Allergy Notes

Cyclosporine is effective treatment for 78% of patients with chronic urticaria

2012-05-21T08:30:00.000-04:00

Chronic urticaria (CU) is a frequent, and difficult clinical problem. When first-line therapy fails, patients are often treated with alternative therapies that either have a poor side effect profile (oral steroids) or little evidence to support effectiveness.

This retrospective chart review included 66 adult CU patients treated with cyclosporine. Chronic urticaria was defined as having urticaria more than 3 days per week for 6 consecutive weeks.

Ciclosporin (INN), cyclosporine (USAN) or cyclosporin (former BAN). Image source: Wikipedia, public domain.

After taking cyclosporine at an average dose of 1.8 mg/kg, 78% patients attained complete remission defined as ≤1 day of hives per month. Recurrence occurred in only 7 patients; all achieved remission with resumption of cyclosporine.

Factors that predicted a favorable response to cyclosporine included:

- shorter duration of urticaria (mean: 55 weeks)
- positive CU Index

Autologous serum skin testing (ASST), prior response to steroids, atopic status, or presence of antithyroid antibodies was not predictive.

Side effects were generally mild and seen in 35% of patients; all were reversible by dose reduction.

The authors concluded that cyclosporine is an effective treatment for CU, shorter duration of disease, and CU index ≥10 predict a successful response.

Chronic Urticaria Treatment (click to enlarge the image).

References:

Factors that predict the success of cyclosporine treatment for chronic urticaria. Hollander SM, Joo SS, Wedner HJ. Ann Allergy Asthma Immunol. 2011 Dec;107(6):523-8. Epub 2011 Oct 5.

Food allergy - top articles in May 2012

2012-05-19T08:30:00.000-04:00

Here are my suggestions for some of the top articles about allergic rhinitis in May 2012:

Cross-reacting allergens between fish, shellfish, arachnids, and insects http://j.mp/IwO5Qk

Navy considers shellfish allergy a contraindication to service http://goo.gl/OeTgD and http://goo.gl/aMrdx

Skin prick testing with extensively heated milk or egg predicts outcome of oral food challenge with the same food http://goo.gl/LTolw

Does milk cause mucus increase in patients who are not allergic to milk? Allergists review the scant evidence http://goo.gl/EMgff

Skin prick testing with extensively heated milk or egg predicts outcome of oral food challenge with the same food http://goo.gl/LTolw

Skin Prick Test Predicts Course of Cow's Milk Allergy - lager wheal size predicts persistence http://goo.gl/5BHOc and http://goo.gl/foJBL

Lessons to Learn from Anaphylaxis Deaths - Atopic Girl's Guide to Living http://goo.gl/anaUf

Baked Milk May Help Kids Outgrow Milk Allergy Faster - NIH http://goo.gl/0gByd

Milk sensitization may cause GERD according to a study of "CMA-induced GERD" http://goo.gl/U21DQ and http://goo.gl/mUwnv

The articles were selected from my Twitter and Google Reader streams. Please feel free to send suggestions for articles to allergycases@gmail.com and you will receive acknowledgement in the next edition of this publication.

Urticaria (hives) - top articles in May 2012

2012-05-18T08:00:00.000-04:00

Here are my suggestions for some of the top articles about allergic rhinitis in May 2012:

A combination of H1 and H2-antihistamine is more effective at improving urticaria than H1 blocker alone http://goo.gl/bShXt

H1 antihistamines are scarcely effective in most patients with idiopathic angioedema without hives http://goo.gl/76WWT

Management of chronic urticaria in Asia: 2010 consensus guidelines (PDF free full text) http://goo.gl/zQKO9

Role of autoimmune testing in chronic idiopathic urticaria: positive CU index and ANA titer predict refractory disease http://goo.gl/XIg96

Interleukin-1 antagonist rilonacept is effective in Schnitzler syndrome (SchS) http://goo.gl/yn1Xu

Hives (Urticaria) - ACAAI Video. Dr. Stanley Fineman explains hives including symptoms, causes, diagnosis, and treatment. Information from the American College of Allergy, Asthma and Immunology (ACAAI).

How to safely administer cold and allergy medications to children at home - CDC video

2012-05-17T08:00:00.000-04:00

In April 2012, a 5-year-old girl died after overdosing on two over-the-counter cold medications with dextromethorphan and cetirizine http://j.mp/HIAtQ7

This CDC video below offers some tips how to prevent such tragic events in the future:

Unlike first, old-generation H(1)-antihistamines introduced from 1942 to the mid-1980s, most of the second (new)-generation H(1)-antihistamines are relatively free from adverse effects. They are not causally linked with fatalities after overdose.

A lethal intoxication with diphenhydramine was described in a 1983 case report: The patient was a 28 year old male who went into hyperpyrexia and tachycardia and died from sudden cardiac arrest. Hemorrhagic pulmonary edema and renal shock were the most prominent pathomorphological findings. At the time of death, the concentration of diphenhydramine was 5 mg/l plasma and was particularly high in the lungs (55 mg/kg) and kidneys (50 mg/kg).

Here is a video demonstrating Opsoclonus Due to Diphenhydramine Poisoning:

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

Practical points on testing for food allergy: avoid using the term "negative" IgE test, use "undetectable"

2012-05-16T08:30:00.000-04:00

Negative predictive value of skin prick tests for predicting IgE-mediated food allergy is greater than 95%. This means that there is still a small percentage (~5%) of patients with negative skin tests who may still have IgE-mediated food allergy.

Generally, try to avoid using the term "negative" IgE test, and use the term "undetectable".

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):

Annual testing is often the practice for determining whether allergy to milk, egg, soy, and wheat have been outgrown, and the testing interval is extended to 2 to 3 years for allergy to peanut, tree nuts, fish, and crustacean shellfish. However, the 2010 Food Allergy Guidelines noted that these testing schedules are not supported by objective evidence.

Skin testing has approximately 30% greater sensitivity than serum IgE (Cleveland Clinic J of Med, 2011, 78-9, 585-592), and a negative skin test typically rules out clinical environmental or food allergy in approximately 90% of patients.

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).

References

Inability to eat peanuts in spite of negative skin tests and serum-specific IgE testing. What to do? AAAAI Ask the Expert, 2012.

Comments from Twitter:

Stuart Carr @allergydoc4kidz: NPV of SPT (good extract or fresh food) very high, but less so for sIgE, where undetectable result much less meaningful. Also need to avoid suggesting positive SPT alone confirms allergy, or wheal size predicts severity of reaction.

Asthma - top articles in May 2012

2012-05-15T10:00:00.000-04:00

Here are my suggestions for some of the top articles about asthma in May 2012:

Only 43% of patients newly diagnosed with asthma in Canada received pulmonary function testing http://goo.gl/eyzg9

Switching from Salmeterol/Fluticasone to Formoterol/Budesonide Combinations is a useful option if asthma that is not controlled http://goo.gl/kEW2Y

Older adults with asthma have a higher rate of allergic sensitization, decreased lung function, and significantly worse quality of life compared with controls http://goo.gl/bGan8

Epigenetic changes may play a role in asthma: DNA Hypomethylation at ALOX12 Linked to Persistent Wheezing in Children http://goo.gl/ovxL7

Rhinitis can cause night cough in children, independent of asthma. Upper airway should be always be examined http://goo.gl/ix1Iu

"Whistling in the Dark" - tracheomalacia in NEJM http://goo.gl/l2dQI

Allergen immunotherapy is a cost-effective treatment in modifying existing allergic respiratory diseases - Chest 2012 http://goo.gl/GdkbH

New type 2 myeloid cell (T2M) may play a role in treatment-resistant asthma - in mice http://goo.gl/amWug and http://goo.gl/itYMr

FeNO monitoring during asthma exacerbation is not a good predictor of spirometric response to oral steroid http://goo.gl/YJBGH

Allergy to dust mite increases risk for wheezing provoked by rhinovirus among asthmatic children aged 7-12 years http://goo.gl/6y5M7

A Patient with Asthma Seeks Medical Advice - NEJM readers ask important questions about recently published article http://goo.gl/Y0mBl

Omalizumab versus 'Usual Care': Substantial beneficial effects of omalizumab in Naturalistic Longitudinal Study http://goo.gl/7rOn2

The articles were selected from my Twitter and Google Reader streams.

Handwritten Video Tutorials in Allergy and Immunology

2012-05-15T08:00:00.000-04:00

Please note: The information if the following videos has not been verified by me. The purpose of this post is just to present the idea of this approach to medical education, not to recommend the content of the videos.

This is the first video on the system of the complement. This tutorial gives an overview of complement while the following tutorials fill in the detail. For more free tutorials and accompanying PDFs visit http://www.handwrittentutorials.com

References:

Handwritten Video Tutorials in Medicine http://goo.gl/ZxFhb and http://goo.gl/R8xse

Comments from Twitter:

AnneMarie Cunningham @amcunningham: Handwritten Video Tutorials in Allergy and Immunology goo.gl/4d22N” love it!!! Well done @hwtutorials #meded

Sensitivity of methacholine challenge lower than previously reported: 69% in Caucasian, 52% in nonatopic patients

2012-05-14T08:30:00.000-04:00

This cohort study included 126 patients with asthma, receiving controller medications, and 93 nonasthmatic controls.

The sensitivity of the methacholine challenge test was 77% and the specificity was 96% with a threshold PC(20) (the provocative concentration of methacholine that results in a 20% drop in FEV(1)) of 8 mg/mL.

The sensitivity was lower in white than in African American participants (69% vs 95%). It was higher in atopic compared with nonatopic (82% vs 52%).

Increasing the PC(20) threshold from 8 to 16 mg/mL did not improve the performance of the test. African American race, atopy, and lower FEV(1) were associated with a positive test result.

Clinicians should take into account the reduced sensitivity of the methacholine challenge test in white and nonatopic asthmatic patients when using this test for the diagnosis of asthma.

References:

Methacholine challenge test: Diagnostic characteristics in asthmatic patients receiving controller medications. Sumino K, Sugar EA, Irvin CG, Kaminsky DA, Shade D, Wei CY, Holbrook JT, Wise RA, Castro M; American Lung Association Asthma Clinical Research Centers. J Allergy Clin Immunol. 2012 Mar 30.

Image source: Spirometry, from Wikipedia, the free encyclopedia, GNU Free Documentation License.

Asthma - top articles in May 2012

2012-05-12T08:00:00.000-04:00

Here are my suggestions for some of the top articles about asthma in May 2012:

Investigating asthma symptoms in primary care | BMJ guide to rational testing http://goo.gl/efKsc

Never assume recurrent shortness of breath is due to asthma without lung function testing, even with history of wheeze. Spirometry with bronchodilator testing is the investigation of choice to diagnose asthma in adults and children older than 10 years. Consider referral for bronchial provocation testing with a direct agent (such as methacholine) or indirect agent (such as mannitol or hypertonic saline) if suggestive history but normal spirometry. Longstanding asthma may evolve in adult life into a syndrome of fixed airflow limitation with poor response to short acting beta agonists (SABAs), so diagnostic reversibility is not always present.

Children living on a farm are at reduced risk of asthma (OR 0.68), hay fever (OR, 0.43), atopic dermatitis (OR, 0.80), atopic sensitization (OR, 0.54) http://goo.gl/qVY2G

The developmental trajectory of pediatric asthma in 3- to-10-year-olds: Male gender is a risk factor for childhood asthma development until at least age 10 years http://goo.gl/iDhGb

Combination inhaled corticosteroid/LABA: don't let the perfect become the enemy of the good http://goo.gl/sFFEM -- ICS/LABA fixed-dose combination therapy perform as well as or better than ICS alone in reducing asthma exacerbations http://goo.gl/FnRij

Older asthmatic patients have a 5-fold increased risk of overall mortality (adjusted odds ratio, 5.2), compared with younger adults. Compared with younger adults, older adults had higher mortality, had higher rates of near-fatal asthma-related events, had higher hospital charges, were more likely to be hospitalized, and had a longer hospital length of stay (P < .001 for all). http://goo.gl/18dEg

Another study casts doubts on the importance of vitamin D levels in asthma http://goo.gl/PPWti

When a patient with asthma starts an inhaled steroid (ICS), the odds are 2 out of 3 that symptoms will improve. However, asthma is a heterogeneous condition that, for the sake of first-line treatment, we have made homogenous. This is the paradox of heterogeneity. When “all comers” are treated with antileukotrienes, the overall therapeutic effect is about half of that observed when a similar group of asthmatic patients is treated with ICSs. http://goo.gl/Hk7Af

The role of tiotropium in the management of asthma (PDF free full text) http://goo.gl/btHbm

Asthma exacerbations before age 4 may have deleterious long-term effects, reducing lung function at school age http://goo.gl/gCwmX

High doses of inhaled ciclesonide do not adversely affect markers of bone turnover in asthmatics over 12 months http://j.mp/K0K2hd

The articles were selected from my Twitter and Google Reader streams.

Asthma exacerbations in children are predicted by (simple) asthma control score and (complex) test of IL-5 in breath

2012-05-11T08:00:00.000-04:00

This prospective one-year study evaluated the ability of non-invasive inflammatory markers in exhaled breath to predict exacerbations of childhood asthma and included 40 children (aged 6-16 yrs). Regular two-month visits at the outpatient clinic were performed. During the course of the study, 16 children developed exacerbations, of which 10 were moderate and 6 severe.

Significant predictors of asthma exacerbation included:

- breath condensate acidity
- interleukin-5 (IL-5)
- asthma control score

Crystal structure of human IL-5. Image source: Wikipedia, public domain.

The exacerbations were best predicted by the asthma control score and by the level of interleukin-5 in exhaled breath condensate. There was a 2-times reduced risk on exacerbations in children with the 10% most optimal values of IL-5 and asthma control score.

Both exhaled breath condensate interleukin-5 level and asthma control score were significant predictors of asthma exacerbations. These parameters can optimize the titration of asthma treatments.

References

Prediction of asthma exacerbations in children: results of a one-year prospective study. Clinical & Experimental Allergy, 2012, DOI: 10.1111/j.1365-2222.2012.03992.x

Interleukin-5 (IL-5)

Title based on a tweet by @AllergyNet

Food Allergies - video lecture by board-certified allergist at UPenn

2012-05-10T10:30:00.000-04:00

Mildred Kwan, MD, PhD, an allergy and immunology specialist at Penn Medicine, discusses food allergies (34 minutes). Source: the official PennMedicine YouTube channel.

Clarithromycin for 3 weeks is effective as add-on treatment of asthma exacerbations in children

2012-05-10T08:00:00.000-04:00

There is inconclusive evidence that macrolide antibiotics may have an effect on asthma exacerbations through their antibacterial and/or anti-inflammatory properties. Some of the previous studies have been disappointing, for example, adding clarithromycin to inhaled steroid in uncontrolled asthma was ineffective

This open-label, randomized, prospective study from Greece included 40 school-aged children with intermittent or mild persistent asthma, presenting with an acute exacerbation. Clarithromycin was given as an add-on therapy, at a dose of 15 mg/kg for 3 weeks.

Children in the clarithromycin group had more symptom-free days (78 vs. 69 days) and less periods with loss of control (9 vs. 19) compared to controls. They had a reduced duration of the index episode (5.0 vs. 7.5 days). However, lung function did not differ between groups.

The authors concluded that when added to regular treatment, a 3-week course of clarithromycin was associated with an increase in the number of symptom-free days, reductions in the number and severity of days with loss of control following index episode, and a decrease in the duration of the initial asthma exacerbation.

It would be interesting to see if these findings can be replicated in a larger population and in children with higher severity of asthma.

References:

Koutsoubari I, Papaevangelou V, Konstantinou GN, Makrinioti H, Xepapadaki P, Kafetzis D, Papadopoulos NG. Effect of clarithromycin οn acute asthma exacerbations in children: an open pilot randomized study. Pediatric Allergy Immunology 2011: 00.

Adding clarithromycin to inhaled steroid in uncontrolled asthma was ineffective

Image source: Clarithromycin structure, Wikipedia, public domain.

Comments from Twitter:

KevFrost @kevfrost: 20 kids who were told they were getting antibiotics did better on subjective scores than 20 that were told they werent?

AnneMarie Cunningham @amcunningham: yes- not such a surprising result... Interested in anti-inflam suggestion of action

Allergic rhinitis - top articles in May 2012

2012-05-09T10:30:00.000-04:00

Here are my suggestions for some of the top articles about allergic rhinitis in May 2012:

Children living on a farm are at reduced risk of asthma (OR 0.68), hay fever (OR, 0.43), atopic dermatitis (OR, 0.80), atopic sensitization (OR, 0.54) http://goo.gl/qVY2G

Amish farm kids remarkably "immune" to allergies - even better than the currently best-protected, Swiss farm kids http://goo.gl/fVNLP

Local allergic rhinitis (LAR): how to diagnose and treat LAR? http://goo.gl/8Yv67

Intralymphatic immunotherapy for cat allergy induces tolerance after only 3 injections - first human study ILIT with MAT–Fel d 1 http://goo.gl/jHAe9

Combined intranasal therapy of azelastine with fluticasone demonstrates superiority to 2 first-line therapies for allergic rhinitis http://goo.gl/NtAEI

Allergic rhinitis in school-age children has a negative impact on learning, quality of life, and family (PDF) http://goo.gl/Bea7v

Immunotherapy prescribed for 5 years by 75% of US-Canadian allergists, for 3 years by the rest of the world http://goo.gl/K0Cr7

Keeping humidity below 50% reduces growth of dust mite - in cities like Davos, Switzerland, and Denver, Colorado, there is little if any dust mite growth http://goo.gl/yDc7u

Rhinitis can cause night cough in children, independent of asthma. Upper airway should always be examined http://goo.gl/ix1Iu

ZETONNA is new non-aqueous, dry nose spray for allergic rhinitis - contains ciclesonide just like OMNARIS (hypotonic) http://goo.gl/tVEba

The 79 authors of WAO WHITE BOOK ON ALLERGY cover all aspects of allergic disease. I’m honored to be 1 of them, the book is free to download http://goo.gl/I9KwE

Asthma and allergy genetic testing by 23andMe

2012-05-09T08:00:00.001-04:00

This is a brief summary of the currently available asthma and allergy genetic testing by the consumer genomics company 23andMe. It is partially funded by Google and started by the wife of Sergey Brin, the co-founder of Google. None of the results is conclusive in terms of diagnosis or clinical management at this time.

Asthma
https://www.23andme.com/health/Asthma

Each copy of T at rs7216389 increased a person’s chances of having childhood asthma. Each copy of a C at rs13153971 increased an individual's odds of asthma by about 1.58 times. Subjects with at least one G at rs4950928 had 0.54 times the odds of asthma compared to those with a C at both copies of the SNP. However, this effect was not seen in all groups the authors examined.

Allergic rhinitis (hay fever)
https://www.23andme.com/health/hay-fever

Each copy of a C at rs7775228 in the HLA region was associated with about 1.3 times higher odds of being allergic to grass pollen. Individuals with the TT genotype at rs2155219 had about 1.2 times higher odds of being allergic to grass pollen compared to individuals with the GT genotype, and those with the GG genotype had about 1.2 times lower odds of being allergic to grass pollen.

Atopic Dermatitis

https://www.23andme.com/health/atopic-dermatitis

There is a preliminary research report on 5 markers.

Again, none of the results is conclusive in terms of diagnosis or clinical management at this time.

Related reading:

SNPwatch: New Genetic Insight into the Causes of Eczema
SNPwatch: Breathe Easier…New Insights From Asthma Research
SNPwatch: Genetic Variant Associated with Food Allergy-related Disorder Eosinophilic Esophagitis
Asthma
Image source: An older version of the company logo from year 2007.

Food Allergies and High School - Anaphylaxis Canada Video

2012-05-08T11:00:00.000-04:00

"High school may seem like a huge step, but being safe with food allergies is manageable as long as you take the right precautions and are prepared. This video shows how you can have a great high school experience by outlining all of the things to keep in mind to avoid an allergic reaction at school."

Steroid Insensitivity in Asthma Linked to Defect of PP2A Enzyme, May Provide Key to New Treatments

2012-05-08T08:00:00.000-04:00

Corticosteroid insensitivity is a barrier of treatment of severe asthma, but the molecular mechanism of the insensitivity has not been elucidated. This UK study investigated the role of protein phosphate 2A (PP2A), a serine/threonine phosphatase.

Steroid sensitivity was determined by the dexamethasone ability to inhibit TNF-alpha-induced IL-8 or LPS-induced TNF-alpha production. The receptor expression and nuclear translocation were analysed by Western-blotting.

Interleukin-8, a chemokine of the CXC subfamily. CXCL8 (IL-8) forms a chemotactic gradient that directs leukocytes (mostly PMNs) towards site of tissue injury/infection. Image source: Wikipedia, public domain.

A PP2A inhibitor reduced steroid sensitivity with reduced glucocorticoid receptor nuclear translocation and increased phosphorylation. PP2A knockdown by RNA interference showed similar effects. In peripheral blood mononuclear cells from severe asthma, the PP2A expression was reduced. Conversely, PP2A overexpression increased steroid sensitivity.

The authors concluded that PP2A regulates glucocorticoid receptor nuclear translocation and corticosteroid sensitivity. This newly-discovered mechanism may provide insight for development of new therapy for severe asthma.

52 chemokines from 4 families have been described. They interact with 20 receptors (click here for a larger image):

References:

Defects of Protein Phosphatase 2A Causes Corticosteroid Insensitivity in Severe Asthma. Kobayashi Y, Mercado N, Barnes PJ, Ito K. PLoS One. 2011;6(12):e27627. Epub 2011 Dec 19.

Chemokines

Coronary stents made of nickel are safe for patients allergic to nickel - Mayo Clinic video

2012-05-07T08:00:00.000-04:00

Mayo Clinic researchers have found that cardiac patients who have skin allergies to metals commonly found in jewelry, such as nickel, are at no higher risk for complications if they receive a stent containing these metal components.

The study included 29 patients with a history of skin allergies to stent metal components who subsequently underwent coronary stent implantation. The research team compared clinical outcomes with a matched control group of 250 non- metal allergic patients who received similar stents. In addition to following the study patients' outcomes in the long term, the team reviewed blood to look for signs of allergic reactions.

According to the lead author: "We found no change compared with pre- and post- stent placement in the metal-allergic patients. While we can't be definitive in our advice or counseling, we can suggest that based on our experience, there doesn't appear to be any evidence of both acute and long-term harm."

The study was published in Circulation: Cardiovascular Interventions. The video is below:

References:

Mayo Clinic study confirms stents are safe for patients allergic to metal

Outcomes After Coronary Stent Implantation in Patients With Metal Allergy. CIRCINTERVENTIONS.111.966614

Atopic dermatitis - top articles in April/May 2012

2012-05-06T08:30:00.000-04:00

Here are my suggestions for some of the top articles about atopic dermatitis in April-May 2012:

S. aureus (enterotoxins), M sympodialis, and allergens are trigger factors of atopic dermatitis - they stimulate dendritic cells http://goo.gl/MYLLZ

The term atopy cannot be used until an IgE sensitization has been documented. The umbrella for a local inflammation of the skin should be dermatitis. http://goo.gl/M76sm

Oral application of bacterial lysate in infancy decreases the risk of atopic dermatitis later in life. From week 5 until the end of month 7, infants were treated orally with bacterial lysate containing heat-killed gram-negative Escherichia coli Symbio and gram-positive Enterococcus faecalis Symbio. http://goo.gl/qIlXB

IL-31 is elevated in atopic dermatitis and correlates with disease activity and Th2 cytokine levels http://goo.gl/o3JXm

Oral phosphodiesterase inhibitor (PDE4) apremilast improved atopic dermatitis in adults in a pilot study http://goo.gl/wO6FU

Decreased vitamin D3 levels found in atopic dermatitis: relationship between IL-31 and oncostatin M http://goo.gl/Qyzbc

Yogurt and diversity of food in the first year of life might have a protective effect against atopic dermatitis http://goo.gl/tZlOY

Atopic dermatitis: the cost of care is $600 per year per U.S. patient http://goo.gl/nJrXn

3 questions in a parental questionnaire sufficient for diagnosing eczema in children: rash? itchy? which areas? http://bit.ly/I9ULHE

Children living on a farm are at reduced risk of asthma (OR 0.68), hay fever (OR, 0.43), atopic dermatitis (OR, 0.80), atopic sensitization (OR, 0.54) http://goo.gl/qVY2G

High total IgE and sensitization to egg at 6 months of age are risk factors for atopic dermatitis after 1 year of age http://goo.gl/uVtP3

Does autoimmunity/“autoreactivity” play a causative role in atopic dermatitis? JACI free article http://goo.gl/BWr2B

The articles were selected from my Twitter and Google Reader streams.

Comments from Twitter:

Henry Ehrlich @AACMaven: Your monthly reviews are swell. Thanks a lot for doing them.

@Allergy: thank you. they are summaries of tweets, arranged by topic. I find them helpful for later review/references, etc.

Hereditary angioedema (HAE) - video explanation

2012-05-04T08:00:00.000-04:00

The video "Ever Heard of HAE?" was produced by Shire Australia to help raise awareness of hereditary angioedema (HAE) among the general community and prompt those who may be living with HAE unknowingly, to seek help:

Here is another video, focused on pathophysiology:

New developments in immunology

2012-05-03T08:00:00.000-04:00

Th17 cells and cytokines

Immunologists continue to focus on the role of TH17 cells in inflammatory disorders, HIV infection, and immunodysregulation disorders.

TACI in CVID

The role of transmembrane activator and calcium modulator and cyclophilin ligand interactor (TACI) mutations in the pathogenesis of CVID is still being investigated. A form of CVID is mediated by impaired TACI expression affecting B-cell function.

DiGeorge syndrome and autoimmunity

The frequency of autoimmunity in patients with partial DiGeorge syndrome was estimated at 8.5%. This results in blood cytopenias and hypothyroidism.

PIDD and cancer

The first manifestation of several primary immunodeficiencies (PIDD) could be neoplasias, most often lymphomas.

Newborn screening for PIDD

New strategies for newborn screening include:

- measuring immunoglobulin κ chain–deletion recombinant excision circles for B-cell lymphopenia
- tandem mass spectrometry for adenosine deaminase deficiency

PIDD treatment

Progress in the treatment of primary immunodeficiencies (PIDD) include:

- increased success with unrelated HLA-compatible donors for hematopoietic stem cell transplantation (HSCT)

- new gene therapy approaches with improved safety features

Induced pluripotent stem cells were developed from patients with primary immunodeficiencies. The hope is they will provide a virtually unlimited resource gene correction studies.

Defects in Toll-like receptor 3 (TLR-3) and its pathway were linked to increased susceptibility to severe viral infections.

References:

Advances in basic and clinical immunology in 2011. Javier Chinen, MD, PhD, William T. Shearer, MD, PhD. JACI, 2011.

Image source: Wikipedia.

Vitamin D deficiency (below 10 ng/mL) may be a risk factor for allergic disorders

2012-05-02T08:00:00.000-04:00

Vitamin D deficiency (VDD) has been reported in very high rates in the U.S. population.

It has been implicated in various diseases such as:

- diabetes
- high blood pressure
- cardiovascular disease
- cancers
- asthma
- anaphylaxis
- food allergy

The National Health and Nutrition examination survey (NHANES) in 2005-2006 was a cross-sectional nationwide survey in the U.S.

An allergy questionnaire inquired about self-reported allergic diseases including allergic rhinitis, allergies, and atopic dermatitis. Data were collected using the question, “Has the doctor or other health professional ever told you that you have allergies?“

The laboratory parameter of vitamin D level lower than 10 ng/mL was used to define severe vitamin D deficiency (VDD). The sample consisted of 5,000 people.

Vitamin D deficiency (VDD) was positively correlated with prevalence of allergies. There was also a correlation with rashes, sneezing, and sinus infections with low vitamin D.

Editor's comment: It all sounds plausible but we need confirmation from randomized controlled trials, which are currently underway. Until their results confirm that vitamin D deficiency plays a role in allergic disease, and supplementation is beneficial, all discussions on the topic are inconclusive.

References:

Vitamin D deficiency as a risk factor for allergic disorders and immune mechanisms. Frieri M, Valluri A. Allergy Asthma Proc. 2011 Nov-Dec;32(6):438-44.

Image source: Wikipedia, public domain.

What's new in indoor mold - Twitter summary from 2012 #AAAAI meeting

2012-05-01T10:30:00.000-04:00

This summary was compiled from the tweets posted by the following allergists/immunologists who attended the 2012 annual meeting of the American Academy of Allergy Asthma and Immunology (AAAAI): Sakina Bajowala, M.D ‏@allergistmommy. The tweets were labeled #AAAAI. The text was edited and modified by me.

High ambient moisture increases the growth of problematics molds. They often cause allergy, but also cause morbidity via release of VOCs toxins (even in the absence of allergy).

Dampness in living and work environments is associated with respiratory health problems. Dry it out, and problems get better.

Long-term exposure to indoor molds is associated with higher risk of symptoms than short-term exposure.

Indoor mold control includes mitigation of facilitating factors (food, water, warmth, shelter).

Stachybotrys ("toxic black mold") requires an extremely damp environment for growth. Aspergillus and Penicillium, less so.

Concrete is generally inhospitable to mold growth. Houses today are so "tight", that it can be difficult to have a source of fresh air intake. This is problematic.

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.

There is a significant association of mold and respiratory problems in pre-exisiting asthma. There is almost enough evidence to establish causation of new onset asthma.

Environmental assessment and remediation should be standardized, and become a mainstream part of high quality medical care.

Brett Green discussed exposure assessment for indoor mold and remediation.

Fungal contamination in U.S. buildings is becoming an increasing concern. Traditional methods of assessment date back to 19th century.

Fungal detection and quantification methods include:

- traditional methods: culture, morphology
- modern methods: antigen, biomass, DNA

A combination of these approaches has been developed including halogen immunoassay:

- collect from environment
- immuno-stain

Microarrays and macroarrays are becoming available for identification of fungi.

In indoor environment, Aspergillus species is well-represented, also Cladosporium and many other fungi.

Tina Reponen discussed indoor mold and asthma onset in children.

Qualitative methods of assessing mold exposure include visible water damage, visible mold, moldy odor.

A study evaluated association between mold exposure and asthma in children from ages 1-7 years. It included a questionnaire, home walk through, and sampling. Visible mold was number two risk factor for wheezing at age 1 year, after maternal smoking. Visible mold at age 1 year remained a risk factor for wheezing at age 3 yrs. Interestingly, mold sensitization was not associated with asthma at age 7 yrs.

Air conditioning at 1 year was inversely correlated with asthma at age 7 yrs (protective effect).

Allergists achieved highest use of social media by any specialty

During the 2012 AAAAI meeting, the allergists achieved the highest use of social media by any specialty. There are more than 100 allergists on Twitter and 30 of them posted simultaneously from the annual meeting, broadcasting thousands of tweets tagged with #AAAAI. The annual AAAAI meeting was attended by approximately 5,000 people. In comparison, the 30 allergists on Twitter reached 250,000 people (measured by TweetReach.com on 03/04/2012).

This summary was compiled from some of the tweets posted by Sakina Bajowala, M.D ‏@allergistmommy. 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.

The new intranasal corticosteroids for treatment of allergic rhinitis are safe

2012-05-01T08:00:00.000-04:00

Intranasal corticosteroids (INSs) are the most efficacious medication for the treatment of allergic rhinitis.

This review summarized topical and systemic adverse events associated with the following INS:

- ciclesonide (CIC) (Omnaris in the U.S.)
- fluticasone furoate (FF) (Veramyst in the U.S.)
- mometasone furoate (MF) (Nasonex in the U.S.)
- triamcinolone acetonide
-fluticasone propionate (Flonase and generic in the U.S.)
- budesonide (Rhinocort in the U.S.)
- beclomethasone dipropionate

No significant topical or systemic complications were observed although none of the included studies were longer 1 year in duration.

The newer formulations of topical corticosteroids for allergic rhinitis, such as CIC, FF, and MF, which have lower systemic bioavailability, may be safer for long-term use.

New studies still do not answer the question if these agents are appropriate for long-term use without oversight by a health care professional (such as over-the counter use which is available in New Zealand, for example).

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

The author of the article is Michael Blaiss, MD, who runs one of the most popular allergist accounts on Twitter @wheezemd

References:

Safety update regarding intranasal corticosteroids for the treatment of allergic rhinitis. Blaiss, Michael S. Allergy Asthma Proc. 2011 Nov-Dec;32(6):413-8.

Allergy Notes

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New developments in immunology

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What's new in indoor mold - Twitter summary from 2012 #AAAAI meeting

The new intranasal corticosteroids for treatment of allergic rhinitis are safe