Allergy Notes: 11/2011

What molds to select for skin prick testing?

The following molds should be selected for a general screening panel for skin prick testing in the U.S.:

- Alternaria alternata
- Aspergillus fumigatus
- Penicillium chrysogenum (notatum)
- Cladosporium herbarum, C. cladosporiodes, C.sphaerospermum (Hormodendrum hordei (consider mix) - Drechslera (Curvularia) spicifera or Bipolaris sorokiniana (Helminthosporium sativum)
- possibly Epicoccum nigrum

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 License.

The following molds should be added for an expanded panel for skin prick testing in the U.S.:

- Fusarium species - solani, vasoinfectum, moniliforme (consider mix). Fusarium has been implicated in food allergy to quorn (meatless foods based on mycoprotein)
- Mucor racemosus
- Aureobasidium (Pullularia) pullulans
- Aspergillus species - flavus, niger (consider mix)
- Trichophyton tonsurans
- Chaetonium globosum
- +/- Candida albicans
- Phoma and Stemphyllium share allergens with Alternaria. Aspergillus and Penicillium have cross-reactive allergens.

References

Appropriate molds for skin testing. AAAAI Ask the Expert, 2011.
Aspergillus niger and its role in human diseases
Allergic reaction after consumption of "meat-free chicken” (Quorn mycoprotein) by a patient with mold allergy
Infectious Fungus Common In Household Drains (Fusarium) - NPR, 2011. "Meatless chicken" (Quorn) is made of Fusarium.

What is the difference between pine tree allergy and "Christmas tree allergy"?

There is a difference between pine tree allergy (pollen allergy in the early spring) and Christmas tree allergy (allergy to mold, in the winter). Dr. Allen Meadows explains it in this video for the ACAAI:

Dr. Meadows was an early pioneer in the use of YouTube to spread healtcare-related messages that benefit his patients and the general public. See more videos on his website for Alabama Allergy and Asthma Clinic PC.

Comments from Twitter:

@SurlyAmy: $45? RT @DrVes: What is the difference between pine tree allergy and "Christmas tree allergy"? goo.gl/Hy7mx

@AxxessMedica: Wow! Who knew? Interesting!

Egg allergic patients may tolerate some foods with eggs, but not others - why?

The egg allergen is affected by the degree of heating. Therefore, there are patients who tolerate cakes and muffins but still react to pancakes, French toast, and scrambled eggs.

Both mayonnaise and ranch dressing contain egg that has been pasteurized but is still more allergenic than egg that has been more extensively heated. Therefore, a challenge would be needed to determine if the patient who is tolerating muffins or pancakes can tolerate products with egg that has been less extensively heated.

Who will "outgrow" food allergy? It depends on the epitope

Each food is composed of many proteins and these proteins have multiple areas, termed epitopes, to which the immune system can respond. Epitopes that are dependent upon the folding of the proteins are called conformational epitopes. Epitopes that are not dependent upon folding are called linear epitopes.

A linear epitope oftens means a more prolonged allergy which is “stable” and persistent. A conformational epitope (egg, milk) often means a mild, transient allergy.

8 top allergens account for 90% of food allergies (click to enlarge the image). The likelihood of a negative oral food challenge is shown in relation to the respective values of skin prick test (SPT) and serum IgE (sIgE).

References:

If patient tolerates egg baked in pancakes and muffins should they be able to tolerate in mayonnaise and ranch dressing? AAAAI, 2011.
Ovomucoid- and ovalbumin-specific IgE/IgG(4) ratios predict reactivity to baked egg. JACI, 2012.
Rare, medium, or well done? Effect of heating on food protein allergenicity http://goo.gl/Z4LbX - It definitely affects milk and egg products.

Image source: Wikipedia, public domain.

"So You Have Asthma Too" educational video for children

"So You have Asthma too" educational video for children.

"I'm a meter Reader" - peak flow meter teaching video.

Future forms of immunotherapy - what is practical?

Allergic respiratory diseases affect 15% of the US population.

The 100-year-old treatment

Allergen immunotherapy (SCIT) has been a treatment option for allergic rhinitis, allergic asthma, and venom allergy for the last 100 years. During the first 75 years, conventional subcutaneous immunotherapy (SCIT) did not change much. However, the last 25 years has seen a growth in the development of alternatives to subcutaneous immunotherapy.

Mechanisms of allergen-specific immunotherapy (click to enlarge the image). CD27 expression on allergen-specific T cells may be a new surrogate for successful allergen-specific immunotherapy (JACI, 2012).

Omalizumab

The addition of omalizumab (trade name Xolair), an anti-IgE mAb, to immunotherapy offers the potential for increased safety and efficacy - for example, transition to SCIT in patients with difficult to control asthma.

Toll-like receptor (TLR) agonists

Activation of the innate immune system through Toll-like receptor (TLR) agonists coupled with allergens may improve the immunologic responses.

Pathogen Recognition Receptors, TLRs. This video is from: Janeway's Immunobiology, 7th Edition Murphy, Travers, & Walport. Source: Garland Science.

Altered allergens

The use of chemically altered allergens, allergoids, recombinant allergens, and relevant T-cell epitope peptides are all approaches that have yielded positive results in research studies.

Alternative modes of delivery

Alternative modes of delivery also hold promise - sublingual immunotherapy (SLIT) is rapidly approaching mainstream use in many countries (U.S. not included, possibly due to polysensation often observed in the American patients).

One thing is clear: the next century of immunotherapy will be vastly different from today's current standard of care.

References:

Future forms of immunotherapy. Casale TB, Stokes JR. J Allergy Clin Immunol. 2010 Nov 19.
Toll-like receptor (TLR)

Which antihistamines to use in chronic kidney disease and hemodialysis?

The general agreement is that some first generation antihistamines are safe, e.g. diphenhydramine, hydroxizine, chlorpheniramine.

Some studies in the recent years confirmed that the second generation antihistamines are also safe but the dose may need modification.

Oral Antihistamines (click to enlarge the image).

Evidence from the multiple-dose study supports the clinical use of cetirizine for ESRF patients on HD. Thus, it is concluded that a prescription of 5 mg cetirizine three times a week during the predialysis period will be the effective and safety renal dosage for ESRD patients on HD.

No significant relationship was observed between the terminal elimination half-life of loratadine or descarboethoxyloratadine and creatinine clearance. Hemodialysis augmented endogenous clearance by less than 1%. The disposition of loratadine is not significantly altered in patients with severe renal insufficiency nor is hemodialysis an effective means of removing loratadine or descarboethoxyloratadine from the body.

The use of H1-receptor antagonists may even help prevent left ventricular remodeling in patients on chronic hemodialysis. A 2010 study suggested a suppressive role of second-generation antihistamines on LV remodeling.

References:

Comparative pharmacology of the H1 antihistamines. J Investig Allergol Clin Immunol 2006; Vol. 16, Supplement 1:3-12. Full text PDF.

Pharmacokinetics of cetirizine in chronic hemodialysis patients: multiple-dose study.
Noiri E, Ozawa H, Fujita T, Nakao A. Nephron. 2001 Sep;89(1):101-4.

Pharmacokinetics of loratadine in patients with renal insufficiency. Matzke GR, Halstenson CE, Opsahl JA, Hilbert J, Perentesis G, Radwanski E, Zampaglione N. J Clin Pharmacol. 1990 Apr;30(4):364-71.

The use of H1-receptor antagonists and left ventricular remodeling in patients on chronic hemodialysis. Omae K, Ogawa T, Yoshikawa M, Nitta K. Heart Vessels. 2010 Mar;25(2):163-9. Epub 2010 Mar 26.

Diagnosis and management of drug hypersensitivity reactions

Classification of drug hypersensitivity reactions

Drug hypersensitivity reactions can be classified as:

- Immediate reactions - occur within 1 hour - type I (IgE-mediated)
- Nonimmediate reactions - occur after more than 1 hour - type IV (T cell-mediated)

Diagnosis of drug hypersensitivity reactions

Prick, patch, and intradermal tests are the most readily available tools.

Determination of specific IgE levels is the most common in vitro method for diagnosing immediate reactions.

New diagnostic tools for for analysis of antigen-specific, cytokine-producing cells include:

- basophil activation test
- lymphocyte activation test
- enzyme-linked immunospot assays

The sensitivity of tests is not 100%; therefore in selected cases provocation tests are necessary.

In the diagnosis of nonallergic hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs), the provocation test with the suspected drug still represents the "gold standard." However, there was no consensus regarding the use of this test in subjects with histories of hypersensitivity reactions to 1 (single reactors) or more (multiple reactors) nonsteroidal anti-inflammatory drugs.

Classification of adverse reactions to drugs: SOAP III (click to enlarge the image).

Management of drug hypersensitivity reactions

Desensitization allows patients to be treated with irreplaceable chemotherapy agents, such as taxanes, platinum salts, and mAbs, to which they have presented hypersensitivity reactions.

Desensitization also permits the use of aspirin in aspirin-sensitive patients undergoing revascularization and in subjects with aspirin-exacerbated respiratory disease.

Another relatively common use of desensitasion is in penicillin allergy.

References:

Diagnosis and management of drug hypersensitivity reactions. Romano A, Torres MJ, Castells M, Sanz ML, Blanca M. J Allergy Clin Immunol. 2011 Mar;127(3 Suppl):S67-73.

Skin test is better than blood test (sIgE) for evaluation of milk allergy, but oral challenge is the best

Food allergy is an immunologically mediated adverse reaction to food protein. Cow's milk protein allergy (CMPA) is the most frequent type of food allergy and may be difficult to diagnose.

This Brazilian study included 190 children aged 1-5 years who underwent:

- skin prick test (SPT) for cow's milk, eggs, wheat and peanuts
- specific IgE test for cow's milk, eggs, wheat and peanuts
- atopy patch test (APT) for cow's milk, eggs, wheat and peanuts

122 children underwent open oral challenge ("the gold standard") for the food to which the child was sensitive or had suspected sensitivity.

Presence of food allergy was confirmed for 41% of children. Among these cases, 88% were due to allergy to cow's milk protein.

Sensitivity and specificity of the tests:

- SPT had 31.8% sensitivity, 90.3% specificity, 66.7% PPV and 68.4% NPV
- IgE test had, respectively, 20.5%, 88.9%, 52.9% and 64.6%
- APT had 25.0% sensitivity, 81.9% specificity, 45.8% PPV and 64.1% NPV.

According to this study, oral challenge is the best method for diagnosing CMPA, because of the low sensitivity and PPV of skin and specific IgE tests.

I agree that an oral food challenge is the best method to diagnose a food allergy. Skin tests and blood tests play an important role in making the decision if the oral challenge is safe. However, the sensitivity of the skin test and blood test is higher than the reported values in the study. Please have a look at the table below for reference:

Comparison of diagnostic methods for peanut, egg, and milk allergy - skin prick test (SPT) vs. specific IgE (sIgE) (click to see the spreadsheet). Sensitivity of blood allergy testing is 25-30% lower than that of skin testing, based on comparative studies (CCJM 2011).

Oral Food Challenges (click to enlarge the diagram).

References:

Costa AJF, Sarinho ESC, Motta MEFA, Gomes PN, de Oliveira de Melo SM, da Silva GAP. Allergy to cow's milk proteins: what contribution does hypersensitivity in skin tests have to this diagnosis? Pediatr Allergy Immunol 2011; 22: e133-e138.

Oral food challenges

Image source: Wikipedia, GNU Free Documentation License.

First example of response to ectoparasite (tick bite) giving rise to food allergy (meat)

The research group from the University of Virginia reported in 2009 a new form of delayed anaphylaxis to red meat related to IgE antibodies to the oligosaccharide galactose-α-1,3-galactose (alpha-gal). Most of these patients had tolerated meat for many years previously. They suspected that some exposure in adult life had stimulated the production of the IgE antibodies. The research focused on tick bites, which are common in the region.

3 patients showed an increase in levels of IgE to alpha-gal of 20-fold or greater after tick bites. IgE antibodies were common in areas where the tick Amblyomma americanum is common.

There was a correlation between IgE antibodies to alpha-gal and IgE antibodies to proteins derived from A americanum.

The results provided evidence that tick bites are a cause, possibly the only cause, of IgE specific for alpha-gal in this area.This is supposedly the first example of a response to an ectoparasite giving rise to an important form of food allergy.

References:

The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1,3-galactose. Commins SP, James HR, Kelly LA, Pochan SL, Workman LJ, Perzanowski MS, Kocan KM, Fahy JV, Nganga LW, Ronmark E, Cooper PJ, Platts-Mills TA. J Allergy Clin Immunol. 2011 Mar 29.

Image source: Giant Microbes Tick (Ixodes Scapularis) Plush Toy.

Masitinib, a c-kit/PDGF receptor tyrosine kinase inhibitor, may improve corticosteroid-dependent asthma

Masitinib is a tyrosine kinase inhibitor targeting stem cell factor receptor (c-kit) and platelet-derived growth factor (PDGF) receptor. Both C-kit (CD117) and PDGF receptor are expressed on mast cells and bronchial structural cells, respectively.

C-kit and PDGF receptor inhibition may decrease bronchial inflammation and interfere with airway remodeling, which are crucial features of severe asthma.

Mast cells. Image source: Wikipedia.

A 16-week study included 44 patients with severe corticosteroid-dependent asthma who remained poorly controlled despite standard therapy.

A comparable reduction in oral corticosteroids was achieved with masitinib and placebo (-78% and -57% in the masitinib and placebo arms, respectively) but the Asthma Control Questionnaire score was better in the masitinib arm.

The authors concluded that masitinib, a c-kit and PDGF-receptor tyrosine kinase inhibitor, may represent an innovative avenue of treatment in corticosteroid-dependent asthma. More studies in severe asthma are needed.

References:

Masitinib, a c-kit/PDGF receptor tyrosine kinase inhibitor, improves disease control in severe corticosteroid-dependent asthmatics. Humbert M, de Blay F, Garcia G, Prud'homme A, Leroyer C, Magnan A, Tunon-de-Lara JM, Pison C, Aubier M, Charpin D, Vachier I, Purohit A, Gineste P, Bader T, Moussy A, Hermine O, Chanez P. Allergy. 2009 Aug;64(8):1194-201.

Sublingual immunotherapy (SLIT) - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

90% of Italian patients on sublingual immunotherapy (SLIT) stopped before reaching the 3-year mark.

SLIT patients who had 4 followup visits per year reported 82% adherence to SLIT. If they had just 1 followup visit per year, the adherence to SLIT was only 30%.

SLIT with a high dose house dust mite (HDM) extract showed a significant reduction in asthma and rhinitis symptom at 3 and 5 yeats of therapy. A 3-year SLIT course was adequate (Tabor et al. in JACI). SLIT with dust mite (DM) for 3 years led to a subsequent 7-year symptom remission.

A Novel Pill with Ragweed Looks Promising for Ragweed Allergy - in Meeting Coverage, ACAAI from MedPage Today.

Sublingual Immunotherapy (SLIT) Improves Ragweed Allergy. Medscape.

A Roundtable Discussion: Sublingual Immunotherapy (SLIT). ACAAI podcast and transcript.

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

How to differentiate between allergic and nonallergic rhinitis on clinical grounds?

Allergic rhinitis (AR) and nonallergic rhinitis (NAR) may present with different clinical and laboratory characteristics. This Italian study included 1,500 adult patients, aged 18-81 years, diagnosed with rhinitis who underwent allergic evaluation including:

- skin prick test

- blood eosinophil counts

- nasal eosinophil counts

- peak nasal inspiratory flow (PNIF) measurement

- evaluation of nasal symptoms using a visual analog scale (VAS)

73% of the patients diagnosed with rhinitis had allergic rhinitis (AR). A higher nasal eosinophils count was associated with AR and a lack of clinical response to antihistamines.

Patients with NAR were older and predominantly female.

AR patients had more sneezing and nasal pruritus, whereas NAR was characterized mainly by nasal obstruction and rhinorrhea.

AR patients had more severe symptoms and recurrent conjunctivitis, whereas NAR patients had more frequent episodes of recurring headaches as well as olfactory dysfunction (problems with the ability to detect smells).

PNIF, blood eosinophil counts and VAS of nasal symptoms were higher in patients with AR.

Several variables were statistically different between AR and NAR:

- clinical response to antihistamines, OR 22.59
- conjunctivitis, OR 4.49
- sneezing, OR 4.09
- nasal pruritus, OR 3.84
- intermittent/severe nasal symptoms, OR 3.66
- mild symptoms, OR 0.21

Several clinical and laboratory parameters may help to exclude the diagnosis of AR.

Treatment Options for Allergic Rhinitis and Non-Allergic Rhinitis (click to enlarge the image).

References:

Differences and Similarities between Allergic and Nonallergic Rhinitis in a Large Sample of Adult Patients with Rhinitis Symptoms. Di Lorenzo G, Pacor ML, Amodio E, Leto-Barone MS, La Piana S, D'Alcamo A, Ditta V, Martinelli N, Di Bona D. Int Arch Allergy Immunol. 2011 Feb 2;155(3):263-270.
Image source: Wikipedia, a Creative Commons license.

Vitamin D in asthma and allergic diseases - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

9% of Americans are deficient in vitamin D and 61% insufficient.

Multiple small studies link lower serum 25(OH)D3 levels and various markers of asthma including an association with lower FEV1.

A study showed an odds ratio 4.2 for increased asthma risk with vitamin D deficiency (Int Arch of Allergy). Other studies were not as supportive of the vitamin D hypothesis and some even showed worsening asthma with higher vitamin D levels. It could be an interplay of vitamin D and genetic factors.

Vitamin D deficiency is associated with increased asthma morbidity, but there are no high quality studies showing that vitamin D treatment decreases asthma morbidity. There are no long-term studies with vitamin D. The dose and the level to aim for are unknown. The trials are currently ongoing. We need multiple measurements of Vit D (OH)3 over the course of the year and prove reaching of vitamin D sufficiency in the trials.

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Flaxseed allergy

Flax (Linum usitatissimum) seeds are increasingly used in bread and as laxatives. Hypersensitivity to flaxseed has been infrequently described. This case report from Spain describes anaphylaxis induced by flaxseed ingestion in a 39-year-old woman.

A type I hypersensitivity reaction was suggested by the clinical course, positive skin prick test(SPT), and histamine release test performed with linseed extracts. The presence of linum-specific IgE (sIgE) was confirmed by immunoCAP assay.

Flaxseed (Linum) might be a source of allergic sensitization that should be taken into account due to its widespread distribution at health food stores.

The treatment is similar to that of other food allergies - avoidance and EpiPen use in case of an anaphylactic reaction.

References:

Anaphylaxis to Linum. León F, Rodríguez M, Cuevas M. Allergol Immunopathol (Madr). 2003 Jan-Feb;31(1):47-9.

Related reading:

Allergy on Flickr: "EpiPen. Another flaxseed incident today. No more munching on food samples at Costco."

A story on Flickr: "So a funny thing happened at lunch...."

Image source: Amazon.com, not a recommendation to buy any products.

Chronic urticaria - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Double dose 2nd generation antihistamines are the mainstay of treatment of chronic idiopathic urticaria (CIU).

Corticosteroids

Corticosteroids are widely used in CIU but not many studies as you might expect have shown efficacy. They are inexpensive.

Omalizumab (Xolair)

There are no good quality studies for the use of steroids in chronic idiopathic urticaria (CIU). In contrast to steroids, a lot of small studies have shown benefit of omalizumab in CIU. Getting it paid for by the insurance companies on the other hand may be extremely difficult.

Cyclosporin

Cyclosporin has 4 successful RCTs for CIU - a lot more than some of the other medications used in CIU. Cyclosporine (CyA) 3-5mg/kg dose is most likely to succeed. UK dermatology guidelines suggest that 75% of patients with CIU will respond to cyclosporin.

Dapsone

Dapsone is successful in CIU at the dose of 25-50 mg/day. Delayed pressure urticaria may be especially responsive to dapsone.

Patient need to have laboratory evaluation and follow-up including G6PD levels, CBC and LFT measurements. Dapsone is inexpensive.

Plaquenil

Patients on plaquenil need retinal check within the first year and every 5 years afterward. There is more risk with accumulated dose greater than 1000 gm.

Montelukast (Singulair)

Antileukotrienes are listed as drug of choice after H1 blocker in European guidelines for CIU. Montelukast is probably the the safest medication for CIU (in addition to 2nd generation antihistamines). No laboratory monitoring is needed.

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Advair and Singulair (montelukast) among top 10 best-selling medications in the U.S.

According to a report from the IMS Institute for Healthcare Informatics, the top 10 best-selling drugs are:

- Lipitor, $7.2 billion (it will be generic in 2012)
- Nexium, 6.3 billion
- Plavix
- Advair Diskus, $4.7 billion
- Abilify
- Seroquel
- Singulair, $4.1 billion (it will be generic in August 2012)
- Crestor
- Actos
- Epogen

Asthma Inhalers (click to enlarge the image).

References:

The 10 Most Prescribed Drugs. WebMD.

Image source: Montelukast, Wikipedia.

Comments from Twitter:

@cntrolledchaos: As a School Nurse now that I think of it...Singulair and Ventolin are probably the most prescribed i see w/ ADHD's a close 2nd. Though we don't give Singulair in schools .... Just see it on Asthma Action Plans w/ albuterol.

Food Allergy - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Genetics

One parent with food allergy doubles risk of food allergy in kids (offspring). If both parents have, there is triple the risk of food allergy in offspring (Finnish data).

Camel milk in cow’s milk allergy (CMA)

Camel milk lacks beta-lactoglobulin, but 20% of patients with cow’s milk allergy (CMA) still react to it. Camel milk can still cause anaphylaxis. A prick test with camel milk may be helpful.

Baked milk in cow’s milk allergy (CMA)

Among baked milk tolerant children, 60% tolerated unheated milk over a 5-year period. That group was 28 times more likely to become tolerant to milk.

There was a significant reduction in milk allergy if the children were continually fed baked milk - 76-80% of the “treatment group” outgrew CMA vs. 24-33% in the control group.

Peanut allergy

The best individual marker for peanut allergy is IgE to r Ara h2. IgE to Ara h6 increases specificity.

Peanut oral immunotherapy (OIT)

In a peanut OIT study, 10% of patients required epinephrine treatment during dose escalation in the hospital but 84% of patients completed 1 year of OIT. The desensitized group was able to tolerate 5 gm of peanut vs. the placebo group was able to tolerate only 280 mg of peanut.

Side effects were common among 103 patients treated with the study protocol: 34% had moderate abdominal pain, sometimes with vomiting, and another 30% had mild abdominal pain (that’s a total of 64% with abdominal pain). Just under 40% of patients complained of oral pruritus, 8% had hives, and respiratory symptoms were reported by 7%. Only 28% experienced no symptoms at all with OIT (72% of patuients had symptoms with OIT). Source: Oral Tx for Peanut Allergy a Viable Option, MedPage Today.

Food challenges

Food Challenges Provide Best Allergy Diagnoses. Only 15% of food-allergic kids have food allergy confirmed through best way to diagnose - an allergist-supervised oral food challenge. Source: USNews.com

Influenza vaccine and egg allergy

Flu vaccine administration was associated with mostly mild hives (4%) even in severe cases of egg allergy. In patients with mild egg allergy (hives only, after egg ingestion), you can addminiter the vaccine in PCP office. For severe egg allergy, administer the influenza vaccine in an allergist office (AAP guidelines).

In summary, in egg allergic children with hives only, flu vaccine can bu given by PCP. If there are more severe symptoms, an undivided dose should be given at allergist's office with a 3-minute observation.

Single Flu Shot Safe for Most Children With Egg Allergy (10/90 split may not be needed) - see allergist for evaluation. Source: Medscape.

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Opsoclonus Due to Diphenhydramine (Benadryl) Poisoning (video)

From the NEJM YouTube channel: Opsoclonus consists of involuntary, irregular, back-to-back, multivectorial, saccadic eye movements while the gaze is fixed. It is seen primarily in association with autoimmune processes after viral infection and with paraneoplastic encephalitis but has also been described after ingestion of organophosphates, lithium, cetirizine, amitryptiline, and diphenhydramine.

The NEJM case report describes a 20-year-old woman was admitted 2 hours after ingesting 5 grams of diphenhydramine in a suicide attempt. She had several seizures. ECG showed sinus tachycardia at 172 beats per minute and opsoclonus.

She required intubation for airway protection. The opsoclonus resolved 8 hours after her admission.

Benadryl disoverer, George Rieveschl, realized the powerful potential of the 19-syllable antihistamine compound while researching muscle relaxants in 1940s.

References:

Opsoclonus Due to Diphenhydramine Poisoning. Shaun D. Carstairs, M.D., and Aaron B. Schneir, M.D. N Engl J Med 2010; 363:e40

George Rieveschl, Inventor of Benadryl, Dies at 91

Former Olympian and coach died of antihistamine overdose

Profilin - a pan-allergen among plants crossreacts between pollen, fruits, vegetables and latex

A 13-year-old girl who had had pollinosis (allergic rhinitis) since the age of 8 began to experience itching of the ears and vomiting after eating fresh fruits such as peach, apple and watermelon at age 10.

Cross-reactivity in Pollen-Food Allergy Syndrome (PFAS) or Oral Allergy Syndrome (OAS) (click to enlarge the image).

The girl displayed positive specific IgE reactions to 6 kinds of pollens, 11 kinds of fruits, numerous vegetables and to recombinant rBet v2.

She also reacted positively to several pollens, fruits and rBet v2 in the skin prick test.

In the component-resolved diagnosis (CRD) using microarray technology, she also tested positive for profilin, which is consired a pan-allergen among plants.

Profilin cross-reacts between pollen, fruits, vegetables and latex.

The Japanese resesearchers who reported this case concluded that the allergic reactions to multiple kinds of foods and pollens were due to cross-reactivity induced by profilin. They think that CRD by microarray is a reliable test in the diagnosis of Pollen-Food Allergy Syndrome (PFAS).

References:

Sensitization Profiles of a Case of Pollen-Food Allergy Syndrome. Sano A, Yagami A, Inaba Y, Yamakita T, Suzuki K, Matsunaga K. Allergol Int. 2011 Jan 25;60(1).

Pollen-Food Allergy Syndrome (PFAS)

Common variable immunodeficiency (CVID) - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Higher doses for IVIG replacement

There is increasing evidence that higher levels of Ig replacement provide better outcomes. However, average number of reported infections has not changed in those on IIVIG since the 1990s, despite rising average IgG trough levels. IVIG infusions raise IgG levels in the saliva and nasal secretions but sinopulmonary infections are still common in antibody deficient patients. Do we need to replace IgM or IgA too? The current formulations provide only IgG replacement.

The dose now aimed for with IVIG seems to be 570 mg/kg/month - a significant increase since 1980's (400 mg/kg/month). However, overall infections have not improved tremendously during that period. This phenomenon could be due to viral infections and sinusitis however which do less well with IVIG replacement. Inflammatory cytokines are increased in nasal secretions in CVID patients and mimic infectious changes. Many CVID patients are also IgA-deficient.

Individual CVID patients may have different optimal IgG trough levels that prevent infections. Don't let insurance companies dictate which levels are "normal." Beware 3rd party payer (insurance companies) limitations when optimizing IgG treatment and dose for patients with humoral immune deficiency.

Is there any actual utility to measuring IgG trough levels in subcutaneous IgG (SCIG) therapy? The PIDD expert Dr. Jordan Orange is not sure.

CVID and GI symptoms

If a patient with CVID has GI complaints, rule out infections, and think about hypertrophied Peyer's patches. For example, it’s not a good idea for a CVID patients to swim in a lake (according to PIDD expert Mark Ballow)..

CVID and respiratory symptoms

If a patient with CVID has respiratory complaints, consider bronchiectasis and granulomatous lung disease. Bronchiectasis outcomes are improving with earlier detection via CT of the chest, but worry about granulomatous disease that may occur in 8-12% of CVID patients.

CXR and high-resolutiom chest CT scan are recommended at baseline in CVID patients. They need yearly spirometry and perhaps a repeat chest CT scan every 5 years.

CVID and maligancy

The malignancies in CVID are predominantly Non-Hodgkin Lymphoma that may occur in 2-8% of patients, and rarely gastric cancer.

Outcome of allogeneic stem cell transplantation (ASCT) in adults with common variable immunodeficiency (CVID) (JACI, 2011).

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Allergic rhinitis - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Allergic rhinitis (AR) and bronchial hyperresponsiveness

Many AR patients have diminished FEF 25-75%, a volume lower than 70% of predicted may be a risk factor for subsequent asthma development (Am J Rhinol Allergy. 2011). 40% of patients with allergic rhinitis have bronchial hyper-responsiveness.

Local allergic rhinitis (non-allergic rhinitis with local IgE production)

Local allergic rhinitis means that the patient is symptomatic to nasal allergen challenge but they have a negative SPT/IgE measurement. There is a debate rewarding the best approach to diagnosis and management (JACI 2011).

Pepper spray (capsacain)

Pepper spray (capsacain) in NAR. The nasal and sinus symptoms improved in 53 seconds but how can a pepper spray have a proper placebo to test a true difference? (Annals of Allergy, Asthma & Immunology, 2011).

Various nasal steroids

There is no evidence for differences in effectiveness of the various nasal steroids. There is a role for patient preference though.

New "dry" nose sprays

There were multiple abstracts at the ACAAI meeting about HFA containing aerosol nasal treatments, with both beclomethasone and ciclesonide being used.

Existing nose sprays deliver the product in large droplets that feel uncomfortably wet to many patients. Complaints that the liquid drips out of their noses or down into their throats are common. The new "dry" formulations are intended to fix these aspects of intranasal steroid sprays. The new ciclesonide and beclamethasone sprays are driven by hydrofluoroalkanes (HFA), the propellant now used in metered-dose asthma inhalers (MedPage Today report from the ACAAI meeting).

Allergy to pets

A practice parameter for "Furry Animals" is coming in 2012.

90% of homes have measurable allergen to cats and dogs. There is a 9-fold risk of back to school asthma for cat allergic children when attending school where there are many cat owners.

Hypoallergenic cat breeds (genetically bred to have no Fel d1) still produce Fel d2 (20% of cat-allergic patients are allergic to this).

There is a possible link between Can f5 (dog allergen) and human seminal fluid allergy.

Cat and mold particle sizes are much smaller, so there is need better filtration vs. dust mite or pollen particles. Also, the smaller sizes makes it easier to get further into the lungs. There is no conclusive evidence that duct cleaning will result in improved allergy symptoms.

Carpeted floors get 100-fold more cat allergen than polished floors.

Skin-prick testing for cat allergy has 100% sensitivity and 93.5% specificity - intradermal testing did not add value (http://goo.gl/HXC9s).

Chronic sinusitis

For chronic inflammatory rhinosinusitis, some experts recommend Pulmicort respules 500 mcg or 1000 mcg in Pediatric Sinus Rinse BID.

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Humidifiers may be among the risk factors for childhood asthma

The Consumer Reports magazine calls the home humidifier a "gift of moisture" and recommends it as a "healthy holiday gift." The scientific evidence seems to be against this recommendation however. Please see the articles in the reference section below for details.

A cross-sectional study of children 1 to 17 years of age living in Buffalo, New York examined the prevalence estimates of indoor and outdoor environmental risk factors for asthma. Significant environmental risk factors were presence of smokers in the household, humidifier or vaporizer use, chemical odors indoors, frequent truck traffic, and chemical odors outdoors.

Overall, smoking, pets, humidifier, and cockroaches were all significantly associated with asthma in the home.

The use of ventilation-air-conditioning systems (42%), personal humidifier or nebulizers (43%), dampness inside the houses were risk factors in people with positive fungi skin test reactivity.

In children with no history of wheezing, an increased risk of developing asthma was associated with a humidifier (relative risk [RR] = 1.7).

Multiple conditional logistic regression analysis showed that after personal susceptibility factors were controlled for, the following were independent risk factors for asthma:

- the mother's heavy smoking (odds ratio (OR) = 2.77)

- use of a humidifier in the child's room (OR = 1.89)

- the presence of an electric heating system in the home (OR = 2.27)

The humidifier use may also increase the dust mite counts in the bedroom. Dust mites "drink" through their surface. In fact, the best measure for dust mite control is to decrease the air humidity to less than 50% (it works for mold control as well).

Unfortunately, humidifiers have just the opposite effect - they increase the air humidity and may promote dust mite growth. Dust mite exposure is one of the most significant environmental factors for development of asthma in children.

Dust mite allergen avoidance. The main allergen is in the dust mite feces. Use 3 control measures for 3-6 months to see an effect on the allergy symptoms (click to enlarge the image).

References:

It is inadvisable to employ a home humidifier in the home of an asthmatic - AAAAI Ask the Expert.

Self-reported home environmental risk factors for childhood asthma: a cross-sectional study of children in Buffalo, New York. Lin S, Gomez MI, Hwang SA, Munsie JP, Fitzgerald EF. J Asthma. 2008 May;45(4):325-32.

Home environmental factors associated with asthma prevalence in two Buffalo inner-city neighborhoods. Lwebuga-Mukasa JS, Wojcik R, Dunn-Georgiou E, Johnson C. J Health Care Poor Underserved. 2002 May;13(2):214-28.

6 last-minute healthy holiday gifts
http://blogs.consumerreports.org/health/2010/12/last-minute-holiday-gifts-christmas-gifts-healthy-holiday-gifts-6-last-minute-healthy-holiday-gifts-.html

[Fungal spores in the environment of the asthmatic patient in a semi-desert area of Mexico].
[Article in Spanish]. Rev Alerg Mex. 2002 Jan-Feb;49(1):2-7.

Indoor risk factors for asthma in a prospective study of adolescents. McConnell R, Berhane K, Gilliland F, Islam T, Gauderman WJ, London SJ, Avol E, Rappaport EB, Margolis HG, Peters JM. Epidemiology. 2002 May;13(3):288-95.

Childhood asthma and indoor environmental risk factors. Infante-Rivard C. Am J Epidemiol. 1993 Apr 15;137(8):834-44.

Childhood asthma and the indoor environment. Dekker C, Dales R, Bartlett S, Brunekreef B, Zwanenburg H. Chest. 1991 Oct;100(4):922-6.

Hygiene hypothesis and allergic diseases - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Farm animal exposure

Farm animal exposure in utero reduces risk of atopic dermatitis (AD). Risk reduction may occur through a TLR mechanism. Multiple different animals are more protective. Diversity of bacteria in farm homes may be the protective factor against atopy.

Pets may be protective

Teens who had cats in the 1st year of life had a decreased risk of cat allergy at the age of 18. Dog exposure may be more protective against all forms of allergy not just allergy to dogs. It could be similar to the barnyard protection against atopic disease. Related reading: Getting a cat increases allergy risk in adults - getting one in adulthood nearly doubles the risk. Reuters and JACI, 2012.

Frequent washing

Dr. Platts Mills reviewed data that frequent washing, especially with soap, may be harming the skin barrier which may lead to increased sensitization. He suggested that daily bathing of infants may contribute to rising prevalence of atopy - hygiene hypothesis may be true.

Epidemiological data

Hay fever data did not show much difference between 1955 and 1995 from Hal Nelson's data but asthma had a much bigger increase. What are the causes for asthma increase during that period? Some experts suggest it could be lack of exercise, obesity, changing indoor environment, or even lack of deep breathing while watching TV. Obesity increases the risk of AD two-fold. Prolonged obesity is worse. Pro-inflammatory issues likely play a role (similar to asthma).

Comparison:

- Bostock in 1819: Allergy is a rare disorder of the privileged class in the UK.
- NHANES data shows 2-5-fold increase in atopy from the 1980's to the 1990's.

With 30% of the population being atopic can we still consider it a disease, asks Phil Lieberman.

There is an inverse correlation between parasite exposure and atopic responses, most recently suggested by data from the former East Germany.

Even in Africa where the asthma rates are low there is an urban affluence link to high positive dust mite sIgE titres. In Costa Rica there is a similar pattern where the water is cleaner, shoes are common and helminths are eradicated but there is more asthma.

In Venezuela children treated for worms were noted to have increased atopic rates that improve with re-infection.

There is a possible link between the lack of omega 3 fatty acids and the risk for atopy. However, supplementation studies in active atopic disease were disappointing.

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Wheezing in infancy - not every wheeze is asthma

30% of children have wheezing during respiratory infections before their third birthday. Why?

Infants are prone to wheeze because of:

- anatomic factors related to the lung and chest wall
- viral infections that lead to wheezing

Wheezing in Children - Phenotypes (click to enlarge the image).

Not every wheeze is indicative of asthma but prediction of asthma in persistent wheezers is possible. Testing for allergy in these infants is worthwhile and can be of significant value in avoidable allergens.

Childhood asthma phenotypes (click to enlarge the image).

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

Treatment of an infant with wheezing depends on the underlying etiology. Response to bronchodilators is not easy to predict.

A trial of inhaled steroid may be warranted in a patient who has:

- responded to courses of oral steroids
- moderate to severe wheezing
- a significant history of atopy including food allergy or eczema

Ribavirin administered by aerosol, hyper-immune respiratory syncytial virus immunoglobulin (RSV IVIG), and intramuscular monoclonal antibody to an RSV protein have been used for RSV bronchiolitis in infants with congenital heart disease or chronic lung disease.

References:

Wheezing in infancy. El-Gamal, Yehia M. MD, PhD; El-Sayed, Shereen S. MD, PhD. World Allergy Organization Journal: May 2011 - Volume 4 - Issue 5 - pp 85-90, doi: 10.1097/WOX.0b013e318216b41f

Treatment of Pediatric Asthma

Asthma - a Twitter summary from the 2011 ACAAI meeting

This summary was compiled from the tweets posted by some of the allergists who attended the 2011 ACAAI meeting. The tweets were labeled #ACAAI. The text was edited and modified by me.

Environmental Tobacco Smoke

Smoking bans reduce childhood asthma morbidity. In the U.S. more than 200,000 asthma admissions per yeat are attributed to Environmental Tobacco Smoke (ETS). The Scottish smoking ban was associated with 18% reduction in hospital admissions for asthma (NEJM 2010).

HEPA filters reduced asthma visits in 6-12-year-old children by 18% when parents smoke.

VCD

Variation on VCD at work is a condition called work-associated irritable larnyx syndrome (WILS) that is found in females with reflux.

Patients with difficult asthma may have a laryngeal dysfunction not just VCD (AJRCCM, a study from Australia).

Tiotropium

Tiotropium works as step-up therapy in adult asthma. There were similar improvements in lung function and symptom-free days as adding LABA (NEJM 2011). Tiotropium was better than doubled ICS and as good as salmeterol in severe asthma.

Tiotropium Respimat inhaler helps patients with asthma but a recent BMJ meta-analysis showed increased cardiovascular mortality with that formulation in COPD (BMJ, 2011).

Anti IL-13 (lebrikuzumab)

Anti IL-13 (lebrikuzumab) shows promise in patients with elevated IL-13 levels in asthma. Lebrikizumab (anti-IL13) was useful for asthma, especially in high periostin subgroup (a marker of airway remodelling). Lebrikizumab improved FEV1, but there was no improvement in symptoms or medication use (NEJM 2011).

Antibiotics

1/6 children with asthma seen the ED are prescribed antibiotics. Generally, antibiotics are not helpful in asthma anyway. More than 2 courses of antibiotics for cough in a 6-month time frame should warrant consideration of asthma as a cause (Pediatrics, 2011).

Mold allergy

In a study in Arizona, Fernandez et al. showed SPT to Alternaria to be surprisingly accurate. 96% of patients with a positive SPT had a positive bronchial provocation test with Alternaria. In Arizona, Alternaria has surpassed dust mite as number one allergen in asthma (due to dry climate).

Immunotherapy

SCIT with HDM allowed for ICS reduction by 50% in children with asthma vs. 30% in controls. PEF also improved. Adding a mite allergoid SCIT to pharmacologic treatment was an effective and safe strategy to reduce corticosteroid doses while maintaining disease control in children with mite-induced allergic asthma (JACI 2011).

ICS/LABA

30% of pediatric patients who stepped down off of ICS/LABA to ICS alone lost asthma control in a study from Louisville. No factors could be identified to predict who would maintain control and who would lose control.

Bronchoconstriction without additional inflammation induces airway remodeling in patients with asthma. Dust mite and methacholine challenge induced constriction. Remodelling was noted with constriction alone, without inflammation. This may suggest a role for LABA in preventing remodelling - an interesting possibility (NEJM).

Inhaled steroids (ICS)

Small particle size inhaled steroids may allow for equal efficacy with 1/2 to 1/3 the dose of a larger size of same steroid.

Inhaled corticosteroids have been associated with decreased risk of cardiovascular deaths in asthmatic women. All cause mortality was lower in asthma patients on inhaled steroids. Does systemic absorption confer a benefit?

SABA update: Levalbuterol may not have any real-life advantages over albuterol. Even in Xopenex package insert, there is a mention that there was no difference in hear rate or tremor.

Antihistamines for asthma?

Symptom scores in asthma patients show comparable improvement when given desloratadine compared to montelukast. Use of antihistamine may prevent the development of asthma in some predisposed children.

Asthma in the elderly

The majority of asthma deaths are in patients older than 65.

Asthma in adults/elderly is still predominantly an atopic disease. In a University of Michigan study, 77% of adult asthma patients were skin test positive.

Depression a significant factor for poor asthma quality of life in the elderly. There was odds ratio of 10.8 for psychological dysfunction in patients with more than 3 exacerbation of asthma in a "severe asthma" cohort (reported in ERJ, 2005).

Other news from the 2011 ACAAI meeting

Text Message Reminders Prompt Kids to Take Asthma Medicine

Children from single-parent homes were more likely to be readmitted to hospital after an asthma exacerbation.

Home Environment Affects Asthmatic Kids

Air Fresheners and Scented Candles May Spur Allergic Reactions

This summary was compiled from some of the tweets posted by Dr. David Fischer @IgECPD4, Robert Silge, MD, @DrSilge, Danny Ramirez, MD @allergysa, and a few others. The tweets were labeled #ACAAI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Disclaimer: The text was edited, modified, and added to by me.

Allergen-specific immunotherapy - how does it work?

Allergen-specific immunotherapy has been used for 100 years as a desensitizing therapy for allergic diseases. It is potentially curative and specific method of treatment.

The mechanisms of action of allergen-specific immunotherapy include:

- early desensitization
- modulation of T-and B-cell responses and related antibody isotypes
- modulation of migration of eosinophils, basophils, and mast cells to tissues, and the release of their mediators

Mechanisms of allergen-specific immunotherapy (click to enlarge the image).

Regulatory T (Treg) cells are key regulators of peripheral tolerance to allergens. Skewing of allergen-specific effector T cells to a regulatory phenotype is a key in healthy immune response to allergens and successful outcome of allergen-specific immunotherapy.

Naturally occurring forkhead box protein 3-positive CD4(+)CD25(+) Treg cells and inducible T(R)1 cells contribute to the control of allergen-specific immune responses by:

- suppression of dendritic cells that support the generation of effector T cells
- suppression of effector T(H)1, T(H)2, and T(H)17 cells
- suppression of allergen-specific IgE and induction of IgG4
- suppression of mast cells, basophils, and eosinophils
- suppression of effector T-cell migration to tissues

New strategies for immune intervention will likely include targeting of effector and Treg cell subsets.

References:

Mechanisms of allergen-specific immunotherapy. Akdis CA, Akdis M. J Allergy Clin Immunol. 2011 Jan;127(1):18-27.

Subcutaneous Immunotherapy (SCIT)

Aspergillus niger and its role in human diseases

What is it?

Aspergillus niger is a cosmopolitan fungus and perhaps the most abundant species of Aspergillus. The name niger is from Latin, black, and aspergillum, a handled sphere for dispersing water, descriptive of the brown-black conidiophore.

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.

Where is the fungus found?

Aspergillus niger is isolated from:

- house dust
- soil
- plant litter
- dried fruits
- nuts and seeds
- untreated textiles such as jute, hemp and cotton bracts
- thorns of rose bushes

Aspergillus niger damages foods such as stored fruits and vegetables, nuts and corn, oil seeds, grains, and dairy products.

Commercial use

This hard working fungus is used commercially. Aspergillus niger is industrially important since it decomposes plastic and cellulose.

It is used commercially in the degradation of organic waste such as squeeze remains from apple, potato garbage, sugar beet wastewater, in beer production, and in the production of organic acids and enzymes.

Clinical significance

Aspergillus niger is a common environmental allergen that plays a role in allergic rhinitis and asthma. It can also cause invasive disease in immunosuppressed patients.

References:

On The Cover – Aspergillus niger. Annals of Allergy, Asthma and Immunology, Volume 107, Issue 3, Page A11 (September 2011).

Pollen Walk - brief videos introduce the major environmental allergens

In this video series Dan Mork, HollisterStier Allergy Pollen Facility Manager he identifies the major allergens found throughout the United States: www.youtube.com/user/JHSAllergy

The JHSAllergy Channel currently features the "Pollen Walk" videos, a series that follows Dan Mork, Pollen Facility Manager, as he identifies the major allergens found throughout the United States. The Pollen Walk series provides an in-depth exploration of the different plants and trees that are the most common culprits of allergies. Each video covers a specific allergen, explaining how to identify the plant and providing valuable information (source: press release).

During my fellowship, we based a mini-project on one of the Pollen Walks led by Dan Mork. The residents participate in an annual "weed walk" aimed at improving the recognition of common pollen-producing plants (weeds and trees) in their area. This planned quality improvement project included the attendance of all staff members (residents, faculty, nurses, research personnel).

The residents were guided through recognizing and analyzing different pollen-producing plants in the field through an one hour walk in the field. They were encouraged to take pictures of pollen-producing plants with a digital camera. The pictures were later uploaded to a photo sharing website by Google, Inc. (Picasa Web Albums, Pollen-producing plants (weeds and trees) in Omaha, Nebraska, and the residents labeled each plant under the guidance of faculty members. This pollen-recognition project was used to improve and change practice or patient care with faculty support and supervision that guided this process.

A poster was presented during the 2009 ACAAI meeting and published in the corresponding journal: Dimov, V.; Randhawa, S.; Auron, M.; Casale, T. Digital Image Sharing Web Service for Recognition of Pollen-producing Plants in a Specific Geographic Region. American College of Allergy, Asthma & Immunology (ACAAI) 2009 Annual Meeting. Annals of Allergy, Asthma & Immunology.

Here are the photos from the Pollen Walk:

Pollen-producing plants (weeds and trees) in Omaha, Nebraska

Enhancing communication with asthma patients to improve outcomes - summary from 2011 CSACI meeting

When to discontinue SCIT? And omalizumab?

When to discontinue SCIT?

As per Dr. Robert Lanier: My goal has always been minimalist. I do one 100 shots for allergy at maintenance level at practice parameter doses and discontinue as a trial- re-institute with issues.

When to discontinue omalizimab?

Dr. Robert Lanier: With Xolair, I have pursued a similar time pattern limitation of two years thinking that is the minimal time frame to achieve immune learning. I discontinue at two years with full intent of re-institution if there is deterioriation.

References:

Omalizumab, when to discontinue? AAAAI - Ask the Expert, 2011.
Image source: Wikipedia, public domain.

Vitamin D in asthma - summary from 2011 CSACI meeting

This summary was compiled from tweets posted by Dr. Stuart Carr @allergydoc4kidz, the president of the Canadian Society of Allergy and Clinical Immunology (CSACI). The tweets were labeled #CSACI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future.

Alia Bazzy-Asaad spoke on vitamin D, asthma and allergy:

Vitamin D controls more than 500 genes, there is an enormous range of function.

Several studies support a protective role for vitamin D in asthma, but there a few negative studies that did not show a difference. Vitamin D levels correlate with lung function (NHANES III). NHANES data suggest lower vitamin D levels now compared to 20 years ago.

There was an Inverse relationship between vitamin D levels and serum IgE, eosinophils, and odds of hospitalization for asthma in Costa Rican children.

Vitamin D levels correlate with asthma control and risk of EIB in Italian children.

The risk of recurrent wheeze by age 3 was decreased with higher maternal intake of vitamin D (greater than 400 IU per day). However, a follow up study showed that cord blood levels of vitamin D correlate with the probability of wheeze over the first 3 years of life, but not asthma diagnosis by age 5.

There are fewer URTI with with higher vitamin D levels.

There is an Inverse relation between house dust mite (HDM) IgE and vitamin D levels seasonally in Australians.

Low vitamin D level at age 6 in males was associated with increased risk of asthma age 14.

Disclaimer: The text was edited, modified, and added to by me. I was invited to speak on the topic of social media use by the allergists during the 2011 CSACI meeting.

Editor's notes:

Despite the ability to get vitamin D from food and the sun, an estimated 40%-75% of people are deficient. The sun is not a reliable source.

Vitamin D is naturally present in few foods. Since 1930, virtually all cow's milk in the U.S. has been voluntarily fortified with 100 IU of vitamin D per cup.

The IOM committee set a level of 4,000 IU as the ‘tolerable upper limit' or the maximum amount of vitamin D that is safe to consume daily. In July 2011, the Endocrine Society Practice Guidelines published recommendations for the evaluation, treatment, and prevention of vitamin D recommending an upper limit of 10,000 IU/day.

Your health care provider can check your vitamin D blood level with a simple blood test.

A minimum vitamin D blood level of 30 nanograms/ml (25(OH)D) is an acceptable level at this time. New studies are ongoing.

References:

Are You Getting Enough Vitamin D? WebMD.

8.2% of the U.S. population has asthma - 25 million people

According to CDC’s National Center for Health Statistics:

- 8.2% of the U.S. population has asthma, or about 25 million people

- 3,395 asthma deaths were reported in 2008

- asthma accounted for 10.5 million lost school days and 14.2 million lost work days in 2008

- 4.2% of the population in 2009 reported at least one asthma attack in the previous year

"How Asthma Makes Me Feel" video. The Allergy & Asthma Network Mothers of Asthmatics (AANMA) asked children to tell us—in pictures and in their own words—how they felt during an asthma attack, and how they felt when they could breathe again. What they told us was enlightening—and heart-rending.

Learn what you can do to control your asthma at http://cdc.gov/VitalSigns/asthma

References:

FASTSTATS - Asthma - Centers for Disease Control and Prevention
Asthma a Problem for Millions. WebMD, 2011.

FeNO use in asthma monitoring - summary from 2011 CSACI meeting

This summary was compiled from tweets posted by Dr. Stuart Carr @allergydoc4kidz, the president of the Canadian Society of Allergy and Clinical Immunology (CSACI). The tweets were labeled #CSACI and they reached more than 10,000 people. I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future.

This summary is from the debate on FeNO (Jonathon Malka) vs. sputum eos (Param Nair) in asthma monitoring.

Pros

FeNO can be helpful in children with suggestive symptoms for asthma but normal lung function. Elevated FeNO predicts better inhaled steroid response, and may increase the acceptance of anti-inflammatory therapy (ICS).

FeNO can be helpful in distinguishing poor asthma control vs. confounders such as GERD.

FeNO can be a useful marker of adherence, and it can prevent unnecessary investigations or therapy changes.

A persistently elevated FeNO is associated with lung function loss over time (according to the TREXA study).

FeNO helps the diagnosis of primary ciliary dyskinesia - if very low in both nose and lungs.

Cons

However, FeNO-based therapy does not decrease asthma exacerbations. FeNO levels are not well correlated with eosinophil levels (based on an anti-IL5 study). It may not tell us what we've assumed - that elevated FeNO is associated with eosinophil infiltrate in bronchial mucosa.

There are too many factors that impact FeNO (including sham odor exposure) to be consistently useful.

Persistent sputum eosinophilia predicts favorable clinical response to anti-IL5.

Disclaimer: The text was edited, modified, and added to by me. I was invited to speak on the topic of social media use by the allergists during the 2011 CSACI meeting.

Only 2-6% of patient candidates receive SCIT, despite potential cost savings of up to 80%

This JACI review discusses health economics of allergen-specific immunotherapy (SCIT) in the U.S.

19 published studies report that allergen-specific immunotherapy (SIT) may decrease health care costs. The studies were conducted outside and within the U.S.

The magnitude of these savings has varied, with up to an 80% reduction in costs seen 3 years after completion of treatment.

As more sophisticated and higher cost drugs, biologics, and medical devices proliferate, it becomes tempting to assume their superiority over traditional treatment such as SIT. However, this is not the case. For example, SCIT is as effective as intranasal steroids for allergic rhinitis, and has the potential to change the long-term course of the disease.

Currently, SIT is used by only a minority (2% to 6%) of appropriate U.S. patient candidates.

As of this centennial year for allergen immunotherapy, health economic attributes of SCIT remain largely unexplored in the U.S. As the only disease-modifying treatment available to patients with allergies, this standard of care must be benchmarked.

Mechanisms of allergen-specific immunotherapy (click to enlarge the image).

References:

Health economics of allergen-specific immunotherapy in the United States. The Journal of Allergy and Clinical Immunology, Volume 127, Issue 1 , Pages 39-43, January 2011.
Image source: OpenClipArt.org, public domain.

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