Breathmobile’s asthma specialists will see your child - LA Times

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From the LA Times:

When Ethan, 11, first got to the local Breathmobile, a free, rolling asthma and allergy diagnosis and treatment clinic, his lung capacity measured at only about 30%. But once there, he was prescribed a new drug and, at a visit last week (his fourth), Ethan was at 93% capacity and doing fine, according to his Breathmobile doctor.

"It's a pretty straightforward program," says Dr. Maria Garcia-Lloret, assistant professor of pediatric allergy and immunology at UCLA's Mattel Children's Hospital, which operates the Long Beach-area Breathmobile. "Parents bring their kids, and we figure out how to best treat them so that they improve and stay stable."

However, in a 2011 study, the Breathmobile program did not result in any significant improvements in asthma management.

References:

Your Money / Your Health: Breathmobile’s asthma specialists will see your child - latimes.com.
The Breathmobile program: a good investment for underserved children with asthma. http://goo.gl/NfQM

"Allergic to peanuts" - Flickr photo

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"Allergic to peanuts" - Flickr photo, lancefisher.

Journal of Allergy and Clinical Immunology is on Twitter @jacionline

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The Journal of Allergy and Clinical Immunology (JACI) is on Twitter @jacionline:

http://twitter.com/jacionline

The JACI’s Twitter feed will updated update you each day on free content and JACI-related news. The journal launched two new blogs recently.

"An epidemic of Chinese sofa and chair dermatitis"

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A chemical added into furniture shipments from China to prevent the growth of mold has been linked to severe rashes.

The chemical, dimethyl fumarate (DMF), can penetrate the fabric and subsequently clothing when a person sits on the furniture and cause contact dermatitis. Dimethyl fumarate is the methyl ester of fumaric acid.

The first five cases were reported in Europe in 2008. Since then, there have been more than 1,000 cases.

References:
Chemical in Furniture Linked to Skin Rashes. WebMD.

Image source: Dimethyl fumarate. Wikipedia,public domain.

Best deal for "sinus rinse"? NeilMed twin pack for $15.99 at Costco

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The best deal for "sinus rinse" is probably NeilMed twin pack for $15.99 at Costco. It has 2 rinse bottles and 250 premixed packets. Amazon has same product for $26.89.

See how you can make you own saline sinus rinse recipe from AAAAI.

The technique of nasal irrigation has been around for centuries and is part of yoga practices but has not been commercialized until recently.

Does nasal rinsing help against allergies? Yes, if your patient is willing to use it. Many patients dislike the method. http://bit.ly/34PyYD

Sinus rinse - Costco.

Related reading:

Video: How to do nasal irrigation

Nasal Irrigation with Saline Solution May be Better Than Saline Sprays for Chronic Rhinitis
SinuSurf (nasal saline rinse with surfactant) associated with loss of smell "for months to years". Discontinue use (PDF) http://goo.gl/awQUP
Costco Still Rocks for Allergy meds - generic alternatives to brand name OTC medications at very reasonable prices
Neti Pot, Nasal Irrigation - Pros and Cons and Slideshow. WebMD, 2011.

Study: Formoterol is safe in most patients with asthma

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Concerns exist that regular long-acting beta(2)-adrenergic agonist (LABA) therapy may increase the risk of serious asthma-related events.

Data were from 13,542 formoterol-randomized and 9968 non-LABA patients 4 years or older (42 trials), of whom 93% and 89%, respectively, received inhaled corticosteroid.

Incidence of all-cause death was low (n=3 and n=4, respectively), with numerically lower all-cause deaths/1000 patient-treatment years in the formoterol-treated group (0.53) versus the non-LABA group (0.82).

Asthma-related hospitalizations/1000 patient-treatment years were lower numerically in the formoterol-treated group (12.1) versus the non-LABA group (16.4).

This meta-analysis showed no evidence of increased risk of asthma-related hospitalization or no asthma-related deaths. A a low incidence of all-cause death and asthma-related intubation were seen with formoterol-containing versus non-LABA treatment.

References:

Safety of formoterol in patients with asthma: combined analysis of data from double-blind, randomized controlled trials. Nelson H, Bonuccelli C, Radner F, Ottosson A, Carroll KJ, Andersson TL, LaForce C. J Allergy Clin Immunol. 2010 Feb;125(2):390-396.e8.

http://www.ncbi.nlm.nih.gov/pubmed/20159250

Asthma drug formoterol (part of ICS/LABA combo Symbicort and Dulera) causes weight loss when taken orally http://goo.gl/nYsLA

Mometasone/formoterol 100/10 mcg b.i.d. showed greater clinical efficacy than its individual components in asthma. ERJ, 2012.

Image source: Combination formulation containing budesonide and formoterol - unopened Symbicort Turbuhaler (left) and opened (middle and right), Wikipedia, public domain.

Scary: "Spring takes my breath away" on Flickr

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Scary: "Spring takes my breath away" on Flickr by lamazone.

"I'm allergic to lots of things: cats, smoke, grass, hay, horses, red wine and many other triggers. It sets off a chain of allergic reactions: coughing, wheezing, itchiness,...

Spring takes my breath away."

It must not be this way. Please see an allergist today to get immediate relief and long-term control: Locate an Allergist - ACAAI

All sizes of this photo are available for download under a Creative Commons license.

Unintentional injections from epinephrine auto-injectors increased from 1994 to 2007

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The number of reported unintentional injections from epinephrine auto-injectors increased from 1994 to 2007.

Those unintentionally injected had a median age of 14 years, 55% were female, and 85% were injected in a home or other residence.

Management was documented in only 27% of cases, of whom 53% were observed without intervention, 29% were treated, 13% were neither held for observation nor treated, and 4% refused treatment.

To prevent these unintentional injections, improved epinephrine auto-injector design is needed, along with increased vigilance in training the trainers and in training and coaching the users, as well as efforts to increase public awareness of the role of epinephrine auto-injectors in the first-aid treatment of anaphylaxis in the community.

Accidental Injection of Epinephrine Into Finger (click to enlarge the image).

References:

Voluntarily reported unintentional injections from epinephrine auto-injectors. Simons FE, Edwards ES, Read EJ Jr, Clark S, Liebelt EL. J Allergy Clin Immunol. 2010 Feb;125(2):419-423.e4.
http://www.ncbi.nlm.nih.gov/pubmed/20159254

Most Accidental Injections of Epinephrine (EpiPen) Into Finger Do Not Require Treatment

Gas stoves may give off more harmful fumes than electric stoves when cooking meat

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The researches measured the amount of polycyclic aromatic hydrocarbons (PAHs), ultrafine particles, and other potentially harmful substances in the breathing zones of the cooks.

Higher levels of PAHs, considered possible cancer-causing substances, were detected when the frying was done on a gas stove.

Exposure to ultrafine particles from the air can cause worsening allergies and lung inflammation. Exposure to cooking fumes should be reduced as much as possible.

References:

Frying Meat on Gas Stoves Poses Greater Risk. WebMD.
Image source: Amazon, used for illustrative purposes only - NOT a suggestion to purchase any product or medication.

Replacing the terms asthma and COPD with "A to E" of airway disease?

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The terms asthma and chronic obstructive pulmonary disease (COPD) have evolved from their original very specific physiology-based definition to describe additional disease entities such as symptoms, airway inflammation and airway structure.

The authors of this review propose that these disease labels should be replaced with a new alphabetical assessment tool for characterizing airway disease, which provides a checklist of 5 relatively independent factors responsible for morbidity in patients with airway disease - ABCDE:

- Airway hyperresponsiveness
- Bronchitis
- Cough reflex hypersensitivity
- Damage to the airway and surrounding lung
- Extrapulmonary factors

Lower Airway Changes in Asthma and COPD

Cellular infiltrate: CD4 in asthma vs. CD8 in COPD.

Differential diagnosis of cough, a simple mnemonic is GREAT BAD CAT TOM. Click here to enlarge the image: (GERD (reflux), Laryngopharyngeal Reflux (LPR), Rhinitis (both allergic and non-allergic) with post-nasal drip (upper airway cough syndrome), Embolism, e.g. PE in adults, Asthma, TB (tuberculosis), Bronchitis, pneumonia, pertussis, Aspiration, e.g foreign body in children, Drugs, e.g. ACE inhibitor, CF in children, Cardiogenic, e.g. mitral stenosis in adults, Achalasia in adults, Thyroid enlargement, e.g. goiter, "Thoughts" (psychogenic), Other causes, Malignancy, e.g. lung cancer in adults).

References:

The A to E of airway disease. Clin Exp Allergy. 2010 Jan;40(1):62-67. Authors: Pavord ID, Wardlaw AJ. http://www.ncbi.nlm.nih.gov/pubmed/20205696

Action plan is a key component of self-management programs in patients with COPD. Thorax, 20111.

Image source: Enlarged view of lung tissue showing the difference between healthy lung and COPD, Wikipedia, public domain.

IL-22 is a possible target for control of autoimmune diseases

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IL-22 is a member of the IL-10 cytokine family and signals through a heterodimeric receptor composed of the common IL-10R2 subunit and the IL-22R subunit. IL-10 and IL-22 both activate the STAT3 signaling pathway (STAT is Signal Transducers and Activator of Transcription).

The IL-10 family includes IL-10, IL-19, IL-20, IL-22, IL-24, and IL-26.

The IL-22 pathway has emerged as a possible target for control of inflammation in certain autoimmune diseases. The findings of this study suggest that few if any infectious complications would be expected with the suppression of IL-22 signaling.

Key elements of the JAK-STAT pathway. Peter Znamenkiy, Wikipedia, public domain.

References:
Redundant and Pathogenic Roles for IL-22 in Mycobacterial, Protozoan, and Helminth Infections. Wilson MS, Feng CG, Barber DL, Yarovinsky F, Cheever AW, Sher A, Grigg M, Collins M, Fouser L, Wynn TA. J Immunol. 2010 Mar 10.
http://www.ncbi.nlm.nih.gov/pubmed/20220096

Image sources: Wikipedia, public domain.

Richmond, VA and Other Southern Cities Make the Top of ‘Worst Asthma Cities’ List

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According to a ranking by the Asthma and Allergy Foundation of America (AAFA), the poor ranking for cities in the South is due in large part to slow adoption of “100% smoke-free” laws. The worst five cities in 2010 for people with asthma are:

Richmond, Va.
St. Louis, Mo.
Chattanooga, Tenn.
Knoxville, Tenn.
Milwaukee, Wis.

There are higher pollen counts in the South. Also, smog in many cities on the list is a problem for people with asthma.


View Larger Map

References:
Worst Cities for People With Asthma. WebMD.

Walmart's suggestion for allergy treatments during spring pollen season

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The Walmart's suggestion for over-the-counter (OTC) allergy treatments during this spring pollen season is based on the advertising brochure shown above and includes:

- Ventolin HFA ReliOn (albuterol) is the least expensive SABA on the market but it contains only 60 doses as compared to 200 for the standard and more expensive MDIs. In any case, if you find that you are using your inhaler too often and you run through one of those quickly, you must call your allergist right away.

- Benadryl (diphenhydramine) - I would not recommend using this product especially since we now have at least two nonsedating antihistamines available over the counter (see below).

- Claritin (loratidine) is a solid choice for nonsedating antihistamine, however, a store brand loratidine is less expensive and is typically offered by Walmart and Costco under their Equate and Kirkland line of products, respectively.

- Zyrtec (cetirizine) is another OTC nonsedating antihistamine and some people find it more effective than Claritin (loratidine). However, around 5-10% of patients may report some drowsiness with cetirizine - a side effect not typically observed with loratidine. Similarly to loratidine, Walmart and Costco usually have lower prices for this medication under their store brands (Equate and Kirkland, respectively).

Allegra (fexofenadine) is nonsedating at any dose but is not available over the counter. Loratidine and cetirizine are nonsedating at therapeutic doses but some side effects start to appear as the dose is increased (cetirizine has this side effect in therapeutic doses in 5-10% of people). Cetirizine is is a major metabolite of an old and very sedating antihistamine called hydroxyzine. Xyzal is levocetirizine, the active enantiomer of cetirizine, and has the same side effect profile. Comparison of the sedating effects of levocetirizine and cetirizine: no difference (http://goo.gl/lGu3Q). Both Allegra and Xyzal require prescriptions.

Related reading:

Allergy drug recommendations for patients on a budget. KevinMD, 2010.

Interactive Allergy Map by Greer Labs. Click your state to find region-specific, common airborne allergens there.

Costco Still Rocks for Allergy meds - generic alternatives to brand name OTC medications at very reasonable prices

Allergy Education: Teaching ideas based on New York Times content

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From the NYTimes:

Lesson Materials: Computers with Internet access, materials for props and costumes, research materials on allergies, the immune system and related topics.

Activity: Divide the class into five groups. Explain that the class will be creating a short play about allergies, with each group creating and performing one act of the play.

Act 1: Introducing Allergies
Act 2: The Healthy Immune System
Act 3: The Immune System: Overreaction to Allergens
Act 4: Help for Allergies
Act 5: Allergy Relief

References:
Allergies Acting Up? Dramatizing the Body’s Responses to Allergens

Inhaled steroids decrease inflammation in COPD but adding LABAs may not enhance these effects

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Inhaled corticosteroids (ICSs) and long-acting β2-agonists (LABAs) are used to treat moderate to severe chronic obstructive pulmonary disease (COPD).

This randomized trial, published in the Annals of Internal Medicine, investigated whether long-term ICS therapy, with and without LABAs, reduces inflammation and improves pulmonary function in COPD.

The stuyd included 114 steroid-naive current or former smokers with moderate to severe COPD.

101 patients were greater than 70% adherent to therapy. Fluticasone therapy decreased counts of mucosal CD3+ cells, CD4+ cells, CD8+ cells and mast cells and reduced hyperresponsiveness, with effects maintained after 30 months.

Reductions in inflammatory cells correlated with clinical improvements in FEV1 decline, dyspnea, and quality of life.

Discontinuing fluticasone therapy at 6 months increased counts of CD3+ cells, mast cells, and plasma cells and worsened clinical outcome. Adding salmeterol improved FEV1 level.

The authors concluded that ICS therapy decreases inflammation and can attenuate decline in lung function in steroid-naive patients with moderate to severe COPD. Adding LABAs does not enhance these effects.

References:

Effect of Fluticasone With and Without Salmeterol on Pulmonary Outcomes in Chronic Obstructive Pulmonary Disease. Ann of Int Med, October 20, 2009, vol. 151 no. 8 517-527.
http://www.annals.org/content/151/8/517.abstract

Frequent exacerbations in COPD: What to do? BMJ 10-minute consultation, 2011.

Image sources: Wikipedia, public domain, Advair Diskus.

Mind Maps: Exploring Google Suggest for Allergy

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What Do You Suggest? is a site that lets you visually explore how Google Suggest autocompletes a query.

See an example for asthma:

http://whatdoyousuggest.net/#asthma,guidelines

References:

Exploring Google Suggest. Google Operating System.

Allergen of the Year: Neomycin

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From Twitter:

@sandnsurf: Neomycin named allergen of the year http://bit.ly/d508Le via @mdconsult

@Paulflevy: never knew there was a competition for this (allergen of the year)! Is there a prize? :)

@rlbates: Not that I know of, but maybe we could come up with something like the Razzie awards. First thought -- the Rashie

@sandnsurf: brilliant, love it. The Rashie it is! We should have a Rashies ceremony at the end of 2010 and have @DrVes preside

@Paulflevy: Maybe the first prize is a year-long subscription to Benadryl!

Good thoughts! A few clarifications are in order. The American Contact Dermatitis Society started selecting "allergen of the year" more than 10 years ago to heighten the awareness that common everyday products can be the cause of contact dermatitis. This is a type IV, cell-mediated, delayed reaction, therefore antihistamines such as over-the-counter Benadryl will not help.

The American Contact Dermatitis Society has named the aminoglycoside antibiotic neomycin as Allergen of the Year for 2010.

From MDConsult:

Because neomycin is sold over the counter, physicians need to remember to ask patients with dermatitis about all products they use, not just prescription medicines. Many patients don’t think to tell you they are using an OTC antibiotic.

Heightened clinical suspicion also is warranted because of delayed reactions. Dermatitis from neomycin often develops 7 days or more after exposure. Most physicians who apply patch test take readings at 48 hours and 96 hours, but a reaction from neomycin may not even appear by 96 hours.

Informing and educating patients about the many vaccines that contain neomycin as a preservative is a third implication for physicians.

A neomycin reaction is not a type 1 IgE-mediated allergy - it’s a type IV reaction that produces eczema.

Also keep cross-reactivity in mind. Neomycin is a member of the aminoglycoside family, which also includes gentamicin, kanamycin, and tobramycin. “It always amazes me that I will see patients who know they are allergic to neomycin, and they will come in to see me because they have very severe ear dermatitis, and they are using tobramycin as an ear drop."

Gold was the 2001 Allergen of the Year, and reactions to gold are common and clinically problematic. Bacitracin (2003) and glucocorticosteroids (2005) are other allergens that are both common and clinically relevant. In contrast, thimerosal (2002) is a common but nonrelevant allergen because it was removed from most products in the United States.

References:
Neomycin named allergen of the year. MDConsult.
How to Diagnose Contact Dermatitis?

Post-Traumatic Basal Cell Carcinoma Associated With Patch Testing - with strongly positive reaction to gold. Actas Dermo-Sifiliográficas (English Edition), 2009.

Image source: Amazon.com, used for illustrative purposes only - NOT a suggestion to purchase any medications.

FDA Announces Removal of Several Asthma Drugs Due to CFC-propeller

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The FDA announced the staged removal of some familiar MDI aerosol asthma/COPD products propelled by chlorofluorocarbons (CFCs) (shown in the figure below).



The affected products, manufacturers and their phase out schedule include:

- Tilade Inhaler (nedocromil; King Pharmaceuticals) -- June 14, 2010
- Alupent Inhalation Aerosol (metaproterenol; Boehringer Ingelheim Pharmaceuticals) -- June 14, 2010
- Azmacort Inhalation Aerosol (triamcinolone; Abbott Laboratories) -- Dec. 31, 2010
- Intal Inhaler (cromolyn; King Pharmaceuticals) -- Dec. 31, 2010
- Aerobid Inhaler System (flunisolide; Forest Laboratories) – June 30, 2011
- Combivent Inhalation Aerosol (albuterol and ipratropium in combination; Boehringer Ingelheim Pharmaceuticals) – Dec. 31, 2013
- Maxair Autohaler (pirbuterol; Graceway Pharmaceuticals) – Dec. 31, 2013

After those dates, these medications will not be sold or distributed in the United States.

Combivent is especially popular with COPD patietns and they may experience additional costs from co-pays on individual inhalers as opposed to the combination. Maxair is breath activated inhaler and the patients who curently use it will need to learn how to use the "standard" push-to-activate MDIs.

As you can see from the chart above, both Combivent and Maxiair Autohaler will be available until the end of year 2013.

Albuterol CFC-MDI was discontinued in December 2008. Epinephrine CFC-propelled inhaler, currently available over-the-counter (not recommended), will be phased out by December 2011.

References:
Asthma and COPD Inhalers That Contain Ozone-depleting CFCs to be Phased Out; Alternative Treatments Available. FDA.

ACAAI

Related reading:

FDA Announces End for CFC-Propelled Inhalers. Dr. Mintz' Blog.

Updated: 04/18/2010

Most Accidental Injections of Epinephrine (EpiPen) Into Finger Do Not Require Treatment

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According to a study of 127 injections, ischemia in the EpiPen-injected finger is rare, and when it does occur, it can be managed with vasodilators.


Accidental Injection of Epinephrine Into Finger (click to enlarge the image).

No patient had any significant local or systemic side effects, and symptoms resolved completely in all cases. 3.1% of patients were reported as having an ischemic finger and all were treated with vasodilator therapy and sent home.

In the absence of signs of poor perfusion (pain, pallor, paresthesias, prolonged capillary refill, and cool temperature), patients with an accidental autoinjector stick require no treatment and can be discharged home. If digital ischemia is present, dilute phentolamine in lidocaine should be injected subcutaneously into the site until the area turns pink.

References:
Medscape, 2010, http://www.medscape.com/viewarticle/720014

Annals of Emergency Medicine, March 29, 2010.

What are the ‘ideal’ features of an adrenaline (epinephrine) auto-injector in the treatment of anaphylaxis? http://goo.gl/lxCh

Figure: Design overview of currently available auto-injectors for emergency self-administration of adrenaline in the treatment of anaphylaxis.

Image source: Don Park and Mat Honan.

Majority of children considered peanut-sensitized by standard tests may not actually have peanut allergy

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Not all peanut-sensitized children develop allergic reactions on exposure.

The study authors ascertained peanut sensitization by skin tests and IgE measurement at age 8 years. Among sensitized children, the diagnosis of peanut allergy versus tolerance was determined by oral food challenges.

They used open challenge among children consuming peanuts (n = 45); others underwent double-blind placebo-controlled challenge (n = 34).

Of 933 children, 11.8% were peanut-sensitized. 19 children were not challenged (17 did not consent).

12 children with a convincing history of reactions on exposure, IgE greater than 15 kUa/L and/or skin test greater than 8mm were considered allergic without challenge.

Of the remaining 79 children who underwent challenge, 7 had more than 2 objective signs and were designated as having peanut allergy.

The prevalence of clinical peanut allergy among sensitized subjects was 22.4%.

Component-resolved diagnostics using microarray detected differences in component recognition between children with peanut allergy and peanut-tolerant children. The peanut component Ara h 2 was the most important predictor of clinical allergy.

The study authors concluded that the majority of children considered peanut-sensitized on the basis of standard tests do not have peanut allergy. Component-resolved diagnostics may facilitate the diagnosis of peanut allergy.

Eight top allergens account for 90 % of all food allergies. They can be remembered by the mnemonic TEMPS WFS:

Tree nuts (almonds, cashews, walnuts)

Egg white (not egg yolk)

Milk

Peanuts

Shellfish (crab, lobster, shrimp)

Wheat

Fish (bass, cod, flounder)

Soy

Molecular Allergy Component Testing, a video by the manufacturer of ImmunoCAP testing system.

References:
Allergy or tolerance in children sensitized to peanut: Prevalence and differentiation using component-resolved diagnostics. Nicolaou N, Poorafshar M, Murray C, Simpson A, Winell H, Kerry G, Härlin A, Woodcock A, Ahlstedt S, Custovic A. J Allergy Clin Immunol. 2010 Jan;125(1):191-197.e13.
http://www.ncbi.nlm.nih.gov/pubmed/20109746?dopt=Abstract

Parents upset children use extensive cleaning measures to ensure they don’t sicken a classmate with peanut allergy http://goo.gl/mK2Qb
Peanut Allergy: An Evolving Clinical Challenge (review), 2011.

Food Allergy: A Short Review

Food Allergen Avoidance

Food Challenges

Mind Maps: Food Allergy

Mnemonics: Food Allergy

Blog articles from AllergyNotes

Image source: Roasted peanuts as snack food, Wikipedia, public domain.

First-generation H1-antihistamines should no longer be available over-the-counter for self-medication

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From the GA2LEN position paper:

First-generation H1-antihistamines obtained without prescription are the most frequent form of self-medication for allergic diseases, coughs and colds and insomnia even though they have potentially dangerous unwanted effects which are not recognized by the general public.

A GA2LEN (Global Allergy and Asthma European Network) task force assessed the unwanted side-effects and potential dangers of first-generation H1-antihistamines.

First-generation H1-antihistamines, all of which are sedating, are generally regarded as safe by laypersons and healthcare professionals because of their long-standing use. However, they reduce rapid eye movement (REM)-sleep, impair learning and reduce work efficiency.

They are implicated in:

- civil aviation, motor vehicle and boating accidents
- deaths as a result of accidental or intentional overdosing in infants and young children and suicide in teenagers and adults
- cardiotoxicity in overdose

Older first-generation H1-antihistamines should no longer be available over-the-counter as prescription- free drugs for self-medication of allergic and other diseases now that newer second- generation nonsedating H1-antihistamines with superior risk/benefit ratios are widely available at competitive prices.

References:
Church MK, Maurer M, Simons FER, Bindslev-Jensen C, van Cauwenberge P, Bousquet J, Holgate ST, Zuberbier T. Risk of first-generation H1-antihistamines: a GA2LEN position paper. Allergy 2010; DOI: 10.1111/j.1398-9995.2009.02325.x.
http://www3.interscience.wiley.com/journal/123276003/abstract

Patient response to different antihistamines will vary http://goo.gl/Q2PiV

Related:

Trying to Diagnose Chronic Urticaria - Medical Student-Style

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Why do you need to check CMP (complete metabolic panel) in chronic urticaria? Please read this excerpt from the blog post below:

"On our third year clinical rotations, she developed hives. It was strange. We immediately assumed the role of medical student detective, trying to determine the source. She tried the non-latex gloves in the OR, to no avail. I remember one weekend, we decided to put all of the plants in her apartment on her back porch, to see if they were the culprit. We regarded her fish Kumar, named after the author of our second year pathology text, suspiciously - even though he was an unlikely candidate for her troubles.

The hives worsened, and became a chronic problem. She visited an allergy-immunology expert, and was loaded up on a triple-drug regimen, in order to try to gain relief on a Christmas visit with her parents to visit her brother in Italy. One night, shortly after returning from Christmas vacation, she called me frantically from the grocery store.

"I am standing in the aisles, looking at the signs for aisle content, and I can't read them. They're blurry. I've always been able to read the signs. What can this mean? I'm scared."

She went to an ophthalmologist, the next week. The ophthalmologist listened to her history, gave her an eye exam, and told her - let's look at your sugar. I am worried. It was sky high. She was diagnosed, in her early twenties, with Type 1 diabetes, about six months after her hives presented. As soon as her diabetes was treated, her hives disappeared."

Diagram (mind map) of acute urticaria (click to enlarge the images).


Diagram (mind map) of chronic urticaria (click to enlarge the images).

References:
Trying to Diagnose Disease - Med Student Style. Mothers in Medicine, 2010.

Urticaria: A Short Review
Mind Maps: Urticaria
Mnemonics: Urticaria
Chronic Idiopathic Urticaria (Hives)

Anti-FceR1 Autoantibodies in Chronic Urticaria

Image source: Urticaria, Wikipedia, public domain.

Video: Getting allergies late in life

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Allergies at your age? Allergies may develop as you get older. News 2's Larry Collins talks to Dr. Brian Dantzler about allergies and age.

Can Allergen Immunotherapy "Cure" Asthma?

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Allergen immunotherapy targets Th2 cells activated by specific allergens.

Immunotherapy results in systemic immunological changes to allergens:

- attenuates T-cell-mediated airway inflammation by down-modulating Th2 and inducing Th1 differentiation

- induces regulatory T cells, which produce IL-10

Immunotherapy improves clinical symptoms and non-specific airway hyperresponsiveness in asthma, and decreases drug requirements.

Current pharmacotherapy, including inhalational corticosteroids, provides powerful symptomatic benefits in asthma. However, pharmacotherapy cannot cure or modify the natural course of asthma.

As immunotherapy targets the background immunological state in asthma, it is expected to lead to long-term amelioration or even cure.

References:
Allergen Immunotherapy in Asthma: Current Status and Future Perspectives. Nagata M, Nakagome K. Allergol Int. 2010 Feb 25;59(1). [Epub ahead of print]

Cold Urticaria in the New York Times

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From the NYTimes:

“I think I’m going to faint,” the tall, 35-year-old man said, grabbing the handrail of the stairs that led up from the beach. His brother turned back to see his older sibling collapse onto the sandy wooden planking.

In the ER, the patient said he was fine until he went swimming that day. But after being in the water for a while, he began to feel lightheaded, and the skin on his hands and feet felt tight, as if it had shrunk in the wash.

The patient’s wife was really worried. An allergy induced by the cold? She sat down at the computer and looked up “allergy induced by the cold.” Up came something she had never heard of: cold-induced urticaria — an allergy to cold itself.

Paradoxically, it is the warmer months that carry the greatest threat; that’s when the sparkling waters of the ocean or neighborhood pool beckon or an unseasonably cool evening can catch you unaware and unprepared. It’s not unusual that his worst symptoms came while swimming, when his entire body was exposed to the cold, the doctor said."


Diagram (mind map) of acute urticaria (click to enlarge the images).


Diagram (mind map) of chronic urticaria (click to enlarge the images).

Physical urticarias

Physical urticaria is defined as hives provoked by physical stimulus such as:

CDC S

Cold urticaria due to cooling the skin
Dermographism due to stroking the skin
Cholinergic urticaria due to exercise, emotion, or heat
Solar urticaria due to sun exposure

Physical urticaria can be confirmed by challenge testing, and is best treated symptomatically by avoidance of provocative stimuli and antihistamines.

Physical urticaria does not respond to steroids since they do not inhibit mast cell degranulation.

Testing procedures for diagnosis of physical urticarias depend on the cause (stimulus):

- Dermographism: Stroking with narrow object, e.g. a tongue depressor

- Cold urticaria: ice cube test

- Heat urticaria: test tube water at 44°C (111°F)

- Pressure urticaria: Sandbag test or a bag with heavy books (Middleton's Allergy textbook, 2 volumes)

- Vibratory urticaria: vibration with laboratory vortex for four minutes

- Cholinergic urticaria: exercise for 15-20 minutes or leg immersion in 44°C (111°F) bath

- Aquagenic urticaria: challenge with tap water at various temperatures

Related reading:

Cold Case. NYTimes.

Urticaria: A Short Review
Mind Maps: Urticaria
Mnemonics: Urticaria
Chronic Idiopathic Urticaria (Hives)
Autologous serum skin test in chronic idiopathic urticaria

Anti-FceR1 Autoantibodies in Chronic Urticaria
The Ice Cube Test: Cold-Induced Urticaria. NEJM Images in Clinical Medicine, 02/2008.
Image: Cold-Induced Urticaria http://twitpic.com/e8lh2 - via @MatthewBowdish
Idiopathic Cold Urticaria. Consultant. Vol. 45 No. 13, November 1, 2005.

"Young mother must wrap up all year round because she is allergic to the cold"http://goo.gl/w25WB - Cold urticaria in Daily Mail.

Treatment of cold urticaria by cold desensitization - AAAAI Ask the Expert, 2011.

Skin testing with penicilloyl-polylysine (PPL) and minor determinant mixture (MDM) does not contribute to evaluation of nonimmediate reactions

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Contribution of skin testing with PPL and MDM in diagnosing cell-mediated hypersensitivity reactions to penicillins actually was "null" in a recent study.

"In cases of nonimmediate reactions (i.e., occurring more than one hour after the drug administration), it is mandatory to test the suspected penicillin (e.g., amoxicillin, ampicillin, etc.)."

All but 4 patients (97.5%) had positive responses to the responsible penicillins. Only 5.5% were positive to PPL (all immediate-reading) and only 10.5% were positive to MDM.

Manifestations of beta-lactams hypersensitivity: MAUS (click to enlarge the images).

Mnemonics for penicillin allergy skin testing

Major penicillin determinant test detects

Majority of patients with penicillin allergy

Minor determinant test

Minorizes the risk

References:

Recommended Tests Not Useful for Gauging Nonimmediate Penicillin Reactions. Medscape.

Adverse Reactions to Drugs: A Short Review
Mind Maps: Drug Allergy
Mnemonics: Drug Allergy

Pearls and Pitfalls of Allergen Testing - JCAAI http://goo.gl/6ThcC and http://goo.gl/Bfnhn

Image source: Penicillin nucleus, Wikipedia, GNU Free Documentation License.

Desloratadine (Clarinex) causes less drowsiness and sedation than levocetirizine (Xyzal)

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Desloratadine and levocetirizine are histamine H(1) receptor antagonists (antihistamines) that were launched in the UK in 2001.

Histamine structure. Image source: Wikipedia.

Exposure data were derived from dispensed prescriptions written by primary care physicians and outcome data were derived from questionnaires that were posted to prescribers at least 6 months after the date of the first prescription.

The cohorts comprised of more than 24,000 patients. The most frequently reported prescribing indication for both drugs was allergic rhinitis without asthma/wheezing (54%).

The incidence of first reports of drowsiness/sedation for levocetirizine or desloratadine was low 0.37% and 0.08%, respectively and statistically different.

Although the reporting rates of drowsiness and sedation are low for both drugs, patients prescribed levocetirizine were more likely to experience drowsiness and sedation in the first month of observation (after starting treatment) than patients prescribed desloratadine.

For patients with allergic rhinitis without asthma/wheezing, the odds of drowsiness/sedation were over six times greater in patients using levocetirizine than desloratadine.

References:

Comparison of the risk of drowsiness and sedation between levocetirizine and desloratadine: a prescription-event monitoring study in England. Layton D, Wilton L, Boshier A, Cornelius V, Harris S, Shakir SA. Drug Saf. 2006;29(10):897-909.

Comparison of the sedating effects of levocetirizine and cetirizine: no difference http://goo.gl/lGu3Q

Title of the day: "B-cells need a proper house, whereas T-cells are happy in a cave"

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A fundamental tenet of immunology is that adaptive immune responses are initiated in secondary lymphoid tissues. This dogma has been challenged by several recent reports.

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

Successful T cell-mediated immunity can be initiated outside of such dedicated structures (lymph nodes - secondary lymphoid tissue), whereas they are required for adaptive humoral immunity.

This resembles an ancient immune pathway in the oldest cold-blooded vertebrates, which lack lymph nodes and sophisticated B-cell responses including optimal affinity maturation.

The T-cell, however, has retained the capacity to recognize antigen in a lymph node-free environment.

B Cell Types (click to enlarge the image).

What chemokine attracts naïve B cells to lymph nodes?

CXCR5. CXCL13 binds to CXCR5.

What chemokine attracts naïve T cells to lymph nodes?

CCR7. CCL19 and CCL21 bind to CCR7.

References:
B-cells need a proper house, whereas T-cells are happy in a cave: the dependence of lymphocytes on secondary lymphoid tissues during evolution. Janin Hofmann et al. Trends in Immunology, 2010.

SLIT with grass pollen associated with increased Foxp3 and humoral changes similar to SCIT

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Foxp3+ cells were increased in the oral epithelium of SLIT- vs. placebo-treated atopics.

IgG1 and IgG4 were increased following SLIT. Peak seasonal IgA1 and IgA2 were increased during SLIT.


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

References:
Sublingual grass pollen immunotherapy is associated with increases in sublingual Foxp3-expressing cells and elevated allergen-specific immunoglobulin G4, immunoglobulin A and serum inhibitory activity for immunoglobulin E-facilitated allergen binding to B cells.
http://www3.interscience.wiley.com/journal/123298968/abstract

Sublingual immunotherapy is an extremely complex issue in the U.S. - AAAAI http://goo.gl/wVOKr

Timothy grass allergy immunotherapy tablets safe and effective in American children with allergic rhinitis http://goo.gl/tsKL4
Sustained effects of grass pollen tablet: Combined symptom and medication scores demonstrated a 33% reduction, Allergy, 2011. 

Efficacy and safety of timothy grass allergy immunotherapy tablet treatment in North American adults - it works. http://goo.gl/ePOFG
Sublingual grass immunotherapy (SLIT): Confirmation of disease modification 2 years after 3 years of treatment. JACI, 2012.