Anaphylaxis - top articles for November 2012

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Here are my suggestions for some of the top articles about anaphylaxis for November 2012:

Anaphylaxis: When It Comes to Education, Give Them All They Need and More http://bit.ly/Pexwcy

2012 Update: World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis http://goo.gl/1JZPI - Discliamer: I am on the WAO Anaphylaxis Committee and co-authored this article.

Price of life-saving allergy injections has spiked: EpiPen price has more than doubled over the past 25 years http://buff.ly/Ps21vI

Sanofi Announces FDA Approval for Auvi-Q, First Voice-guided Epinephrine Auto-injector http://goo.gl/4GfPr

New Epinephrine Auto-Injector Talks Patients Through Injection Process, has a 5-sec countdown, signaling lights http://goo.gl/rYJZI

EpiPen manufacturer offers free injectors to US schools http://bit.ly/ND8JDf -- The offer coincides with launch of voice-guided, smaller competing device.

First Voice-Guided Epinephrine Injector - the size of a credit card and the thickness of a cell telephone http://goo.gl/HhDzL

Anaphylaxis - WAO 2012 synopsis http://goo.gl/AdlyA

Anaphylaxis in an emergency setting – elicitors, therapy and incidence of severe allergic reactions http://buff.ly/PqkQC4

Anaphylaxis after contact with a vomited food allergen http://buff.ly/Pufdmt - This is the first report of anaphylaxis to food ingested by another person.

Anaphylaxis in an emergency setting: foods are frequent elicitors of severe allergic reactions in general population. Anaphylaxis in the ED: a strong underuse of adrenaline by emergency physicians, not reflecting treatment protocols http://buff.ly/Qt2H9S

Limitations of tryptase in anaphylaxis: concentration remains unaltered in a considerable number of patients during acute anaphylaxis http://buff.ly/PITGXm

PAF level was elevated in all patients with severe anaphylaxis, but this was not true for either histamine or tryptase. These data are consistent with a pivotal role for PAF as a mediator of anaphylaxis http://buff.ly/QL26wp

Wheat-Dependent Exercise-Induced Anaphylaxis Sensitized with Hydrolyzed Wheat Protein in Soap http://buff.ly/RMOra0

A Real-Life Study on Acquired Skills from Using an Adrenaline Autoinjector: training of patients/caregivers by allergists does not guarantee the permanence of acquired skills on anaphylaxis in the long run. Regular follow-up visits should be fostered. http://buff.ly/RTNCwg

Anaphylaxis 101 is an educational program and website by the distributor of EpiPen, Mylan Specialty http://buff.ly/Sy5gsi

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: Lots of important current papers shared by @DrVes Anaphylaxis - top articles for November 2012 bit.ly/Qy1i2K

Systemic reactions from allergy skin testing: 0.4% for skin prick testing, 3.2% for intradermal

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Skin testing is the diagnostic cornerstone for allergies and is considered extremely safe, carrying only a small risk of systemic reactions.

A prospective study included 1,500 patients at the University of South Florida and aimed to determine the 12-month incidence of systemic reactions (SRs) to skin prick testing (SPT) and intradermal skin testing (ST). Epinephrine (0.2 mL of a 1:1,000 dilution) was administered intramuscularly in the deltoid as soon as any remote signs or symptoms occurred.


A wheal with multiple pseudopods and a satellite lesion in the upper left. Image source: Modified from Sakurako Kitsa's photostream, Flickr (used with the author's permission).

Four percent (3.6%) of patients had systemic reactions:

- 6 with skin prick testing (SPT), 0.4% of patients, 1 for every 240 patients tested
- 46 with intradermal testing

83% of patients with reactions were female, and 33% had asthma.

Systemic symptoms included:

- pruritic eyes, nose, or pharynx
- worsening cough
- sensation of difficulty swallowing
- worsening nasal congestion
- rhinorrhea
- chest tightness or shortness of breath
- generalized pruritus
- sneezing
- wheeze
- urticaria

No severe asthma, shock, hypotension, unconsciousness, or biphasic reactions occurred.

Treatment of reactions

100% of patients received epinephrine intramuscularly, 92% received oral prednisone, 7% oral prednisone to take 6 to 8 hours after a reaction, 96% oral antihistamine, and 12% nebulized albuterol.

Among patients who had allergy skin testing, systemic reactions occurred in:

- 0.4% for skin prick testing (SPT), 1 for every 240 patients tested
- 3.2% for intradermal testing

An older study (1993) showed that the probability of inducing systemic allergic reactions by skin testing was less than 0.02%. This probability has increased 20 times as of year 2009, to 0.4%.

100% of patients quickly responded to epinephrine intramuscularly (IM) in the deltoid. This immediate administration of epinephrine seems to prevent more serious and biphasic reactions.

Patients that should be considered at higher risk of systemic/anaphylactic reactions:

- women
- history of previous anaphylactic reactions
- small children
- pregnant women
- uncontrolled asthma
- high degree of reactivity

If your clinic sees 5-6 new patients per day and all of them undergo skin testing, you could expect one systemic reaction every 10 weeks, so be prepared.

The current allergy skin tests are virtually painless. This video by Dr. Bassett, a board-certified allergist from New York City, shows what to expect when visiting an allergy clinic for diagnosis and treatment:



From ACAAI online allergy lectures (COLA): This is a documentary about a workshop designed to teach and assess the ability of allergy/Immunology fellows to perform allergy skin tests. Held on April 20, 2012:



References:

http://www.ncbi.nlm.nih.gov/pubmed/19492661
http://www.ncbi.nlm.nih.gov/pubmed/16689179
http://www.ncbi.nlm.nih.gov/pubmed/8267250
http://www.ncbi.nlm.nih.gov/pubmed/19771451

Comments from Twitter:

David Fischer, MD @IgECPD4: What is the relative safety of doing skin prick testing in patients on beta-blockers? Pretty good from this study http://www.aacijournal.com/content/6/1/2

@Allergy: Skin prick testing on BB safe in 199 patients http://bit.ly/HI5EyF - However, Incidence of systemic reactions is 1:250 with SPT

David Fischer, MD @IgECPD4: 1:250 if looking at which population: venom/penicillin or inhalant/food? Inhalant/food much lower: Euro review http://t.co/THZRPePA

David Fischer, MD @IgECPD4: Lockey's data recent but much higher/worse than other references in blog post. Lin (3rd) article quotes 0.02% risk with 14 yrs and 10K pt.

@Allergy: There are regional differences, e.g. number of skin tests per visit in the U.S., multisensitized vs. monsensitized patients.

David Fischer, MD @IgECPD4: Really depends on severity of pt population, venom/penicillin vs food/inhalant, no of tests picked and methods/doses picked 4 tests.

Food allergy - top articles for November/December 2012

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Here are my suggestions for some of the top articles about food allergy for November/December 2012:

Recommendations regarding influenza vaccination for persons who report allergy to eggs http://goo.gl/LnME4

Study proposes COLAP as a new diagnostic tool for GI food allergy. COLAP stands for colonoscopic allergen provocation http://goo.gl/WB8BJ

First Voice-Guided Epinephrine Injector - the size of a credit card and the thickness of a cell telephone http://goo.gl/HhDzL

Consumption of peanuts and tree nuts during pregnancy might decrease the risk of allergic disease in children http://goo.gl/PiQ1N

Restriction of food products in the classroom to prevent food allergic reactions not a good idea - AAAAI Ask the Expert http://goo.gl/Jvsdw

Siblings and dog exposure in the first year of life decrease the risk of egg allergy http://buff.ly/PZJXhV

FPIES challenges are problematic: emesis and dehydration require fluid resuscitation in 50% of reactive challenges http://buff.ly/P4zn6d

Anaphylaxis after contact with a vomited food allergen http://buff.ly/Pufdmt -- First report of anaphylaxis to food ingested by another person.

Wheat-Dependent Exercise-Induced Anaphylaxis Sensitized with Hydrolyzed Wheat Protein in Soap http://buff.ly/RMOra0

Anaphylaxis in an emergency setting: foods are frequent elicitors of severe allergic reactions in general population. Anaphylaxis in the ED: a strong underuse of adrenaline by emergency physicians, not reflecting treatment protocols http://buff.ly/Qt2H9S

Steaming, spicing, or tea boiling weaken the allergenicity of egg proteins http://buff.ly/QIEWup

"Allergy Action Plan: Bring The Paperwork To Life" (video) http://buff.ly/QN8tTW

Peanut allergy: Patients with a positive SPT greater than the 95% PPV do not need an Arah2 testing undertaken http://bit.ly/SwbwBQ

More evidence flu shot is safe for the egg-allergic. Egg-allergic kids should get the flu shot from a doctor who can recognize and, if needed, treat a severe reaction http://buff.ly/Qk0nPU

Cow's milk is the most expensive allergic disease due to the cost of infant formulae (study) http://buff.ly/Qk1cYM

Unusual form of IgE-mediated anaphylaxis triggered by low-molecular-weight oligosaccharides in cow's milk formula http://buff.ly/SFK54T

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.

Asthma and Allergy Medications - Preferred Drug List Illinois Medicaid

To contact us Click HERE

If you have similar info for other states, please post it in the comments section below.

Inhaled Steroids

Preferred

Advair
Advair HFA
Asmanex
Dulera
Flovent
Qvar
Symbicort

Non-Preferred

Alvesco
budesonide respules (Prior approval NOT required for patients age 7 and under.)
Pulmicort

Leukotriene Antagonists

Preferred

montelukast
zafirlukast

Non-Preferred

Zyflo
Zyflo CR

Nasal Steroids

Preferred

flunisolide
fluticasone

Non-Preferred

Beconase AQ
Nasonex
Omnaris
Qnasal
Rhinocort Aqua
triamcinolone AQ
Veramyst
Zetonna

Nasal Preparations - Other

Preferred

First-Line

azelastine (For children through age 18)
Patanase (For children through age 18)

Second-Line

azelastine (For patients over age 18)
Patanase (For patients over age 18)

Non-Preferred

Astepro
Dymista
ipratropium spray

Ophthalmics – Allergic Conjunctivitis

Preferred

azelastine
Bepreve
Pataday
ketorolac
Alrex
cromolyn sodium

Non-Preferred

Emadine
epinastine
Lastacaft
Patanol
Alamast
Alocril
Alomide

References:

Preferred Drug List Illinois Medicaid. October 1, 2012, revised October 26, 2012.
http://www.hfs.illinois.gov/assets/pdl.pdf

Day 1285 - It's All In Your Head

To contact us Click HERE

"Many people know about other contributing factors such as heredity, food triggers, lack of sleep, poor posture, etc., but are not aware of any psychological connection.
Headache specialists report that many of their patients resist any discussion of emotional or psychological contributors to their recurrent headaches. Some people fear that pursuing this avenue could uncover evidence of "mental illness." Others feel that the existence of these factors would make their pain less real because it would then be "all in their heads". In just about all cases, neither of these 2 things is true!
Headache is definitely a biological disorder. However, since the body and the mind are interconnected, your emotional and psychological states can have an effect on your overall health, including your headaches. Here's why:
- When your emotional and psychological systems are in good working order, they help to create a positive environment that contributes to the health of your body.
- When these systems aren't working so well...for example, if you feel anxious, depressed or angry on a frequent basis — and especially if you find it difficult to shake these feelings — a negative environment can be created in your body that may contribute to a specific headache episode or create a fertile breeding ground for headaches to occur.
The relationship between anxiety, depression and headache is not fully understood. However, it is known that the brain chemical serotonin plays a role in all of them. Some headache specialists have theorized that these disorders may share a common mechanism in the brain.
Research has shown that some chronic headache sufferers also suffer from depression and/or anxiety. It is important to note that these sufferers' psychological conditions may not be caused by their headaches. Rather, tendencies towards depression or anxiety may be inherent in their personalities or ways of thinking. Or, they may be the result of an intense and prolonged level of stress which may lead to psychological conditions such as anxiety or depression. Regardless of the cause, having frequent headaches and feeling a lack of control over them may cause an existing condition of depression or anxiety to worsen. This situation can easily snowball, creating a vicious cycle of headache and emotional distress.
Unfortunately, emotional and psychological factors are often not considered in the treatment of headache. Doctors (especially those who are not headache specialists) tend to emphasize medical treatment — and rightly so. This is the traditional "first line of defense" and is effective for most headache patients. So is appropriate to start — and, for most, to stop — there. Also, some doctors today are cautious not to focus on psychological factors during the earlier stages of headache treatment — possibly overcompensating for the days when many doctors treated patients as if the pain was "all in their heads."

Doctors who do bring up psychological contributors as a possibility often find that their patients want to avoid psychological treatment, fearing a "mentally ill" diagnosis or having a concern that the presence of these factors would mean that their headaches are not a serious medical problem. This is very unfortunate because nothing could be farther from the truth!"*

*http://www.excedrin.com/psychological-contributors-to-headaches.shtml

It has taken me over three years to write this post.

When the headache started - which now seems all those years ago - I went to see a psychologist about it. The headache had exacerbated to such a degree that I was unable to work and felt completely depressed about my situation. After telling her about the distress that the headache had caused, she looked at me, arms gently folded over her lap, and stated “It must be such a headache having this pain!” and gave a little chuckle. I brushed aside this silly joke, ignoring it and thinking that maybe she had unintentionally let it out. However, when the very same joke repeated itself over the course of the next sessions, I felt hurt, frustrated and angry that a person contending to be there to help could actually end up aggravating a situation. I could bear it no longer and after a few sessions I left. That was the last of any psychological treatment I have undergone.

The possibility of the headache being related to a close friend’s death which took place a few months before the onset of my headache, has crossed my mind more than once. But nearly four years down the line I do not think the headache is related to this, or at least entirely to this. It is possible that I have not yet recovered from the shock of losing such a close friend. I truly believe there is a strong link between body and mind and that a traumatic event can undoubtedly have consequences on one’s body. The passage above taken from a Headache Centre webpage discusses this in further detail. Just today I also came across an article on the BBC website on a similar topic.

The reason it has taken me so long to write anything on this is that I am unable to draw the line between the “it could be a psychologically caused headache ” to a “it’s all in your head” (i.e. fictional). I am certain, from the manner in which this question is usually addressed to me, that by ‘psychological’ the word ‘fictional’ is intended. Does anyone feel the same?

Day 1285 - It's All In Your Head

To contact us Click HERE

"Many people know about other contributing factors such as heredity, food triggers, lack of sleep, poor posture, etc., but are not aware of any psychological connection.
Headache specialists report that many of their patients resist any discussion of emotional or psychological contributors to their recurrent headaches. Some people fear that pursuing this avenue could uncover evidence of "mental illness." Others feel that the existence of these factors would make their pain less real because it would then be "all in their heads". In just about all cases, neither of these 2 things is true!
Headache is definitely a biological disorder. However, since the body and the mind are interconnected, your emotional and psychological states can have an effect on your overall health, including your headaches. Here's why:
- When your emotional and psychological systems are in good working order, they help to create a positive environment that contributes to the health of your body.
- When these systems aren't working so well...for example, if you feel anxious, depressed or angry on a frequent basis — and especially if you find it difficult to shake these feelings — a negative environment can be created in your body that may contribute to a specific headache episode or create a fertile breeding ground for headaches to occur.
The relationship between anxiety, depression and headache is not fully understood. However, it is known that the brain chemical serotonin plays a role in all of them. Some headache specialists have theorized that these disorders may share a common mechanism in the brain.
Research has shown that some chronic headache sufferers also suffer from depression and/or anxiety. It is important to note that these sufferers' psychological conditions may not be caused by their headaches. Rather, tendencies towards depression or anxiety may be inherent in their personalities or ways of thinking. Or, they may be the result of an intense and prolonged level of stress which may lead to psychological conditions such as anxiety or depression. Regardless of the cause, having frequent headaches and feeling a lack of control over them may cause an existing condition of depression or anxiety to worsen. This situation can easily snowball, creating a vicious cycle of headache and emotional distress.
Unfortunately, emotional and psychological factors are often not considered in the treatment of headache. Doctors (especially those who are not headache specialists) tend to emphasize medical treatment — and rightly so. This is the traditional "first line of defense" and is effective for most headache patients. So is appropriate to start — and, for most, to stop — there. Also, some doctors today are cautious not to focus on psychological factors during the earlier stages of headache treatment — possibly overcompensating for the days when many doctors treated patients as if the pain was "all in their heads."

Doctors who do bring up psychological contributors as a possibility often find that their patients want to avoid psychological treatment, fearing a "mentally ill" diagnosis or having a concern that the presence of these factors would mean that their headaches are not a serious medical problem. This is very unfortunate because nothing could be farther from the truth!"*

*http://www.excedrin.com/psychological-contributors-to-headaches.shtml

It has taken me over three years to write this post.

When the headache started - which now seems all those years ago - I went to see a psychologist about it. The headache had exacerbated to such a degree that I was unable to work and felt completely depressed about my situation. After telling her about the distress that the headache had caused, she looked at me, arms gently folded over her lap, and stated “It must be such a headache having this pain!” and gave a little chuckle. I brushed aside this silly joke, ignoring it and thinking that maybe she had unintentionally let it out. However, when the very same joke repeated itself over the course of the next sessions, I felt hurt, frustrated and angry that a person contending to be there to help could actually end up aggravating a situation. I could bear it no longer and after a few sessions I left. That was the last of any psychological treatment I have undergone.

The possibility of the headache being related to a close friend’s death which took place a few months before the onset of my headache, has crossed my mind more than once. But nearly four years down the line I do not think the headache is related to this, or at least entirely to this. It is possible that I have not yet recovered from the shock of losing such a close friend. I truly believe there is a strong link between body and mind and that a traumatic event can undoubtedly have consequences on one’s body. The passage above taken from a Headache Centre webpage discusses this in further detail. Just today I also came across an article on the BBC website on a similar topic.

The reason it has taken me so long to write anything on this is that I am unable to draw the line between the “it could be a psychologically caused headache ” to a “it’s all in your head” (i.e. fictional). I am certain, from the manner in which this question is usually addressed to me, that by ‘psychological’ the word ‘fictional’ is intended. Does anyone feel the same?

Sputum inflammatory phenotypes are not stable in children with asthma

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Two distinct, stable inflammatory phenotypes have been described in adults with asthma: eosinophilic and non-eosinophilic. This study evaluated sputum cytology in 51 children with severe asthma and 28 with mild to moderate asthma who were followed over 3–6 months.

78% of the children had increased levels of inflammatory cells in at least one sputum sample. In the longitudinal analysis, 63% of children demonstrated two or more phenotypes.

Change in phenotype was not related to change in inhaled corticosteroid (ICS) dose or asthma control, nor was it reflected in a change in exhaled nitric oxide (FENO).

Remarkably, 41% of children fulfilled the criteria for non-eosinophilic asthma on one occasion and eosinophilic on another. There were no differences in severity, asthma control, atopy, ICS dose or FEV1 between those who were always non-eosinophilic and those always eosinophilic.


Eosinophil. Image source: Wikipedia.

The authors concluded that sputum inflammatory phenotypes are not stable in children with asthma.

This study was included in the monthly review of the top asthma articles at the website of the World Allergy Organization (WAO) (I am the web editor of the project).

References:

Sputum inflammatory phenotypes are not stable in children with asthma. Louise Fleming et al. Thorax 2012;67:675-681 doi:10.1136/thoraxjnl-2011-201064