Allergy Notes

Hypersensitivity reactions to paracetamol (acetaminophen, Tylenol) appear to be increasing

2013-05-22T09:00:00.000-04:00

Hypersensitivity reactions to paracetamol (acetaminophen, Tylenol) appear to be increasing, but there are few prevalence data.

This study included 32 patients with suspected paracetamol allergy who underwent skin tests and an oral challenge.

Patients presented with a combination of urticaria, angioedema (face, hands), erythema (cutaneous features in 94%), dyspnea (including laryngeal edema), rhinoconjunctivitis, cough, abdominal pain and anaphylaxis.

Only 2 patients had a positive skin prick test (SPT) and unequivocal history of acute urticaria/facial angioedema/conjunctivitis/cough after paracetamol. One patient had a positive intradermal test.

Oral challenge was positive in 15 of 31 patients (including self-challenge in 4).

Overall, paracetamol hypersensitivity was confirmed in 50% patients.

75% of paracetamol-allergic patients tolerated NSAIDs. 25% were intolerant of NSAIDs.

Specific IgE may be a mechanism underlying paracetamol hypersensitivity in some patients. In 81% of patients, negative skin tests did not exclude paracetamol hypersensitivity, suggesting that it may be mediated by leukotrienes.

The authors suggested that in suspected paracetamol allergy, skin tests should be performed along with oral challenge.

References:

Paracetamol Hypersensitivity: Clinical Features, Mechanism and Role of Specific IgE. Rutkowski K, Nasser SM, Ewan PW. Int Arch Allergy Immunol. 2012 May 3;159(1):60-64.
http://goo.gl/zZp9q

Comments from Google Plus:

Ahmad Gandour: This study only included 32 we need a larger study ?

Boyan Hadjiev: Better 32 than just case reports. This type of study takes lots of time and energy. The makers of Tylenol would certainly NOT sponsor it (or so I am inclined to believe). I say kudos to the researchers. Still if you look at results, you can't rely on ANY skin tests to predict outcome at all!!! Sounds like oral challenge is the only way, and it was positive in 50% of patients. That's pretty low.

Atopic dermatitis associated with food allergy accelerates progression of allergic march

2013-05-20T08:30:00.000-04:00

Studies demonstrate the comorbidity of food allergy (FA) and allergic march. This study assessed prevalence and comorbidity of allergic diseases in 3,000 Japanese students.

The lifetime prevalence of allergic rhinitis (AR), atopic dermatitis (AD), bronchial asthma (BA), and FA was 36%, 16%, 10%, and 7%, respectively.

Comorbidity with AD lowered the onset age of both BA and AR. Comorbidity with FA was the highest risk factor for the progression of allergic march.

AD associated with FA accelerates the subsequent progression of allergic march.

Allergic (atopic) march (click here to enlarge the image):

References:

Prevalence and impact of past history of food allergy in atopic dermatitis. Kijima A, Murota H, Takahashi A, Arase N, Yang L, Nishioka M, Yamaoka T, Kitaba S, Yamauchi-Takihara K, Katayama I. Allergol Int. 2013 Mar;62(1):105-12. doi: 10.2332/allergolint.12-OA-0468. Epub 2012 Dec 25.

Cross-reacting allergens between fish, shellfish, arachnids, and insects

2013-05-14T08:30:00.000-04:00

The increased consumption of fish and shellfish has resulted in more frequent reports of adverse reactions to seafood.

Cross-reactivity is a problem

Potential cross-reacting allergens have been identified within the fish family and between shellfish, arachnids, and insects.

Prick-to-prick tests may be needed

The diagnostic approach may require prick-to-prick tests using crude extracts of both raw and cooked forms of seafood for screening seafood sensitization. This approach may be required before a food challenge or where food challenge is not feasible.

Different epitopes may explain different disease severity

IgE antibodies from individuals with persistent allergy may be directed against different epitopes than those in patients with transient allergy.

Mutated proteins as future immunotherapy

Mutated less allergenic seafood proteins have been developed for allergen-specific immunotherapy but this approach is still experimental and not ready for prime time.

References:

Fish and shellfish allergy in children: Review of a persistent food allergy. Tsabouri S, Triga M, Makris M, Kalogeromitros D, Church MK, Priftis KN. Pediatr Allergy Immunol. 2012 May 3. doi: 10.1111/j.1399-3038.2012.01275.x. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/22554093?dopt=Abstract

Image source: Gadus morhua, Atlantic cod. Wikipedia, public domain.

Comments from Twitter:

Dr. Ellis @DrAnneEllis: Crustaceans are the "bugs of the sea"

Prescribing inhaled steroid during ED visit for asthma decreases admissions, saves $7k per 100 patients

2013-05-13T09:30:00.000-04:00

This cost-effectiveness analysis compared 3 ED-based inhaled corticosteroid (ICS) delivery options:

- usual care (recommending outpatient follow-up)
- prescribe (uniformly prescribing ICS)
- dispense (uniformly dispensing ICS)

Rates of ED relapse visits and hospitalizations within 1 month of ED visit were compared across all 3 arms.

Rate of return to ED per 100 patients within 1 month of the ED visit was 10 visits for the usual care arm, 9 visits for the prescription arm, and 8 visits for the medication-dispensing arm. Rates of hospitalization per 100 patients were 2.4, 2.2, and 1.9, respectively.

Including indirect costs related to missed parental work, total costs per 100 patients were $27,100, $22,000, and $20,100, respectively. Total cost savings per 100 patients comparing the usual care arm with the medication dispensing arm was $7000.

This study suggests that uniform prescribing or dispensing of ICS at the time of ED visit for asthma may lead to a decreased number of ED visits and hospital admissions within 1 month and provides substantial cost-savings.

Asthma Inhalers (click to enlarge the image).

References:

A Cost-Effectiveness Analysis of Inhaled Corticosteroid Delivery for Children with Asthma in the Emergency Department. Annie Lintzenich Andrews, et al. The Journal of Pediatrics, Volume 161, Issue 5 , Pages 903-907.e1, November 2012
http://www.jpeds.com/article/PIIS002234761200532X/abstract

Image source: Image source: FDA and Wikipedia, public domain.

Auvi-Q inventors -- twins with food allergies -- profiled by CNN

2013-05-09T09:00:00.000-04:00

From CNN:

Evan and Eric Edwards have life-threatening allergies and wanted to develop a better way to deliver epinephrine, a drug used to treat serious allergic reactions. Their vision started shortly after graduating from high school and became a reality 15 years later. About a month after Auvi-Q's launch, a mother described how her daughter had a severe allergic reaction. She described how Auvi-Q helped her by "having a voice walking through the steps in an emergency situation." In her opinion, Auvi-Q saved her daughter's life.

References: Twins create life-saving allergy device - CNN.com http://bit.ly/10HKplg

How to use a metered dose inhaler (MDI) - CDC teaching videos

2013-05-08T13:03:00.005-04:00

Using a metered dose inhaler with a spacer:

Using a metered dose inhaler (inhaler in mouth):

Using a metered dose inhaler one to two inches from mouth:

Inhaled steroids at high doses may cause adrenal insufficiency

2013-05-03T08:30:00.000-04:00

Adrenal insufficiency is a potential complication of therapy with inhaled corticosteroids (ICS). Previous studies found the highest risk of adrenal insufficiency with fluticasone. This study reexamined the relationship between the use of ICS and adrenal insufficiency by using a cohort of patients treated for respiratory conditions during 1990-2005 in Quebec, Canada, with follow-up until 2007.

Cases of adrenal insufficiency were matched with up to 10 controls. 392 cases were identified (incidence rate=1/10,000 person-years). The rate of adrenal insufficiency was not significantly higher among all current users of ICS. However, patients receiving the highest dosages showed a greater risk (OR=1.84).

Inhaled corticosteroids at high doses appear to be a significant independent risk factor for adrenal insufficiency. Physicians prescribing ICS at higher doses should be aware of the signs and symptoms of adrenal insufficiency in their patients.

Asthma Inhalers (click to enlarge the image).

References:

The use of inhaled corticosteroids and the risk of adrenal insufficiency. Lapi F, Kezouh A, Suissa S, Ernst P. Eur Respir J. 2012 Oct 11. http://www.ncbi.nlm.nih.gov/pubmed/23060630

No effect from montelukast on respiratory symptoms and lung function in wheezy infants

2013-04-29T09:00:00.000-04:00

This study from Finland investigated the effectiveness of montelukast in recurrently wheezy infants and randomized 113 children (6–24-month-old) with recurrent wheezing to receive either placebo or montelukast daily for an 8-week period.

There was no significant difference in symptom-free days between the two groups, or the use of rescue medication, exhaled nitric oxide fraction (FeNO) or airway parameters measured by whole-body plethysmograph, squeeze technique, and methacholine challenge.

Montelukast therapy did not influence the number of symptom-free days, use of rescue medication, or lung function in recurrently wheezy, very young children.

Not all wheezing is asthma

Wheezing occurrences in children:

- single episode in 30% to 50% of children before 5 yr of age
- 40% who wheeze before 3 yr of age continue at 6 yr (“persistent wheezers”)
- 50% of infants who wheeze once will wheeze again within several months

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

Childhood asthma phenotypes:

- transient early wheezers - wheeze sometime during first year of life; risk factors include prematurity, history of parental smoking during pregnancy, and passive exposure to tobacco smoke; such patients do not respond to inhaled bronchodilators or inhaled corticosteroids (ICS); wheezing tends to remit as child’s airway gets larger (between ages 2-3 yr)

- nonatopic wheezers - 0 to 6 yr of age; wheeze associated exclusively with viral infection; usually no eczema or family history; wheezing tends to remit by 6 yr of age

- atopic wheezers - past 5 yr of age, allergic - have positive blood and skin testing to inhalant allergens; tend to present within 2 to 3 yr of age, and continue to wheeze; wheezing not related to URTI

Childhood asthma phenotypes (click to enlarge the image).

References:

The effect of montelukast on respiratory symptoms and lung function in wheezy infants. Anna S. Pelkonen et al. ERJ March 1, 2013 vol. 41 no. 3 664-670. http://erj.ersjournals.com/content/41/3/664.short
Image source: Montelukast, from Wikipedia, the free encyclopedia, public domain.

Winning Athletes with Asthma and EIB (video)

2013-04-25T08:00:00.000-04:00

From the ACAAI Allergist channel on YouTube: The Kloser family of Colorado lives life on the edge. When competitive athletes Christian and Mike were diagnosed with asthma and exercise-induced bronchoconstriction (EIB), they refused to let it slow them down. They share their story and successful treatment from an allergist with the American College of Allergy, Asthma and Immunology (ACAAI):

Being overweight increases susceptibility to indoor pollutants among urban children with asthma

2013-04-24T08:30:00.000-04:00

This study from Johns Hopkins School of Medicine (Baltimore, Md) included 148 children (age, 5-17 years) with persistent asthma that were followed for 1 year. Participants were predominantly African American (91%) and had public health insurance (85%), 16% were overweight, and 28% were obese.

Overweight or obese participants had more symptoms associated with exposure to fine particulate matter measuring less than 2.5 μm in diameter (PM(2.5)) than normal-weight participants. They also had more asthma symptoms associated with nitrogen dioxide (NO(2)) exposure.

However, there was no relationship with coarse particulate matter (2.5 and 10 μm) and health care use, lung function, or pulmonary inflammation.

Being overweight or obese can increase susceptibility to indoor PM(2.5) and NO(2) in urban children with asthma.

Interventions aimed at weight loss might reduce asthma symptom responses to PM(2.5) and NO(2). Reducing indoor pollutant levels might be beneficial in overweight children. However, the effect of these measures on lung function is not clear from this study.

References:

Being overweight increases susceptibility to indoor pollutants among urban children with asthma. Lu KD, Breysse PN, Diette GB, Curtin-Brosnan J, Aloe C, Williams DL, Peng RD, McCormack MC, Matsui EC. J Allergy Clin Immunol. 2013 Feb 9. pii: S0091-6749(13)00006-7. doi: 10.1016/j.jaci.2012.12.1570. http://www.ncbi.nlm.nih.gov/pubmed/23403052
Image source: Wikipedia, public domain.

Severe asthma greatly increases the risk of pulmonary embolism (study)

2013-04-18T09:30:00.001-04:00

Patients with asthma have activated coagulation within the airways which may lead to an increase in venous thromboembolic events (VTE). This study from The Netherlands assessed the incidence of VTE in 648 patients with mild-moderate and severe asthma as compared to a control population.

All patients completed a questionnaire about a diagnosis of deep-vein thrombosis (DVT) and pulmonary embolism (PE) in the past, their risk factors, history of asthma and medication use. All VTE were objectively verified.

In total, 35 VTE events occurred at a median age of 39 years, 16 events of deep-vein thrombosis (DVT) and 19 events of pulmonary embolism (PE).

The incidence of PE in patients with severe asthma was 0.93 (per 1000 person-years, 0.33 in mild-moderate asthma, and 0.18 in the control group, respectively. Severe asthma and oral corticosteroid use were independent risk factors of PE (hazard ratios: 3.33 and 2.82 respectively). Asthma was not associated with DVT.

The study authors concluded that severe asthma greatly enhances the risk of pulmonary embolism, particularly if chronic corticosteroids are used.

References:

Risk of deep-vein thrombosis and pulmonary embolism in asthma. Christof J. Majoor et al. ERJ December 20, 2012 erj01503-2012.
Image source: Saphenous vein, Gray's Anatomy, 1918 (public domain).

Pro-con debate - ACOs are, or are not, good for the practicing allergist - Twitter summary from 2013 #AAAAI meeting

2013-04-15T08:30:00.000-04:00

Asthma - Twitter summary from 2013 #AAAAI meeting

2013-04-10T10:51:00.002-04:00

Local allergic rhinitis (LAR) - Twitter summary from 2013 #AAAAI meeting

2013-04-02T09:00:00.000-04:00

How Global Warming Is Making Allergies Worse - NationalJewish video

2013-03-24T00:41:00.001-04:00

From NationalJewish:

If you are one of the 40 million Americans who suffer from seasonal allergies, brace yourself — this could be a rough year. Doctors say they are already seeing a surge of springtime allergies — and global warming could make things worse for a long time to come.

National Jewish Health (previously National Jewish Medical and Research Center) is a research institute located in Denver, Colorado specializing in respiratory, immune and allergic research and treatment. It was founded in 1899 to treat tuberculosis, and is today considered one of the world's best medical research and treatment centers (source: Wikipedia).

Related:

Allergy Forecasts for 2013 - YouTube http://bit.ly/11y3Nb3

Immunotherapy: SCIT (“allergy shots”) and SLIT - Twitter summary from 2013 #AAAAI meeting

2013-03-21T09:00:00.000-04:00

Mast Cell Disorders - Twitter summary from 2013 #AAAAI meeting

2013-03-20T09:57:00.002-04:00

Contact dermatitis and patch testing for the allergist - Twitter summary from 2013 #AAAAI meeting

2013-03-18T09:30:00.000-04:00

This summary was compiled from the tweets posted by allergists/immunologists who attended the 2013 annual meeting of the American Academy of Allergy Asthma and Immunology (AAAAI) (see the list at the end). The tweets were labeled #AAAAI. The text was edited and modified by me.

With contact dermatitis, history is extremely important. Patch testing recommended in all cases of chronic hand eczema given high positive predictive value for contact allergy. Suspect venous stasis as a contributing factor for leg dermatitis when lesions worsen or fail to respond to topical steroid treatment.

Cosmetics

Dr Luz Fonacier spoke first on cosmetics.

The average adult uses 12 personal hygiene products per day. Cosmetics are now being marketed to children. Some cosmetics (esp mascaras) are contaminated with nickel.

Most affected site of ACD (allergic contact dermatitis) from nail varnish is the neck. Most common ACD chemicals are fragrances.

Balsam of Peru

Food related contact dermatitis from balsam of Peru (gums, mouthwash, toothpaste) can also cause hives with tomato-containing products. Here is a list of foods containing balsam of Peru http://bit.ly/XxfR5h

Tomato ACD is associated with balsam of Peru. The balsam is often implicated in systemic contact dermatitis rather than localized.

Common rashes - 2-minute video overview by a dermatologist for About.com:

Resins

How to avoid formaldehyde resins - wear 100% silk, polyester, acrylic, nylon, etc. (baggy clothes).

Resin in shin guards and neoprene can cause allergic contact dermatitis (ACD) reactions.

PPD allergy

PPD is found in hair dye, body painting and temporary tattooing (like henna). PPD sensitization is life long!

Alternatives to PPD are semi-permanent dyes based from vegetable oils.

Patch testing

With the current T.R.U.E. test, you can still miss 27% of clinically relevant allergens. Typical chemicals missed by the current TRUE test include propolis, fragrance mix II, DMDM hydantoin, cinnamic aldehyde, iodopropynyl.

So, if you have a negative patch test (35% of patients) - ACD is still possible, and you need to do more tests, and consider irritant contact dermatitis, and other diagnoses. Biopsy may be indicated.

A negative patch test is reassuring, but positive patch test doesn't prove that a serious complication is due to ACD.

TRUE testing during pregnancy? Speakers say avoid it.

Metals

Luckily, ACD is rare with pacers and defibrillators.

Nickel ACD

Nickel is the #1 agent in contact dermatitis. A lichenified plaque on the abdomen is a classic presentation of nickel ACD. However, nickel can also cause systemic reactions.

Nickel sensitization may be related to dietary nickel intake.

Nickel is most common ACD allergen in orthodontics. Nickel allergy can cause systemic plaques (remote from contact site) if continued nickel contact despite local symptoms.

Nickel ACD is usually a permanent sensitivity.

In gynecological implants, the most common metal is copper.

Pre-implantation eval (patch testing) should only be done with those with previous history of ACD.

Occupational ACD

About 15.5% of lifetime is spent at work, so workplace exposures do cause significant dermatitis.

MSDS sheet

Often, manufacturers of patch tests provide standardized panels for various professions (dental, metal workers, etc). Reading a MSDS sheet is a helpful skill for allergists to have. What to look for in MSDS - reactive components, cleaning compounds, metals.

You can use the actual materials from work, dilute if needed, test to components separately and together. An irritant control may be an issue.

Many chemicals implicated in ACD can also cause asthma if you inhale them (eg in machine operators, metal working fluids, glues).

Joint prostheses and ACD

Dr. Pacheco discussed hip, orthopedic and medical devices. Joint prostheses go back to ancient Egypt!

No pre-implantation testing is necessary for patients without a solid history of metal sensitization.

The need for revision in joint replacement is 7%, It is rare that allergy is a cause of revision, mostly they are related to infection, biomechanical failure, etc.

The presentation with ACD from metal joint replacements is not typically localized rash - it is mostly with pain, chronic effusion, etc.

The stainless steel composition is 10-24% Ni, 18% Cr, 65% Fe.

Bone cement is mainly methyl methacrylate, but it may contain other chemicals too (it can even be antibiotic-infused). Methyl methacrylate was once used in artificial nails but it has been removed due to asthma and ACD concerns - but it is a great joint cement!

Both bone cement and spacers are made from methyl methacrylate in replacement joints.

John Browning discussed contact and irritant dermatitis.

Malassezia dermatitis is found on head, neck and upper trunk. Lanolin in Aquaphor (a common cream used in AD) can cause allergic contact dermatitis (ACD).

Phytophotodermatitis

Photodermatitis presents with hyperpigmented marks after sun exposures due to a phototoxic reaction.

Phytophotodermatitis is an irritant contact dermatitis from squeezing citrus fruit in the sun - it causes postinflammatory hyperpigmentation.

ACD to mangos is itchy rash around the mouth due to urushiol (in peel and sap).

Tomato ACD is associated with balsam of Peru. The balsam is often implicated in systemic contact dermatitis rather than localized.

Perioral dermatitis can be due to spacers for asthma, ICS or topical steroids.

PTBP-FR dermatitis can be due to sports gear, foam (in bras), wet suits, etc. Sensitization by para-tertiary-butylphenolformaldehyde resin (PTBP-FR), which is particularly useful as a leather glue, has been known for 30 years (http://www.ncbi.nlm.nih.gov/pubmed/2533533).

“Toilet seat dermatitis"

“Toilet seat dermatitis" - location matches where they sit on the toilet - this is an irritant reaction from cleaning solutions on toilet seat.

Toilet seat dermatitis is usually secondary to an irritant reaction (chemical cleaners) but can be due to urushiol exposure.

Allergists are on Twitter - follow them

Allergists increased Twitter use 470% in one year - 25 allergists reached 250,000 individuals from the 2012 #AAAAI meeting (see the references here). This summary was compiled from some of the tweets posted by the following allergists:

https://twitter.com/DrAnneEllis
https://twitter.com/MatthewBowdish
https://twitter.com/nmchase

This is a list of the allergists who used Twitter to post updates from the 2013 #AAAAI meeting. The list is open for edit, please feel free to add your own info.

I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Here is how to do it: Twitter for Physicians: How to use Twitter to keep track of the latest news and scientific meetings, and share information with colleagues and patients.

Disclaimer: The text was edited, modified, and added to by me. This is one of a series of posts that will be published during the next few weeks.

Eosinophilic esophagitis (EoE) - Twitter summary from 2013 #AAAAI meeting

2013-03-14T08:30:00.000-04:00

Drug allergy - Twitter summary from 2013 #AAAAI meeting

2013-03-13T09:26:00.001-04:00

Pet and pest allergy - practice parameters - Twitter summary from 2013 #AAAAI meeting

2013-03-12T09:00:00.000-04:00

Filaggrin mutations and atopic dermatitis - Twitter summary from 2013 #AAAAI meeting

2013-03-08T08:00:00.000-05:00

Primary immunodeficiencies - Twitter summary from 2013 #AAAAI meeting

2013-03-07T08:30:00.000-05:00

Chronic cough - Twitter summary from 2013 #AAAAI meeting

2013-03-06T09:30:00.000-05:00

This summary was compiled from the tweets posted by allergists/immunologists who attended the 2013 annual meeting of the American Academy of Allergy Asthma and Immunology (AAAAI) (see the list at the end). The tweets were labeled #AAAAI. The text was edited and modified by me.

From https://twitter.com/MatthewBowdish:

Cough is a $1B, with a "B," industry per year.

What causes cough?

Dr Canning: What causes cough? Mechanical stimulation (mucus, foreign body, tumor), capsaicin, bradykinin, citric/tartaric acid.

There are three big causes of chronic cough: rhinitis, asthma, GERD - but also chronic bronchitis, foreign body, ACEI, infection, ILD, tumor.

In multiple species, there are only two main/conserved/distinct pathways for cough: C-fibers and cough receptors. Cough receptors are essentially mechanoreceptors, they're insensitive to capsaicin but sensitive to acid.

Icatibant is approved for HAE. It's not a viable tx for cough, but bradykinin antagonism is a viable target for cough.

Dr. Brooks: Cough is a warning sign similar to pain and if we understood pain reflexes better, we might understand cough better. Cough reflex probably appeared more than 100 million years ago.

Dr. Balkissoon: Response to reflux cough can be quite lengthy and high doses (PPI BID and ranitidine qhs + lifestyle measures). Metoclopramide (Reglan) can be used for aggressive medication therapy with chronic cough due to GERD (it tightens lower esophageal sphincter). Reglan is also helpful as prokinetic agent in addition to effects on LES.

Postinfectious (post viral) cough is extremely stubborn. It can last for months.

ACEI and cough

ACEI cough mechanism probably related to substance P, bradykinin, PGs. Patients on ACEI for CHF have worse cough than those on ACEI for HTN.

ACEI cough can last for TWO MONTHS after ACEI removed.

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

Treatment of chronic cough

Cough suppressing meds can be centrally-acting (opioids, dextromethorphan, diphenhydramine) or peripheral (benzonatate).

Laryngeal sensory neuropathy (neurogenic cough) can be treated with gabapentin, pregabalin, amitriptyline, nortriptyline.

BREAK THE COUGH CYCLE! Diet, PPI, nasal steroids, benzonatate, oral steroids, exercises.

A suggested cough algorithm: chlorpheniramine 8 mg bid-qid, if no help then prednisone 40mg x 5 days then 20 mg x 5 days, if help ICS plus maybe LTRA. Then, aggressive GERD therapy, if no help, start Reglan 10 mg bid-qid, then other diagnostic studies.

How to set up a cough center in private practice

Dr. Madell Sher: A cough center is a nice way to expand your scope of practice and make a difference in your community. We have a global approach to disease and cough should be right up our alley as allergists/asthma specialists.

Set up separate phone number, branded center and acquire a website.

@MatthewBowdish: Dr Sher just mentioned our cough center at the Storms Clinic! http://bit.ly/ZxTtim

Review previous records, and include a 2-page questionnaire including Leicester cough questionnaire, physical exam with laryngeal hyperfxn on expiratory phase. VCD is often inspiratory hypofunction, but just as important to us is laryngeal hyperfxn on expiratory phase.

Leicester questionnaire evaluates social isolation, depression, anxiety and others, expressing concern.

Dr Sher’s experience with 275 pts - CRS 70%, UACS 55%, GERD 53%, Asthma 13%, Eos Bronchitis 3%, some ACEI/lung ca/bronchiectasis.

Response to PPIs in chronic cough can take months.

Dr. Sher: In the non-smoker without ACEI and a normal CXR and you've treated rhinitis/GERD/asthma, then IT'S THE COUGH REFLEX, STUPID!

Cough reflex sensitivity has variable inflammatory, neurogenic and behavioral components. All “coughers” are different and have variable expression.

Upper Airway Cough Syndrome (post-nasal drip) is probably the most common etiology.

Chlorpheniramine is the best antihistamines for chronic cough - non-sedating antihistamines do not work as well, if at all.

Diet may be more important than PPI in chronic cough.

Dr. Sher: Asthma is an uncommon cause and inhalers (especially powders such as Advair Diskus) can be irritating.

Oral steroids are very important in chronic cough, especially postinfectious cough; variable effect in acute viral cough. Longer, low-dose oral steroid therapy may be needed (similar to neurodermatitis).

Dr. Balkissoon discussed his experience in an academic cough center. A nice part about being at National Jewish is to have all specialists under the same roof (pulm, AI, ENT, GI, speech path). Speech therapy is extremely helpful in chronic cough, from respiratory retraining to vocal exercises.

Gary Stadmauer spoke on importance of rhinolaryngoscopy in chronic cough. Rhinolaryngoscopy is an extension of the physical exam via a small device. You you cannot be a true upper respiratory specialist without looking at all of the upper airway .

Reflux-cough patients do not necessarily improve on rhinolaryngoscope even though they may improve clinically after treatment with medications.

@MatthewBowdish: Everyone tweeting allows me to 'attend' multiple sessions. Don't forget to download the #AAAAI meeting app - it's great to plan your day - most evaluations can be done via the app too.

Allergists are on Twitter - follow them

Allergists increased Twitter use 470% in one year - 25 allergists reached 250,000 individuals from the 2012 #AAAAI meeting (see the references here). This summary was compiled from some of the tweets posted by the following allergists:

https://twitter.com/MatthewBowdish

This is a list of the allergists who used Twitter to post updates from the 2013 #AAAAI meeting. The list is open for edit, please feel free to add your own info.

I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Here is how to do it: Twitter for Physicians: How to use Twitter to keep track of the latest news and scientific meetings, and share information with colleagues and patients.

Disclaimer: The text was edited, modified, and added to by me. This is one of a series of posts that will be published during the next few weeks.

Comments from Twitter:

Farris Timimi, MD @FarrisTimimi: Gr8t overview!

Ann Wu MD MPH @Asthma3Ways: Good summary. Cough more than 8 wks in adults: chronic.

@CAREAllergy: I am glad Cough got the attention it deserves and our work did not go in vain. Thanks to all of our great speakers and attendees!

Early life environment and microbiome influence on allergic diseases - Twitter summary from 2013 #AAAAI meeting

2013-03-01T10:24:00.003-05:00

This summary was compiled from the tweets posted by allergists/immunologists who attended the 2013 annual meeting of the American Academy of Allergy Asthma and Immunology (AAAAI) (see the list at the end). The tweets were labeled #AAAAI. The text was edited and modified by me.

Early life environmental influences on development in allergic diseases

Susan Prescott MD PhD (@susanprescott88) presented on early life environmental influences on development in allergic diseases

Allergic disease is the most common, and the earliest onset, non-communicable disease. Non-communicable diseases (NCD) are more common in affluent and industrialized nations, but ironically burden the poor the most. Despite the prevalence of allergic disease, it has largely been neglected on the world political stage, when compared to other NCD's.

By 2030, expect 52 million deaths from NCD's. This crisis can't be addressed without combatting factors which dictate our risk. Big 4 NCDs - Type 2 DM, COPD, heart disease and cancer. Inflammation is a common feature of all NCDs (non communicable disease).

Dr Prescott: We live a life similar to animals in captivity, so we shouldn't be surprised when we have stress levels similar to them.

Jonathan Tam ‏@sirartichoke: Irony: Dr. Prescott warns of the dangers of sedentary indoor lives to dark room full of sitting allergists with full day of lectures planned.

"There are no areas in the world where food allergy is declining"

In Australia 16% of children had sensitization to egg and half had a positive challenge. Highest in the world. People of Asian genetic background appear to have a higher propensity to atopy/food allergy, especially in Westernized countries.

There is an Interdisciplinary, international network studying inflammatory diseases: In-FLAME.

Early life inflammation leads to increased C-reactive protein (CRP) during pregnancy and early life associated with inflammatory disease. In utero exposures may drive predisposition to sustained inflammatory responses.

Affluence --> Low microbial environments --> increased baseline inflammation --> sustained inflammatory response --> increased Non-communicable diseases (NCD).

Allergy itself further drives ongoing inflammation and can increase risk of other NCD's, e.g. cardiovascular disease.

Biodiversity in GI tract may be protective

Has eradicating H. pylori increased risk of obesity, insulin resistance, autoimmunity, allergy, asthma? Modern diets alter the gastrointestinal microbiome, thus increasing risk of NCD. Can pre/probiotics help modulate this risk?

Antibiotics from agricultural products (even low doses) can alter human gut flora and increase risk of metabolic disease.

Smoking and pollutants, diet, microbial exposures can also modulate gene expression. There are incredibly intertwined relationship of genetics and environment.

What can we do to induce tolerance in early life?

Exercise, stress-reduction during pregnancy, low-inflammatory diet, microbial biodiversity are all potential measures.

A BMJ fish oil study in pregnant women showed a small but stat significant reduction in AD and egg allergy.

A Cochrane review of the use of probiotics for allergic disease showed improvement in atopic dermatitis but no other allergic disease.

Gene-environment interaction

Harald Renz presented on gene-environment interaction in chronic inflammatory disease.

Pre- and post-natal environment provides an opportunity for early immuno-education and programming. Having older siblings, early day care, traditional farming lifestyle are all associated with lower risk of asthma.

Acinetobacter lowfii, Staph sciuri, Lactococcus lactis, Lactobacillus GG, and others may reduce asthma risk.

The microbial "fingerprint" is unique in various organ systems. Intestinal and pulmonary microbiomes are linked.

C-section is associated with a different microbiome for baby than vaginal delivery. It is associated with increased risk of asthma, atopy. Someone in audience mentioned they're aware of study where children born by C/S and having their Mom's vaginal secretions given to them.

Epigenetics

In each cell, only about 20K of 100K genes will actually be expressed - determined by chromatin packaging. If the chromatin is packaged in the "wrong way", celles will get aberrant gene expression that lead to disease states in those cells. If chromatin is heavily condensed you won't see gene expression - histones and methyl groups influence this.

We used to think that 98% of genome is "junk" DNA - we now know this junk DNA contains important determinants of gene expression. Epigenetics can explain population changes over time that would not be explained by things like Darwinian theory.

Genome is static; Epigenetic is dynamic - subject to continuous "editing"

We were all born with a genetic "script" that can be modified with environmental exposures - can edit our script. Developmental plasticity may explain early origins of human disease such as allergy and asthma. Exposure to synthetic chemicals, pollutants and dietary choices can influence disease development via epigenetic alterations.

Maternal exposure to polycyclic aromatic hydrocarbons was associated with childhood wheeze in Ho's study through gene hypermethylation. We need to think about exposures as groups not just individually - Ho calls this an "Exposisome".

Firefighters are examined because of frequent chemical exposures. They've studied a gene that gets modified the longer they work.

There are several ways through which epigenetics works to affect gene expression - non coding RNAs, DNA methylation, histone acetylation or modification. DNA methylation leads to gene silencing. Prenatal tobacco smoke exposure affects global and gene specific DNA methylation.

Hypomethylation increases with age - "Epigenetic Drift".

Biome and Immune Interactions

Andrew Kau presented on sorting out microbiota, diet and immune interactions: lessons from malnutrition.

Human microbiota: we are all living with a large variety of microorganisms. Skin, gut, sinopulmonary tract, etc. Nutritional value of food is shaped by microbiota.

16S rRNA gene is characterized as powerful method of classifying different bacteria, using PCR amplification.

Enterobactericeae colonization in small intestine is associated with environmental enteropathy. Akkermansia muciniphilia is a microbe which may be protective against inflammatory bowel disease.

Microbiome

Jeffrey Gordon, MD presented on Microbiome in Health and Disease. The Gordon Lab URL: http://gordonlab.wustl.edu

The Gut Microbiome is like “Dining with Trillions of Fascinating Friends.”

Microbiota = collection of microorganisms. Microbiome = collection of genes present in the microbiota.

Our microbiota varies as a function of lifestyle. Therefore, it can only be understood in the context in which we live. By mid-century, world population will be ~9 billion. How can we feed all these people in a healthy way? Can studying the gut microbiome help us identify which foods are compatible with long-term health?

We begin to develop microbial colonization at birth, and it transitions to the "adult" pattern in the first 3 years of life.

In industrialized societies, there is less biodiversity within the gut microbiome than in agrarian societies.

Maternal vitamin D and asthma risk

Maria Magnus presented on maternal vitamin D and asthma risk.

1,25-dihydroxy vitamin D is the active form of Vitamin D. Maternal 25(OH)D increased with age and education, and varied by month of sampling. There was an inverse association between maternal vitamin D and asthma/LRTI in children.

Home environment

Use of forced air HVAC and incidence of asthma trend up together. VOC's are more predominant indoors, as houses are built to be so airtight nowadays. Tighter homes estimated to increase asthma symptoms by 20%.

Damp indoor spaces are a major risk factor due to dust mite, mold and pests. Mold in damp environments is associated with the development and severity of asthma.

Installation of insulated windows is associated with increased levels of house dust mite.

Bisphenol A (BPA)

BPA is found in most types of plastics and is an estrogen mimetic and 93% of Americans have detectable urinary BPA.

BPA (bisphenol A) may increase risk of CAD, brain tumor, miscarriage, PCOS. Approximately 90% of population is exposed.

"BPA-free" generally means that Bisphenol S (BPS) has been substituted. Some studies suggest BPS may be even worse than BPA.

Allergists are on Twitter - follow them

Allergists increased Twitter use 470% in one year - 25 allergists reached 250,000 individuals from the 2012 #AAAAI meeting (see the references here). This summary was compiled from some of the tweets posted by the following allergists:

https://twitter.com/allergistmommy
https://twitter.com/DrAnneEllis
https://twitter.com/IgECPD
https://twitter.com/mrathkopf

This is a list of the allergists who used Twitter to post updates from the 2013 #AAAAI meeting. The list is open for edit, please feel free to add your own info.

I would strongly encourage you to post updates on Twitter from the CME conferences that you are planning to attend in the future. Here is how to do it: Twitter for Physicians: How to use Twitter to keep track of the latest news and scientific meetings, and share information with colleagues and patients.

Disclaimer: The text was edited, modified, and added to by me. This is one of a series of posts that will be published during the next few weeks.

Comments from Twitter:

Dr John Weiner @AllergyNet: Good info here. Thank you MT @Allergy: Microbiome and Allergy - Twitter summary from 2013 #AAAAI meeting bit.ly/WwOzf9

Airmid Healthgroup @AirmidHealth: Twitter summary 2013 #AAAAI via @Allergy Mold in damp environments associated with asthma development & severity goo.gl/fb/2FQd8