Immunotherapy Basics Part 1 - Dr. Jay Portnoy reviews the basics of allergen immunotherapy (allergy shots) starting with its history and the extracts used to administer it. Held on August 13, 2012.
Immunotherapy Basics Part 2 - Dr. Jay Portnoy describes the process for writing a prescription for allergen immunotherapy (allergy shots). Held on August 13, 2012.
The two lectures are part of the ACAAI COLA YouTube channels that features more than 100 online conferences focused on allergy and immunology. The project is hosted by the allergy and immunology department at Mercy Children's Hospital in Kansas City and features many outside speakers.
Mechanisms of allergen-specific immunotherapy (click to enlarge the image):
This study from Turkey included 76 children 6 to 11 years of age (mean age 8.7) with asthma who completed Childhood Asthma Control Test (C-ACT) and underwent fractional concentration of exhaled nitric oxide (FeNO) and spirometric measurements during the monthly clinic visits.
A C-ACT score of 22 or less had 69% sensitivity and 77% specificity in determining not well-controlled asthma, whereas an FeNO value of 19 ppb or higher had 61% sensitivity and 59% specificity. Receiver operating characteristic curve analysis revealed that the C-ACT was better than FeNO for identifying patients with uncontrolled asthma.
A C-ACT score of 22 or less (odds ratio, 8.75) and an FeNO of 19 ppb or greater (odds ratio, 2.60) were indicators for uncontrolled asthma.
The authors concluded that C-ACT is superior to FeNO in determining the control status of children with asthma.
Editor’s note: Measurement of fractional concentration of exhaled nitric oxide (FeNO) has its place in the care of adults and children and is incorporated in the asthma guidelines (http://ajrccm.atsjournals.org/content/184/5/602.abstract). However, considering the cost of the device (for example, Niox Mino is priced above $3,000 in the U.S.), the use of a simple paper- or computer-based C-ACT score test has obvious cost-saving advantages. It is encouraging to have the scientific evidence that supports that this cost-saving approach can also be more accurate in children with asthma.
The Childhood Asthma Control Test∗: Retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. JACI, 2010 http://bit.ly/Rid5Nl
Comments from Twitter:
Dr John Weiner @AllergyNet: Reassuring. Many of us use ACT
This study from Australia included 147 children at high atopic risk who were followed from birth to age 10 yrs. Atopy was measured by skin prick tests at 6 months, and 2 and 5 yrs. History of wheeze and doctor-diagnosed eczema and asthma was collected regularly until 10 yrs of age.
At 10 yrs, 60% of the cohort was atopic, 26% had eczema, 18% asthma and 20% persistent wheeze. 36% experienced at least one lower respiratory infection (LRI) associated with fever and/or wheeze in first year of life.
Children who had wheezy or, in particular, febrile LRI in infancy and were atopic by 2 yrs, were much more likely to have persistent wheeze (RR 3.51) and current asthma (RR 4.92) at 10 yrs.
Severe viral respiratory infections in infancy and early atopy are risk factors for persistent wheeze and asthma. The strongest marker of the asthmatogenic potential of early life infections was concurrent fever. The study conclusions are interesting especially in the light of the recent hypothesis that implicates acetaminophen (paracetamol) in the etiology of pediatric asthma. Many children with febrile respiratory illness receive acetaminophen (paracetamol) as symptomatic therapy which may aggravate or confound their risk profile.
Here are my suggestions for some of the top articles about allergic rhinitis for July 2012:
It will be at least 5 to 10 years before oral immunotherapy for food allergy could be used clinically. A single 'failure' of oral immunotherapy for food allergy could result in a serious, even life-threatening reaction http://buff.ly/PE3pQv
The latest on oral immunotherapy for food allergy - video by the director of Mass General food allergy center http://bit.ly/TII88O
Long-ago asthma diagnosis didn't explain boy’s difficulty breathing - The Washington Post http://wapo.st/QGMfTC
Epinephrine Self-Administration in Anaphylaxis: EpiPen delivers 74% of the dose vs. 26% for Anapen, Twinject, Adrenaclick http://goo.gl/oms0A - Syringe-based autoinjectors (eg, Anapen, Twinject, and Adrenaclick) are only capable of delivering 25.7% of the total 300 µg (77 µg or 0.08 mL of the 0.3 mL) of the dose contained in the device, whereas the EpiPen autoinjector (a cartridge-based device) delivers 74.3% (223 µg or 0.22 mL of the 0.3 mL) of the dose contained in its device.
Anaphylaxis: When It Comes to Education, Give Them All They Need and More http://bit.ly/Pexwcy
Allergy to beer in LTP-sensitized patients: beers are not all the same. Skin testing can identify the culprit http://buff.ly/PrX3zg
Suspect co-factor enhanced food allergy in food, alcohol, exercise and NSAID allergic reactions http://buff.ly/PrXhqa
The Use of Complementary and Alternative Medicine by Pediatric Food-Allergic Patients in Japan http://buff.ly/MnB1TP
Price of life-saving allergy injections has spiked: EpiPen price has more than doubled over the past 25 years http://buff.ly/Ps21vI
Experimental "skin patch could free thousands of sufferers from peanut allergy" http://goo.gl/AFCq7
Negligible risk of allergic reactions to wine in patients allergic to milk, egg, fish (despite traces of casein, isinglass, egg found in wine) http://goo.gl/zzK3O
EpiPen manufacturer offers free injectors to US schools http://bit.ly/ND8JDf -- Coincides with launch of voice-guided, smaller competing device
New Epinephrine Auto-Injector Talks Patients Through Injection Process, has a 5-second countdown, signaling lights http://goo.gl/rYJZI
The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.
Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.
Dr. Phil Lieberman reviews new information about the causes and treatment of anaphylaxis for COLA video lectures. Held on July 9, 2012.
The Conferences Online Allergy (COLA) initiative, led by Jay Portnoy, has been a great service to the allergy and immunology community in the U.S. and worldwide. Most of the talks from the past year are available online for free on YouTube and can be watched from any internet connected device from any corner of the world.
COLA is the ultimate experience in remote education in the field of allergy and immunology. It was made possible by the efforts of the team assembled by Dr. Portnoy and the free servers and bandwidth provided by Google.
Dr. Lieberman is one of the leading experts on anaphylaxis and his video lecture should be on your must-watch YouTube list.
How the allergens change during the season: mnemonic TGR MI DC/DC ("a Tiger with an MI went to DC") "There's spring time, where you have the tree pollen. Summer time, where you have the grass pollens. And then there's the fall time when you have the weed pollen.”
This sequence is remembered by the mnemonic TGR MI DC/DC ("a Tiger with an MI went to DC").
Pollen calendar: TGR MIDC/DC
Tree pollens Grass pollens Ragweed and weed pollen
Characteristics of allergic sensitization among asthmatic adults older than 55 years: results from the National Health Allergy Season Year Round. WTOC-TV Savannah. Interactive Allergy Map by Greer Labs. Click your state to find region-specific, common airborne allergens there.
‘Botanical sexism’ blamed for making life miserable for allergy sufferers as male trees fill city skies with pollen http://goo.gl/cx5tH
Interactive Allergy Map by Greer Labs. Click your state to find region-specific, common airborne allergens there.
‘Botanical sexism’ blamed for making life miserable for allergy sufferers as male trees fill city skies with pollen http://goo.gl/cx5tH
Upregulation of glucocorticoid receptor beta (GR beta) has been implicated in steroid resistance in severe asthma in previous studies with some conflicting results. GR beta has been proposed as a dominant negative isoform of glucocorticoid receptor alpha (GR alpha). It has been suggested that GR beta can cause steroid resistance via reduced expression of histone deacetylase 2 (HDAC2).
Epigenetic determinants activate or silence genes through alterations in DNA, histone methylation and acetylation.
DNA associates with histone proteins to form chromatin. Image source: Wikipedia, GNU Free Documentation License.
This bronchoscopic study from two UK centres found that protein and RNA expression for GR alpha, GR beta, and HDAC2 did not differ between patients with different asthma severity and controls. HDAC1 expression was increased in patients with severe asthma compared with healthy volunteers.
The authors concluded that HDAC1 and HDAC2 expression was not downregulated in severe asthma. These data do not support upregulated GR beta and reduced HDAC expression as the mechanism of steroid resistance in severe asthma. Conflicting literature findings may be explained by cross-reactivity of commercially-available antibody tests.
The diagnosis of asthma in younger children is difficult and based on clinical assessment of symptoms and results of physical examination. Respiratory wheeze has traditionally been used to define asthma in young children but there have been concerns that this definition is too narrow and may miss children with milder asthma who do not wheeze but have other symptoms such as cough or shortness of breath.
Here is what wheezing sounds like (click to play the embedded video):
This study from Denmark included 411 children born to asthmatic mothers that were followed prospectively to age 7 years (313 had the full follow-up).
The total number of acute clinic visits for asthma symptom was associated with later asthma (P < .0001), whereas the presence of wheeze at these visits was not (P = .5). The number of clinic visits for troublesome lung symptoms was also associated with later asthma in children who had never presented with any wheeze.
A quantitative global assessment of significant troublesome lung symptoms in the first 3 years of life is a better predictor of asthma than assessment of wheeze. Doctor-diagnosed wheeze is not a prerequisite for the diagnosis of asthma, and relying on the symptom of wheeze will likely be an important cause of undertreatment.
Editor’s note: The findings of this study are significant considering the widely used modified Asthma Predictive Index relies on 4 wheezing episodes during the past year (http://www.jacionline.org/article/S0091-6749(10)01034-1/abstract). Future predictive tools may need to incorporate symptoms other than wheezing to achieve better accuracy and clinical applicability.
There is a way of understanding how much modern medicine has to offer individual patients. A simple statistical concept called the “Number-Needed-to-Treat” (NNT) offers a measurement of the impact of a medication or therapy by estimating the number of patients that need to be treated in order to have an impact on one person.
Here are a few examples pertinent to allergy and immunology
Combination Inhalers (Steroids Plus Bronchidilators) for Childhood Asthma | The NNT http://goo.gl/0rh9u
Combination Inhalers (Steroids Plus Bronchidilators) for Adult Asthma | The NNT is 73 for asthma attack prevention http://goo.gl/ZgNir
Here are my suggestions for some of the top articles about immunodeficiency for August 2012:
Primary immunodeficiency disease can be overlooked for years - one patient's story: http://goo.gl/P8VCk - People with primary immunodeficiency also face another hurdle with insurance, largely because antibody replacement therapy is very expensive — $200,000 or more a year.
TLR9 and MyD88 play central role in protective immunity to malaria http://goo.gl/VVF07
Interpretation of antibody response to pneumococcal vaccines - AAAAI Ask the Expert http://goo.gl/J2HEc
The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.
Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.
Chitin (C8H13O5N) is a long-chain polymer of a glucose derivative. It is the main component of the cell walls of fungi, the exoskeletons of arthropods, such as crustaceans (crab, lobster and shrimp) and insects, including ants, beetles, etc. The English word "chitin" was derived from the Latin word "chitōn", meaning mollusk. Chitinases are digestive enzymes that break down glycosidic bonds in chitin.
A cicada sheds its chitinous exoskeleton. Image source: Wikipedia, Creative Commons "Attribution ShareAlike 2.0 France" Licence.
Structure of the chitin molecule. Image source: Wikipedia, public domain.
Chitinases are digestive enzymes that break down glycosidic bonds in chitin. Because chitin composes the cell walls of fungi and exoskeletal elements of some animals (including worms and arthropods), chitinases are generally found in organisms that either need to reshape their own chitin or to dissolve and digest the chitin of fungi or animals (source: Wikipedia).
Chitinase from barley seeds. Image source: Wikipedia, public domain.
Bronchial remodeling, including increased bronchial smooth muscle (BSM) mass, contributes to bronchial obstruction in asthma. A role of the chitinase 3-like 1 protein (YKL-40) has been evoked in asthma.
This study from France enrolled 40 patients with asthma. Bronchial specimens obtained by fiberoptic bronchoscopy or lobectomy, and cell proliferation was assessed. The involvement of protease activated receptor (PAR)-2 and YKL-40 was analyzed in both asthmatics and controls.
YKL-40 increased BSM cell proliferation and migration through PAR-2 dependent mechanisms. YKL-40 epithelial expression was correlated with smooth muscle mass in asthma.
This study suggests that YKL-40 promotes smooth muscle cell proliferation and migration through a PAR-2–dependent mechanism.
Here are my suggestions for some of the top articles about food allergy for August 2012:
Food Allergy in Preschool Children: high frequency of reactions caused by accidental and nonaccidental exposures. Undertreatment of severe reactions with epinephrine was a substantial problem. Areas for improved education include the need for constant vigilance, accurate label reading, avoidance of nonaccidental exposure, prevention of cross-contamination, appropriate epinephrine administration, and education of all caretakers. http://buff.ly/LxscEh
The most common foods involved in allergic reactions are milk (42% of reactions), eggs (21%), and peanuts (8%). "Food allergies are unpredictable. You can't predict what a reaction will be based on past reactions." While many children outgrow milk & egg food allergies, food challenges should never be done outside of medical settings. http://buff.ly/Lc90cK
Coffee Anyone? Are You at Risk of Allergy? (editorial review) http://goo.gl/2Jf2H
Dust of green coffee beans can cause occupational allergy - chitinase of C. arabica identified as the first known coffee allergen Cof a 1. Note: this is inhalational, not food allergy http://buff.ly/QfcYnJ
Red Meat Allergies Triggered by Tick Bite – Allergist Dr Bassett on Fox News http://goo.gl/dTd3K
Clinical Allergy and Immunology - 2011 free full text review in Ulster Med J. http://goo.gl/1GE0o
A self-regulation intervention can improve quality of life for families with food allergy - JACI http://goo.gl/KFnsj
Eating peanut/tree nuts during pregnancy may decrease asthma and rhinitis in children - Danish Birth Cohort study http://goo.gl/jfaZM
Why the tests using recombinant, or artificially produced proteins can fail to diagnose peanut allergy http://bit.ly/POpE7l
Mothers who are breast-feeding should avoid eating foods to which an infant is allergic - AAAAI Ask the Expert http://goo.gl/FcN2p
Two chemotactic cytokines could act as markers of the effectiveness of a desensitization protocol in milk allergy http://buff.ly/LKBER7
Dating Anxiety in Adolescents and Young Adults With Food Allergies (study) http://goo.gl/lDPnX
Sanofi Announces FDA Approval for Auvi-Q, First Voice-guided Epinephrine Auto-injector http://goo.gl/4GfPr
The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.
Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.
Sir David Jack, the former Director of Research and Development at Glaxo, died in November 2011 at the age of 87 years. He probably did more to benefit patients with asthma and chronic obstructive pulmonary disease than anyone else in history, according to his obituary in the journal Thorax written by Peter J Barnes.
Sir David Jack discovered:
- the first beta-2-selective agonist (salbutamol, called albuterol in the U.S.)
- the first inhaled corticosteroid (beclomethasone dipropionate)
- the first long-acting beta-2-agonist (salmeterol)
- the most widely used inhaled corticosteroid (fluticasone propionate)
- the best-selling asthma treatment of all time (Seretide. called Advair in the U.S.).
He also discovered several other important drugs, including the histamine H2-receptor antagonist ranitidine (Zantac), which became the best-selling drug of its day, and sumatriptan (Imigran), a novel therapy for migraine.
David Jack was born in is a small town in Scotland, the sixth and youngest child of a coal miner.
It is extraordinary that the other great drug discoverer of our time, Sir James Black, who went on to discover beta-blockers and histamine H2-receptor antagonists, was born in the same year (1924) in a nearby village.
Nick Watts, Feb 19, 2012: I can't believe that one man discovered what is basically the entire first couple of steps of the modern treatment for asthma. Thanks for the share.
Dr John Weiner @AllergyNet: Thanks Ves, I was unaware of this. His obit: http://www.telegraph.co.uk/news/obituaries/finance-obituaries/8897458/Sir-David-Jack.html
A decade ago celiac disease was considered extremely rare outside Europe and, therefore, was almost completely ignored by health care professionals.
In only 10 years, key milestones have moved celiac disease from obscurity into the popular spotlight worldwide.
Now we are observing another interesting phenomenon that is generating great confusion among health care professionals. The number of individuals embracing a gluten-free diet (GFD) appears much higher than the projected number of celiac disease patients, fueling a global market of gluten-free products approaching $2.5 billion (US) in global sales in 2010.
This trend is supported by the notion that, along with celiac disease, other conditions related to the ingestion of gluten have emerged as health care concerns.
This review summarized the current knowledge about the 3 main forms of gluten reactions:
- allergic (wheat allergy)
- autoimmune (celiac disease, dermatitis herpetiformis and gluten ataxia)
- possibly immune-mediated (gluten sensitivity). We need to be extremely cautious in calling somebody gluten sensitive. It may be sensitivity to FODMAPs instead. It could have nothing to do with gluten at all. http://buff.ly/1k2UjNW
New nomenclature and classifications are proposed (see the figures below).
New classification is being proposed for gluten-related disorders: celiac disease; dermatitis herpetiformis; gluten ataxia; wheat allergy; gluten sensitivity. WSJ, 2012.
Recent studies support the existence of the new condition nonceliac gluten sensitivity which is defined as symptoms with negative celiac antibodies and biopsy (http://goo.gl/57IlB).
Dr. Francisco Bonilla describes how to evaluate a patient with recurrent infections for primary immunodeficiency for COLA video lectures. Held on July 6, 2012.
Measurement of whole peanut-specific IgE (sIgE) is often used to confirm sensitization but does not reliably predict allergy. Ara h 2 is the dominant peanut allergen detected in 90% to 100% of patients with peanut allergy. Ara h 2 IgE could help improve diagnosis of peanut allergy.
This study from Australia included 200 infants from the population-based HealthNuts study who underwent:
- skin prick tests to determine peanut sensitization
- a peanut oral food challenge (OFC) to confirm allergy status
By using the previously published 95% positive predictive value of 15 kU(A)/L for whole peanut sIgE, a corresponding specificity of 98% was found in this study.
At the equivalent specificity of 98%, the sensitivity of Ara h 2 sIgE is 60%, correctly identifying 60% of subjects with true peanut allergy. This is compared with only 26% correctly identified by using whole peanut sIgE.
When using a combined approach of sIgE testing for whole peanut followed by Ara h 2 for the diagnosis of peanut allergy, the number of oral food challenges (OFC) required was reduced by almost two thirds.
The authors concluded that Ara h 2 plasma sIgE test levels provide higher diagnostic accuracy than whole peanut plasma sIgE levels. It is a new diagnostic tool to distinguish peanut allergy from peanut tolerance, which might reduce the need for an oral food challenge (OFC).
Editor's note: The test costs $300 in the U.S. and is not covered by most health insurances (uKnow Peanut from Phadia http://bit.ly/OJjRyI).
This video by the manufacturer of sIgE assays Phadia tries to explain the concept of Molecular Allergology in two minutes:
References:
Increasing the accuracy of peanut allergy diagnosis by using Ara h 2. Dang TD, Tang M, Choo S, Licciardi PV, Koplin JJ, Martin PE, Tan T, Gurrin LC, Ponsonby AL, Tey D, Robinson M, Dharmage SC, Allen KJ; HealthNuts study. J Allergy Clin Immunol. 2012 Feb 29. [Epub ahead of print]
Peanut allergy: Diagnostic accuracy of sIgE to Ara h 6 in adults is as good as Ara h 2 http://buff.ly/1uU314i
Food allergies can result in life-threatening reactions and diminish quality of life. In the last several decades, the prevalence of food allergies has increased.
More than 170 foods have been identified as being potentially allergenic but a minority of these foods cause the majority of reactions (8 food allergens cause 90% of reactions). Please have in mind that the common food allergens vary between geographic regions.
8 foods cause 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):
Treatment of food allergy involves strict avoidance of the trigger food.
Medications, such as epineprine, manage symptoms of disease, but currently, there is no cure for food allergy. OIT and herbal formula trials are ongoing but there is no conclusive evidence of sustained benefit yet.
References:
ICON: Food allergy. Burks AW, Tang M, Sicherer S, Muraro A, Eigenmann PA, Ebisawa M, Fiocchi A, Chiang W, Beyer K, Wood R, Hourihane J, Jones SM, Lack G, Sampson HA. J Allergy Clin Immunol. 2012 Feb 22. [Epub ahead of print]
Here are my suggestions for some of the top articles about anaphylaxis for July 2012:
Epinephrine IM injection in the thigh (but not the upper arm) results in fastest rise of blood levels of epinephrine http://j.mp/HNwwK0
Paucis Verbis: Anaphylaxis - from Academic Life in Emergency Medicine http://goo.gl/ZCS0J
Management of anaphylaxis in schools: Despite training, school personnel perform poorly when asked to demonstrate EpiPen http://bit.ly/I5R3Ld
Anaphylaxis caused by skin contact with persulfates in hair-bleaching products - prick and patch tests can help http://goo.gl/FXvMM
Lessons to Learn from Anaphylaxis Deaths - Atopic Girl's Guide to Living http://goo.gl/anaUf
FDA Sends Warning Letter to Pfizer Over EpiPen Ads - full text here: http://goo.gl/0ITDf
Involvement of the dog allergen Can f 5 in a Case of Human Seminal Plasma Allergy http://goo.gl/cQSvj
BMJ Learning @BMJLearning: Once again, our most popular module: Anaphylaxis: an update on management ow.ly/bp2yD
Epinephrine in the treatment of anaphylaxis. Adult intramuscular dose is 0.3 to 0.5 ml of 1:1,000 concentration http://goo.gl/Qad6S
Rapidly-disintegrating sublingual 40 mg epinephrine tablet had similar bioavailability to epi 0.3 mg autoinjector http://goo.gl/LyzyU
Epinephrine Self-Administration in Anaphylaxis: EpiPen delivers 74%of dose vs. 26% for Anapen, Twinject, Adrenaclick http://goo.gl/oms0A - Syringe-based autoinjectors (eg, Anapen, Twinject, and Adrenaclick) are only capable of delivering 25.7% of the total 300 µg (77 µg or 0.08 mL of the 0.3 mL) of the dose contained in the device, whereas the EpiPen autoinjector (a cartridge-based device) delivers 74.3% (223 µg or 0.22 mL of the 0.3 mL) of the dose contained in its device.
The articles were selected from my Twitter stream @Allergy and Google Reader RSS subscriptions. Some of the top allergy accounts on Twitter contributed links. I appreciate the curation provided by @JuanCIvancevich @AllergyNet @IgECPD4 @DrAnneEllis @AACMaven @AllergieVoeding @allergistmommy @mrathkopf @wheezemd.
Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.
Comments from Twitter:
Dr John Weiner @AllergyNet: That’s after 2.5secs. 10secs amount not reported. I have asked Anapen distributor in Australia to respond. Will follow-up
@Allergy: re: Epi & "That’s after 2.5secs. 10sec amount not reported" - 90% of EpiPen dose gets in 1 sec according to a recent Annals letter.
Dr John Weiner @AllergyNet: @Allergy Thanks Ves, useful info. Anapen distributor is seeing if their in-house registration data is available for release. Update: Aussie reg agency says Anapen delivers full dose.
Researchers from Cleveland Clinic (disclaimer: I had worked with several of them prior to 2008) conducted a chart review of 72 patients who had patch testing for allergic contact dermatitis related to orthopedic implants.
The 72 patients with potential metal hypersensitivity from implanted devices were divided into 2 groups depending on timing of their patch testing:
History of hypersensitivity to metals was a predictor of positive patch test results to metals in both groups.
Positive patch test results indicating metal hypersensitivity influenced the decision-making process of the referring surgeon in all preimplantation cases.
All those patients with metal hypersensitivity who received an allergen-free implant had surgical outcomes free of hypersensitivity complications.
In patients who had positive patch test results to a metal in their implant after implantation, removal of the device led to resolution of associated symptoms (6 of 10 patients).
Patch testing should be perfomed in patients with a clinical history of metal hypersensitivity before prosthetic device implantation. The decision on whether to remove an implanted device after positive patch test results should be made on a case-by-case basis.
This study from Sweden evaluated 3,000 children at ages 1, 2, 4, 8 and 12 years. Parental questionnaires were used to obtain data on allergy-related diseases.
At 12 years, 58% of the children had eczema, asthma and/or rhinitis at some time of their lives. Disease turnover was high for all three diseases throughout the study.
Comorbidity increased with age, and at 12 years, 7.5% of all the children were affected by at least two allergy-related diseases.
- increased comorbidity
- more persistent disease
- increased the risk of having any allergy-related disease (adjusted OR 1.76) up to 12 years
Male sex was associated with an increased risk throughout childhood.
Allergy-related diseases affects a majority of children (58%). Eczema, asthma and rhinitis develop dynamically throughout childhood, and allergic comorbidity is common.
Allergy-related diseases should be neither seen nor studied as isolated entities. In any patient with one allergy-related condition, always look for the 4 components of the "allergic march":
