymph node showing afferent and efferent lymphatic vessels. Image source: Wikipedia, public domain.

Direct injection of the major bee venom allergen phospholipase A(2) or the major cat fur allergen Fel d 1 into inguinal lymph nodes were compared with subcutaneous injections.

Only intralymphatic immunisation stimulated the production of the Th1-dependent subclass IgG2a, which is associated with improved protection against allergen-induced anaphylaxis.

The authors concluded that in this mouse model, intralymphatic immunisation induced more than 10-fold higher IgG2a responses with 100-fold lower allergen doses than subcutaneous immunisation.

References:
Intralymphatic Injections as a New Administration Route for Allergen-Specific Immunotherapy. Martínez-Gómez JM, Johansen P, Erdmann I, Senti G, Crameri R, Kündig TM. Int Arch Allergy Immunol. 2009 Apr 2;150(1):59-65. [Epub ahead of print]

Does omalizumab (Xolair) cause bleeding or thrombocytopenia?

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Case description:

A 34-year-old Caucasian female started treatment with omalizumab for uncontrolled asthma 3 weeks ago. Two weeks after the first injection she noticed a slightly heavier period than usual and a 7 x 10 cm bruise on the left calf. She read the medication brochure and wants to know if omalizumab is the cause of her perceived increased tendency to bleed.

Does omalizumab (Xolair) cause bleeding or thrombocytopenia?

No.

The medication information brochure lists thrombocytopenia among the potential adverse reactions from omalizumab with a frequency lower than 1%. Omalizumab binds to Cε3 region of IgE.

An extensive PubMed search does not show any articles that associate omalizumab with increased bleeding.

In pre-clinical studies, thrombocytopenia (reduced platelet count) was observed in juvenile cynomolgus monkeys receiving omalizumab at doses 3.7–20-fold greater than the highest dose recommended in humans. This observation was made after initiation of the phase III clinical trials and led to implementation of increased surveillance of platelet counts in all ongoing and subsequent clinical studies.

There was, however, no evidence of a clinically relevant impact on platelet count during omalizumab treatment in clinical studies. Shift analyses of platelet counts showed no differences between the omalizumab and control groups. In the all-controlled-studies population, a decrease in platelet count from baseline occurred frequently in both the omalizumab and control groups (70.7% and 65.7%, respectively).

The majority of patients had a decrease in platelet count of less than 50 × 10*9/L (55.2% with omalizumab and 52.4% with controls) or no change/increase in platelet counts (29.3% with omalizumab and 34.3% with controls). In the omalizumab group, 3.4% of patients had a decrease in platelet count of 100 × 10*9/L or greater, compared with 2.3% of patients in the control group.

References:
Safety and tolerability of omalizumab. Corren J, Casale TB, Lanier B, Buhl R, Holgate S, Jimenez P. Clin Exp Allergy. 2009 Mar 17. [Epub ahead of print].
Omalizumab: A Monoclonal Anti-IgE Antibody: Laboratory Values. Medscape.
Image source: Wikipedia, public domain.

Practical points on using NIOX MINO fractional exhaled nitric oxide (FENO) measuring device

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The practical points below represent a summary from a presentation on the FENO measurement device NIOX MINO. They were initially posted on Twitter as text messages.

- NiOX Mino requires daily biological calibration in the U.S., required by FDA, not in Europe. The initial calibration of NiOX Mino takes 4 days, if regular calibration is not performed, the device "locks you out."


NIOX MINO display. The device needs to be plugged in at all times.


NIOX MINO - the patient's side of the device.

- NiOX Mino's display is on the back of the device - it requires a mirror to see the indicator "cloud" when you are using the device.


The display is on the back of the device - it requires a mirror to see the indicator "cloud" when using it.


The "cloud" indicator.

- When exhaling into the NiOX Mino device, it indicates a correct maneuver by emitting a sound similar to a Scottish bag pipe.

- The ATS guidelines require an one hour interval between eating or drinking and FeNO measurement.

- NiOX Mino FeNO cutoff point for "normal" value is 20 - similar to ACT. Difference: FeNO greater than 20 implies poor control, ACT greater than 20 implies good control.

The cost of device: $2,500, 100-test sensor/100 mouth pieces: $1,600, 300-test sensor: $3,400. The sensor lasts 9 months. Unsuccessful test maneuvers don't "use up" the sensor which lasts only 300 measurements.

- A replacement sensor costs $3,400 - the cost of each test is $17 - the reimbursement is $16.


Individual mouth pieces that must be used with NIOX MINO. Each extra mouth piece costs $4. The mouth pieces are included with the purchase of a sensor for 100 or 300 tests.


Inflammation in asthma (mind map). FeNO is a marker of oxidative stress. See more Allergy and Immunology mind maps here.

References:
FDA Approves NIOX MINO for Asthma Monitoring. Medgadget, 2008.
Allergic asthma associated with increased FeNO, but only in never-smokers
Exhaled nitric oxide (FeNO) in asthma and sinusitis

Updated: 04/22/2009

CDC Video: Get The Picture - Child Immunizations

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Get The Picture: Child Immunizations

"After talking with parents across the country, CDC put together this short video to help answer the tough questions that real moms had about childhood immunizations. Understanding the importance of vaccines is crucial for you to protect your children's health."

Carmine hypersensitivity ("red pill") masquerading as azithromycin hypersensitivity

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Macrolide hypersensitivity is a rarely reported event. Carmine dye has become increasingly important as a provocative agent for allergic reactions.

Carmine, also called Crimson Lake, Cochineal, Natural Red 4, C.I. 75470, or E120, is a pigment of a bright red color obtained from the carminic acid produced by some scale insects ("beetle juice"), such as the cochineal and the Polish cochineal, and is used as a general term for a particularly deep red color.


Carminic acid. Image source: Wikipedia, public domain.

This is a case report of a woman with documented carmine hypersensitivity, who reported anaphylaxis 90 minutes after ingestion of a generic azithromycin. She had not problems with the brand name Zithromax taken on previous occasions.

The cause of anaphylaxis was an allergy to the carmine dye in the tablet's coating rather than to the antibiotic (azithromycin).


Azithromycin. Image source: Wikipedia, public domain.

Seven extracts were prepared including carmine dye, crushed dried female cochineal insects, crushed tablets of Zithromax (Pfizer Inc.) and generic azithromycin (Teva Pharmaceuticals), and the crushed colored coatings from both tablets. The exctracs were dissolved in normal saline, and then applied as a skin-prick test and read at 30 minutes.

The skin-prick skin test results were 4+ to histamine and carmine dye, but negative to cochineal insect extract, Pfizer crushed tablets, and negative control. The patient was 1+ to the Teva crushed tablet, but was 4+ to the Teva brand coating and negative to the Pfizer brand coating, which did not contain carmine.

The patient subsequently ingested Pfizer Zithromax without any sequelae.

According to the authors, this is the first reported case of carmine anaphylaxis attributed to carmine-containing medication.

References:

Carmine hypersensitivity masquerading as azithromycin hypersensitivity. Greenhawt, Matthew1; McMorris, Marc; Baldwin, James. Allergy and Asthma Proceedings, Volume 30, Number 1, January/February 2009 , pp. 95-101(7).
Testing for red coloring agents added to foods - AAAAI Ask the Expert, 2011.

The data suggests an extremely rare occurrence of azithromycin allergy http://goo.gl/6fZHL
Carmine, from Wikipedia, the free encyclopedia.

The best price for azithromycin is at Costco: 18 tablets for $18.

Drug provocation tests remain the key to diagnosing macrolide allergy http://goo.gl/WM5rj

Image source: Variations on a common tablet design, which can be told apart by both color and shape. Wikipedia, Ragesoss, Creative Commons Attribution ShareAlike 3.0 License.

Twitter comments:

@AllergyNet: For me, x2/25 yrs, x1 in sausage x1 in chocolate RT @Allergy: Carmine allergy masquerading as azithromycin allergy http://goo.gl/gST6h

@AllergyNet: Macrolide antibiotic allergy: Which tests are really useful? http://j.mp/jAr3zV Bottom line: NONE (except challenge) Full PDF

Reasons for outpatient consultations in allergy/immunology

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The study authors retrospectively reviewed the electronic medical records of all outpatient A/I consultations during one year (January-December, 2006) at a tertiary care referral center which is a GME training site.

There were 1412 A/I consults requested during the 1-year period. The consults per month ranged from a low of 69 to a high of 157.

The referrals consisted of 35% pediatric and 65% adult patients: 74.3% of referrals from primary care, 19.8% from specialty care, and 5.9% from the emergency department.

The most common reasons for outpatient consultation included:

- 57.2% patients for chronic rhinitis
- 20.4% for asthma
- 13.9% for food allergy
- 6.3% for venom allergy
- 4.8% for atopic dermatitis
- 4.7% for drug allergy
- 4.4% for chronic urticaria
- 3.2% for acute urticaria
- 2.4% for immunodeficiency
- 2.2% for anaphylaxis

References:
Reasons for outpatient consultation in allergy/immunology. Dietrich, Jeffrey J.1; Quinn, James M.; England, Ronald W. Allergy and Asthma Proceedings, Volume 30, Number 1, January/February 2009 , pp. 69-74(6).
Image source: OpenClipArt.org, public domain.

Allergy and Immunology News of the Day

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Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

• NEJM: LABAs to be used only if other controller meds alone do not provide adequate, rather than optimal, asthma control. We know that LABAs are effective; the data must be gathered to prove they are safe. http://is.gd/sPHj
  
  
• CNN: Five places to escape seasonal allergies: slopes, sea, beach, desert, big city http://is.gd/spO3 - No guarantee with any of them...
  
  
• BBC Interactive Primer on Allergies: Videos and more http://news.bbc.co.uk/2/hi/...
  
  
• Saline irrigation for nasal allergies. Plausible, but we'll never have a placebo comparison: http://twurl.nl/wccewl
  

• Ludwig von Beethoven had at least moderate asthma, apparently: http://bit.ly/4XmXV
  
  
• Faces of Asthma from National Library of Medicine: http://tinyurl.com/d4scoz
  
  
• Breath of Life: a NLM exhibition examining the history of asthma, personal experiences, and treatments http://bit.ly/OiWT4

Image source: OpenClipArt.org, public domain.

Review of chronic urticaria and autoantibodies to high-affinity receptor for IgE

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Chronic urticaria is a common heterogeneous condition that can be quite debilitating.

80-90% of patients with chronic urticaria have no specific cause for their disease, which is therefore labeled “chronic idiopathic urticaria.”

30-50% of idiopathic cases may be autoimmune or related to mast cell and basophil abnormalities.

An autoantibody to the high-affinity receptor for IgE (FcepsilonRI) binding to the alpha-chain (FcepsilonRIalpha) may be pathogenic of chronic autoimmune urticaria.


Role of IgE and mast cells in allergy. Image source: Wikipedia.

The gold standard for detecting autoantibodies to FcepislonRI is the functional in-vitro donor basophil histamine release assay.

References:
The spectrum of chronic urticaria. Najib, Umer1; Sheikh, Javed. Allergy Asthma Proc. 2009 Jan-Feb;30(1):1-10.
Autoantibodies to the High-affinity IgE Receptor in Chronic Urticaria: How Important Are They? Medscape, 2005.

Anti-FceR1 Autoantibodies in Chronic Urticaria

Allergic shiners assessed via computer-analyzed digital pictures correlate with chronicity and severity of allergic rhinitis

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The study authors developed a novel computerized method to measure allergic shiners and enrolled a cohort of children with or without allergic rhinitis.

A standardized digital photograph was taken during each visit, and a modified Pediatric Rhinoconjunctivitis Quality of Life Questionnaire was completed. Subject global assessment for nose symptoms and subject global assessment for eye symptoms (SGAE) were self-recorded daily.

The study included 126 children with allergic rhinitis and 123 healthy control subjects.

Shiners were darker and larger in children with allergic rhinitis. Darkness and sizes of allergic shiners were paradoxically inversely correlated. Darkness of allergic shiners positively correlated with the duration of allergic rhinitis, and SGAE values but sizes of allergic shiners did not.

Shiners were found to be darker in children with scores of eye symptoms of greater than 6 and SGAE values of greater than 0. Shiners were larger in children with scores of other symptoms of greater than 9 and activity limitations of greater than 4.

The authors concluded that computer-analyzed allergic shiners correlate with the chronicity and severity of allergic rhinitis.

References:
Quantitative assessment of allergic shiners in children with allergic rhinitis. Chien-Han Chen et al. JACI, Volume 123, Issue 3, Pages 665-671.e6 (March 2009)
Image source: Nikon D700 — a 12.1 megapixel full-frame DSLR, Wikipedia, Motorrad-67, the copyright holder of this file allows anyone to use it for any purpose, provided that the copyright holder is properly attributed.

Occupational asthma reviewed in JACI

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The workplace is a significant contributor to the burden of asthma. Although the majority of cases probably represent what is labeled work-exacerbated asthma, in a significant number of subjects, asthma is actually caused by 1 or more agents present in the workplace; this is occupational asthma.

Occupational asthma (OA) may account for 25% or more of de novo adult asthma.

Two types of occupational asthma are distinguished:

1. asthma with a latency period and acting through an apparently immunologic mechanism (high-molecular-weight agents and low-molecular-weight agents)

2. asthma without a latency period.

OA is caused by:

1. sensitizing agents
1-1. high-molecular-weight agent such as a protein from biological sources
1-2. low-molecular-weight reactive chemical such as an isocyanate

2. irritants, for example, the reactive airways dysfunction syndrome

Timely removal from exposure leads to the best prognosis in OA.

Work-related asthma (WRA) has 3 phenotypes:

1. sensitizer-induced occupational asthma (OA) caused by high-molecular-weight (HMW) proteins or low-molecular-weight (LMW) chemicals

2. irritant-induced asthma

3. work-exacerbated asthma

When evaluating patients for occupational asthma, sputum eosinophil counts at 7 and 24 hours after specific inhalation challenge have a greater sensitivity and positive predictive value than exhaled nitric oxide (eNO).

References:
Occupational asthma: Current concepts in pathogenesis, diagnosis, and management. Mark S. Dykewicz. JACI, Volume 123, Issue 3, Pages 519-528 (March 2009)
Agents causing occupational asthma. Jean-Luc Malo et al. JACI, Volume 123, Issue 3, Pages 545-550 (March 2009)

Hairdressers Working in Hair Salons for Women are at increased risk for occupational asthma - prevalence is 9.5% http://goo.gl/fKPDq

Occupational sensitization to soy allergens in workers at a processing facility, high molecular weight allergens Gly m 5 and Gly m 6 may be the respiratory sensitizers http://goo.gl/6oXYd
Workforce occupational asthma in New Zealand. The highest risks: printer/baker/sawmill labourer/metal processing. Ann Occup Hyg. 2010.
Image source: A factory worker in 1940s Fort Worth, Texas. Wikipedia, public domain.

Phadia Announces FDA Clearance of ImmunoCAP Rapid - "first point-of-care test" to assist in the diagnosis of allergy

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From the press release:

"ImmunoCAP® Rapid is the first point-of-care test to assist in the diagnosis of allergy in the physician’s office. Needing only a small sample of whole blood taken from the fingertip, the single-use, disposable device provides a first look at the IgE profile for patients based on the 10 most common inhaled allergens in the US.

With 2 minutes hands-on, the results are available in just 20 minutes, allowing the physician to quickly make evidence-based decisions." Click to view the test procedure (PDF) or click to watch the movie.

Two products are available:

- ImmunoCAP Rapid Wheeze/Rhinitis Child (PDF)

- ImmunoCAP Rapid Asthma/Rhinitis Adult (PDF)

It looks like Phadia is trying to position this device in direct competition with the skin prick test. ImmunoCAP Rapid is not the "first point-of-care test" - the skin prick test is.

ImmunoCAP Immunoassay

The ImmunoCAP method was developed by Phadia. It utilizes a “sandwich” ELISA technique:

1. The ImmunoCAP sponge has allergen bound to it and serves as the first piece of bread ("bottom half").

2. Patient serum is added and specifc IgE to that allergen binds to the allergen on the sponge - this is the "meat" of the ELISA sandwich.

3. All of the unbound protein is washed away abd anti-IgE is added - this binds to the sIgE that was captured by the sponge in step two. The anti-IgE conjugate is the "second piece of bread" ("top half").

Allergen-specific IgE levels are not comparable between different laboratory methods - for example, ImmunoCAP vs. DPC Immulite 2000. Predictive values of specific IgE levels published in the literature for management of food allergies are based on studies using the ImmunoCAP assay. These predictive values cannot be applied to specific IgE levels from other assay systems.

References:
Phadia Announces FDA Clearance of ImmunoCAP Rapid. Yahoo Finance.
Allergy blood testing: A practical guide for clinicians - CCJM review, 2011.
Image source: ImmunoCAP Rapid.

Allergy and Immunology News of the Day

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Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

• Phadia Announces FDA Clearance of ImmunoCAP Rapid - first point-of-care test to assist in the diagnosis of allergy http://is.gd/s9Vi
  
  
• People who smoke both tobacco and marijuana may have a particularly high risk of developing COPD http://bit.ly/2ISqJp
  
  
• CNN: Researchers had women smell men's T-shirts: they were most attracted to the men with the most different MHC from them http://is.gd/sd7h
  
  
• The Claim: Nasal Irrigation Can Ease Allergy Symptoms http://bit.ly/ddNsD - It may actually be true...
  
  
• AAAAI: Obama's unlikely quest for 'hypoallergenic dog' is a common misconception http://bit.ly/bKvrE

Image source: OpenClipArt.org, public domain.

Allergy and Immunology News of the Day

Tweet

Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

• Despite high prevalence of asymptomatic GERD in poorly controlled asthma, PPIs do not improve asthma control. Asymptomatic gastroesophageal reflux is not a likely cause of poorly controlled asthma http://bit.ly/dJf1
  
  
• "Veterinarian has not yet heard of any pets becoming allergic to their owners." http://is.gd/s54w
  
  
• iPhone application Eat Safe may help travelers with food allergies: shows up to 18 products that the patron can’t eat http://bit.ly/I1TVJ
  
  
• TV report on alternative allergy treatments: "Nambudripad's Allergy Elimination Techniques" doesn't sound like a good idea http://bit.ly/2xMGb

Image source: OpenClipArt.org, public domain.

Neuroticism and stressful life events may increase risk of asthma in middle-aged adults

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Stressful life events can trigger asthma exacerbations, but could also contribute to the development of incident asthma. Stress-related personality traits (e.g. neuroticism and extroversion) may increase asthma risk.

A population-based sample of 5114 middle-aged adults completed questionnaires between 1992 and 1995 -- 4010 (83%) were followed-up by questionnaires in 2002-2003.

High neuroticism predisposed to developing asthma (RR = 3.07) but high extroversion did not. Having broken off a life partnership increased asthma risk (RR = 2.24) but death of a close person or unemployment did not.

The authors concluded that high levels of neuroticism may increase the risk of asthma in middle-aged adults. Having broken off a life partnership was the only stressful event, which was associated with incident asthma.

Interpersonal conflicts may increase asthma risk, possibly along an immunological pathway.

References:
Neuroticism, extraversion, stressful life events and asthma: a cohort study of middle-aged adults. Loerbroks A, Apfelbacher CJ, Thayer JF, Debling D, Stürmer T. Allergy. 2009 Feb 25.
Physical or sexual abuse doubles asthma risk
Chewing gum reduces stress and improves memory. Really?
Video: What people do under stress -- chewing a necktie
Chronic stress at work can make you sick
Image source: openclipart.org, public domain.

Occupational Allergy: 7 Workplace Triggers

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From ABC News:

1. Latex
2. Pets
3. Beauty Products
4. Cleaning Supplies
5. Fragrances
6. Mice
7. Mold

References:
Allergies on the Job: 7 Workplace Irritants. ABC.

Allergy and Immunology News of the Day

Tweet

Health News of the Day is a daily summary made from the selected links I post on Twitter. It is in a bullet points format with links to the original sources which include 350 RSS feeds that produce about 2,500 items per day.

• Abdominal obesity is strongly associated with decreased lung function. Abdominal obesity is already linked with diabetes, high blood pressure and heart disease as part of metabolic syndrome. Researchers defined abdominal obesity as a waist circumference of greater than 35 inches for women and 40 inches for men http://is.gd/m8zL
  
  
• The American Board of Allergy and Immunology is on Twitter @a_iboard and Facebook http://is.gd/rP40
  
  
• Food-specific IgG4, or ratio food-specific IgG4/IgE, may predict tolerance development in food allergy http://is.gd/mckX
  
  
• Maternal immune cells "teach" those of the fetus how to balance the need for self-defense and immunologic tolerance http://is.gd/oZYq
  
  
• Video: Horse treated for grass allergy with avoidance and antihistamines http://bit.ly/spSw8
  
  
• Psoriasis drug Raptiva (efalizumab) is withdrawn from the market due to 3 cases of PML http://is.gd/rGgx and http://is.gd/rGgD
  
  
• Efalizumab (Raptiva), mAb against CD11a, was also tried for treatment of severe atopic dermatitis http://is.gd/rGpt
  
  
• PPIs do not improve asthma control in patients with asthma and GERD who do not have heartburn symptoms http://bit.ly/4iHC

Image source: OpenClipArt.org, public domain.

Platelets play important roles in the late phase of the immediate hypersensitivity reaction

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Platelets have a role in most inflammatory reactions including in the immediate hypersensitivity reaction (IHR) in skin.


Megakaryocyte. Platelets, or thrombocytes, are small, irregularly shaped anuclear cells, which are derived from fragmentation of precursor megakaryocytes. Image source: Wikipedia, GNU Free Documentation License.

Sensitized mice developed biphasic responses characterized by early-phase and late-phase reactions (LPRs). The early phase reaction was not suppressed at 1 hour, but platelet depletion significantly reduced the LPR at 24 hours. Systemic administration of antiplatelet compounds also suppressed the LPR significantly.

These results show that platelets play important roles in the LPR of the IHR in skin by forming platelet-leukocyte complexes via P-selectin in blood and secreting several chemokines that attract leukocytes to skin.


P-selectin is a cell adhesion molecule (CAM) found in granules in endothelial cells and activated platelets. Image source: Wikipedia, GNU Free Documentation License.

References:
Platelets play important roles in the late phase of the immediate hypersensitivity reaction. Risa Tamagawa-Mineoka et al. JACI, Volume 123, Issue 3, Pages 581-587.e9 (March 2009)
Will Platelet-Activating Factor (PAF) be the "BNP" of Anaphylaxis?

5 inflammation-sensitive plasma proteins associated with an increased incidence of COPD hospitalizations

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The relationship between plasma markers of inflammation and the incidence of chronic obstructive pulmonary disease (COPD) is still unclear. This population-based study explored whether raised levels of 5 inflammation-sensitive plasma proteins (ISPs) predicted hospital admissions for COPD during 25 years of follow-up.

Spirometric tests and measurements of five ISPs (fibrinogen, ceruloplasmin, 1-antitrypsin, haptoglobin, orosomucoid) were performed in 5247 healthy men from a Swedish city.


Ceruloplasmin (ferroxidase). Image source: Wikipedia, public domain.

Raised plasma ISP levels were associated with an increased incidence of COPD requiring hospitalisation.

Alpha globulins are a group of globular proteins in plasma, which are highly mobile in alkaline or electrically charged solutions:


Schematic representation of a protein electrophoresis gel. Image source: Wikipedia, public domain.

Alpha 1 globulins:
- α1-antitrypsin
- Orosomucoid (acid glycoprotein)

Alpha 2 globulins:
- Haptoglobin
- Ceruloplasmin

References:
Plasma markers of inflammation and incidence of hospitalisations for COPD: results from a population-based cohort study. G Engström1,2, N Segelstorm1, M Ekberg-Aronsson1, P M Nilsson1, F Lindgärde1 and C-G Löfdahl. Thorax 2009;64:211-215, 6 November 2008. doi:10.1136/thx.2008.102079.

Basophil activation test in venom allergy should be performed within 4 hours of taking the blood sample

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The basophil activation test (BAT) is a widely validated and reliable tool especially for the diagnosis of hymenoptera venom allergy.


Basophil granulocyte. Image source: Wikipedia.

Basophil activation test should be performed as early as possible after taking the blood sample, preferably within 4 h.

In contrast to the skin test, BAT can be performed in patients undergoing treatment with antihistamines.

BAT should be performed only at validated laboratories.

Mnemonic:

B
Basophils
Blood circulation
Bigger granules (1.2 µm)
Bilobar nucleus

References:
The basophil activation test in the diagnosis of allergy: technical issues and critical factors. Sturm GJ, Kranzelbinder B, Sturm EM, Heinemann A, Groselj-Strele A, Aberer W. Allergy. 2009 Feb 20.
Mast Cells and Basophils

Control of rhinitis in asthma patients leads to better quality of life

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The goal of asthma therapy is to achieve an optimal level of disease control and health related quality of life (HRQoL).

In an Italian study, 122 asthma patients completed the Asthma Control Test (ACT) and Rhinitis Symptoms score (T5SS).

Asthma control was unsatisfactory in 44% of patients.

Irrespective of their level of control, patients with rhinitis symptoms showed worse HRQoL.

The study authors concluded that asthma control in real life is unsatisfactory. Rhinitis and asthma influence each other in terms of control and HRQoL. The control of rhinitis in asthma patients can lead to an optimization of HRQoL, while this phenomenon is not so evident in asthma.

The ARIA recommends that all asthma patients must be evaluated for rhinitis and vice versa.

References:
Does asthma control correlate with quality of life related to upper and lower airways? A real life study. Braido F, Baiardini I, Balestracci S, Ghiglione V, Stagi E, Ridolo E, Nathan R, Canonica GW. Allergy. 2009 Feb 20.
Image source: Illustration for "Aquiline or Roman Nose", Wikipedia, GNU Free Documentation License.

"Allergist Buyers Guide” by ACAAI simplifies search for products and services

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The ACAAI launches Allergist Buyers Guide - an online product marketplace for allergists and immunologists:

"As our specialty’s first comprehensive listing of allergy-immunology products and services, the Allergist Buyers Guide provides ACAAI members and other industry professionals with a unique online search tool that will give them quick access to a comprehensive directory of industry-specific products and services.

The fully searchable site features listings of companies — including ACAAI Annual Meeting exhibitors — grouped into business segments, such as clinical support services, medical equipment, practice management, and pharmaceuticals. In addition, companies may also include videos, testimonials, and product specifications."

Smoke exposure interacts with gene ADAM33 to increase asthma risk

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ADAM33 is the first identified asthma gene by positional cloning (also known as ADAM metallopeptidase domain 33 or Adamalysin). ADAM stands for "A Disintegrin And Metalloprotease."

ADAM33 gene encodes a member of the ADAM (A Disintegrin And Metalloprotease domain) family - membrane-anchored peptidase proteins structurally related to snake venom disintegrins. ADAMs are classified as Sheddases because they cut off or shed extracellular portions of transmembrane proteins. For example, ADAM 10 can cut off part of the HER2 receptor, activating it. Sheddase inhibitors active on ADAM-10 and -17 can potentiate anti-cancer therapy.

Sheddases are membrane-bound enzymes that cleave extracellular portions of transmembrane proteins, releasing the soluble ectodomains from the cell surface.

ADAM33 is associated with early-life lung function and decline of forced expiratory volume in 1 s (FEV1).

In utero and postnatal cigarette smoke exposure (CSE) leads to:

- reduced lung function
- development of BHR and asthma

The study authors confirmed associations between ADAM33 and the development of asthma (BHR).

SNPs associated with atopic diseases

Filaggrin gene

Filaggrin is essential for epidermal barrier function. SNP associated with eczema and asthma.

17q12-21 gene

ORMDL3 protein defects associated with asthma.

5q22-32 gene

CD14 is a lipopolysaccharide (LPS) receptor. SNPs associated with asthma and atopy.

3p21-22 gene

CCR5 is a chemokine receptor. SNP can be protective against asthma.

Xp22 gene

TLR7 and TLR8 are recognition receptors for viral ssRNA. SNPs assciated with asthma, rhinitis, atopic dermatitis.

5q31 gene

IL-13 is a cytokine that induces IgE secretion, mucus production, and collagen synthesis (fibrosis). SNPs associated with asthma.

ADRB2 gene

ADRB2 gene encodes β2-adrenergic receptor. Argenteum (Arg) or Arg/Arg phenotype associated with decreased albuterol response compared to Gly/Gly phenotype at residue 16.

ADAM33 gene

Type 1 transmembrane protein involved in cell-to-cell interactions. SNPs associated with asthma.

References:
Smoke exposure interacts with ADAM33 polymorphisms in the development of lung function and hyperresponsiveness. Reijmerink NE, Kerkhof M, Koppelman GH, Gerritsen J, de Jongste JC, Smit HA, Brunekreef B, Postma DS. Allergy. 2009 Feb 19.
ADAM33, from PubMed and Wikipedia, the free encyclopedia.
Healthvalue: Sheddases and ADAMs.
Image source: ADAM metallopeptidase domain 33, Wikipedia, public domain.

Mouse allergen levels higher in schools than in homes

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A study investigated allergen exposure in schools compared with homes with a specific focus on children with asthma.

Dust samples were collected from 4 urban elementary schools in the northeastern United States and from 38 student bedrooms. Samples were analyzed for:

- cat (Fel d 1)
- dog (Can f 1)
- cockroach (Bla g 2)
- dust mites (Der f 1/Der p 1)
- mouse urinary protein (MUP).

Cat and dog allergens were detectable in most school samples (96% and 78%, respectively), but at low levels.

Cockroach allergen was detectable in only 11% of school samples.

Mouse allergen was detectable in 89% of school samples. In contrast, MUP was detectable in only 26% of bedroom samples.

The authors concluded that there were:
- higher levels of MUP in school than homes
- lower levels of Der f 1 in schools than homes

It is important to recognize that children with asthma may encounter varying levels of allergens in environments outside the home, such as schools.


Mind map diagram: Indoor allergens.

References:
Mouse allergens in urban elementary schools and homes of children with asthma. Sheehan WJ, Rangsithienchai PA, Muilenberg ML, Rogers CA, Lane JP, Ghaemghami J, Rivard DV, Otsu K, Hoffman EB, Israel E, Gold DR, Phipatanakul W. Ann Allergy Asthma Immunol. 2009 Feb;102(2):125-30.
Indoor Allergen Avoidance. Allergy Cases.
Allergy to rodents in the workplace is an occupational health problem affecting research, pharmaceutical and toxicological sectors. Allergy to rodents: an update. Clin Exp Allergy. 2010 Sep. http://goo.gl/od2p

Cockroaches as a potential explanation for dramatic variations between neighborhoods in asthma rates among NYC children. Reuters, 2011.
Image source: House Mouse, Mus musculus. Wikipedia, George Shuklin, Creative Commons Attribution ShareAlike 1.0 License.

Mold and mother's smoking during infancy are the strongest risk factors for pediatric asthma

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Exposure to mold has been associated with exacerbation of asthma symptoms in children.

In this study from Ohio, the risk of asthma at the age of 3 years was defined by an Asthma Predictive Index (API). Visible mold was evaluated by means of home inspection.

(1-3)-beta-D-glucan is one of the major structural components of fungi, the levels were measured in settled dust.


Various fungi including Penicillium and Aspergillus spp. growing in axenic culture. Image source: Wikipedia, Dr. David Midgley Cultures: Dr. David Midgley University of Sydney, Australia, Creative Commons Attribution ShareAlike 2.5 License.

Children aged 3 years with high visible mold in the home during infancy were 7 times more likely to have a positive API.

Mother's smoking was the strongest significant risk factor for the future development of asthma.

The authors concluded that the presence of visible mold and mother's smoking during infancy were the strongest risk factors for a positive API at the age of 3 years.

Regarding the mold/asthma link, certain findings have been found consistently: 1. the mold has to be visible, 2. the mold has to be in the room where they live, 3. the patient does not have to be allergic to mold to have symptoms because the some molds release irritant volatile compounds in the air.

Asthma Predictive Index (API) (modified)

Children under 3 years of age who had 4 or more episodes of wheezing in the past year that lasted more than 1 day and affected sleep are significantly likely to have persistent asthma after the age of 5 years if they also have either:

1. one of the following:
- parental history of asthma
- a physician diagnosis of atopic dermatitis
- evidence of sensitization to aeroallergens

OR

2. two of the following:
- evidence of sensitization to foods
- greater than 4% peripheral blood eosinophilia
- wheezing apart from colds


Modified Asthma Predictive Index (API) (click to enlarge the image).

References:

Mold exposure during infancy as a predictor of potential asthma development. Iossifova YY, Reponen T, Ryan PH, Levin L, Bernstein DI, Lockey JE, Hershey GK, Villareal M, LeMasters G. Ann Allergy Asthma Immunol. 2009 Feb;102(2):131-7.

The Asthma Predictive Index: A very useful tool for predicting asthma in young children. Jose A. Castro-Rodriguez. JACI, 2010.
In Scotland, passage of smoke-free legislation was associated with 18% decrease in asthma hospitalizations per year http://goo.gl/6LdK

The Asthma Predictive Index: Not a useful tool in clinical practice. J Allergy Clin Immunol. 2010.

Smoke-free laws reduce asthmatic symptoms http://goo.gl/K1U5h

Exposure to visible mold and/or dampness during first 2 years of life associated with asthma risk - but odds ration (OR) was very close to 1.0. Allergy, 2011.

IL-12, IL-18 and TNF increased in both acute and chronic hypersensitivity pneumonitis

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IL-12, IL-18 and TNF increased in both acute and chronic hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is characterized by a granulomatous inflammation and may show various forms of clinical presentation:
- acute
- subacute
- chronic forms

The TH1-associated cytokines interleukin (IL) 12 and IL-18 and tumor necrosis factor alpha (TNF-alpha) may be involved in the pathogenesis of both the acute and chronic forms of HP.

In a German study, patients underwent BAL 0 to 6 days after the last antigen exposure.

The production of IL-12, IL-18, and TNF-alpha by AMs was increased in patients with both acute and chronic forms. The levels showed no difference between patients with acute and chronic HP.

The authors concluded that an increased release of IL-12, IL-18, and TNF-alpha by AMs is associated with both the acute and chronic forms of HP.


Mind map of HP


Causes of HP

References:
Interleukin 12, interleukin 18, and tumor necrosis factor alpha release by alveolar macrophages: acute and chronic hypersensitivity pneumonitis. Ye Q, Nakamura S, Sarria R, Costabel U, Guzman J. Ann Allergy Asthma Immunol. 2009 Feb;102(2):149-54.
Hypersensitivity pneumonitis (HP). Allergy Cases.

CNN video: "My son's struggle against deadly food allergies"

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CNN: "My son's struggle against deadly food allergies"

Air pollution near the home increases asthma severity in children

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Hospital encounters for asthma (admissions or ED visits) have been associated with air pollution.

In a review of hospital records for 2,768 children in California, the investigators found that locally generated air pollution near the home affects asthma severity in children. Risk may begin during infancy and continue in later childhood, when asthma diagnoses are clearer.

References:

Repeated hospital encounters for asthma in children and exposure to traffic-related air pollution near the home. Delfino RJ, Chang J, Wu J, Ren C, Tjoa T, Nickerson B, Cooper D, Gillen DL. Ann Allergy Asthma Immunol. 2009 Feb;102(2):138-44.
Traffic exposure associated with decreased lung function in asthma

How does diesel exhaust impact asthma? Thorax, 2010.

Air Pollution as an Emerging Global Risk Factor for Stroke - 2.5% of all deaths, 8th leading risk factor for mortality http://goo.gl/KnezA
Air levels of SO(2) and NO(2) were associated with increased risk of ER visits due to asthma and COPD http://1.usa.gov/171oIN
Is air pollution of the 20th century a cause of current asthma hospitalizations? Thorax, 2011.
Airways changes related to air pollution exposure in wheezing children: pollution decreases FEV1. ERJ, 2012.
Image source: Interstate 80, seen here in Berkeley, California, is a freeway with many lanes and heavy traffic, Wikipedia, GNU Free Documentation License.

Combination of aspirin and montelukast (Singulair) decreases hypersensitivity reactions during rapid desensitization

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Rapid desensitization is a process in which drug-allergic patients receive their target dose in incremental steps, resulting in a state of temporary tolerance. Consequently, first-line therapy (most commonly antibiotics) can be delivered safely, even in patients who present with severe hypersensitivity reactions (HSRs) to the given agent.

A small subset of patients has persistent HSRs during rapid desensitization that can be refractory to antihistamines and corticosteroids.

A study included 14 patients with HSRs to platinum chemotherapy that persisted during rapid desensitization. The patients were then pretreated with:

- acetylsalicylic acid (asprin) 325 mg orally
- montelukast, 10 mg orally, 2 days before and on the day of desensitization

78 desensitizations in 14 patients were performed. Using acetylsalicylic acid and montelukast, 86% of patients (12/14) experienced substantial improvement in symptoms (grade 0.5 vs grade 2.14). All patients received their target dose of chemotherapy, and there were no severe systemic HSRs.

The authors concluded that pre-treatment with asprin and montelukast lessens the severity of HSRs during rapid desensitization.

Aspirin Desensitization

Aspirin desensitization should only be done in a monitored environment (hospital) in a patient with FEV1 of at least 70% of predicted.

Example protocol: starting dose is 40.5 mg. The dose is doubled over an interval of 1.5 to three hours until the desired daily dose is met. The patient must take the daily dose indefinitely.

Leukotriene antagonist (LTRA, Singulair) should be initiated prior to the procedure.

Aspirin desensitization can have beneficial effects in patients with aspirin-induced asthma, sinusitis, and can decrease the risk of recurrence of nasal polyps in this population. The desensitized state only lasts as long as daily administration is continued. If a dose is missed, the refractory period may last 48-72 hours.

References:
Acetylsalicylic acid and montelukast block mast cell mediator-related symptoms during rapid desensitization. Breslow RG, Caiado J, Castells MC. Ann Allergy Asthma Immunol. 2009 Feb;102(2):155-60.

Urinary leukotriene E(4)/exhaled nitric oxide ratio predicts montelukast response in childhood asthma http://goo.gl/i5cG
Image source: Coated 325 mg aspirin tablets, Wikipedia, GNU Free Documentation License, Version 1.2.