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Showing posts with label illness. Show all posts
Showing posts with label illness. Show all posts

Thursday, January 7, 2016

What's new in Allergy and Immunology?



What's new in allergy and immunology
Disclosures: Anna M Feldweg, MD Nothing to disclose. Elizabeth TePas, MD, MS Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2015. | This topic last updated: Jan 06, 2016.
The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ASTHMA AND COPD
Early use of azithromycin to prevent lower respiratory tract illness in preschool children with recurrent wheezing (December 2015)
The potential utility of macrolide antibiotics in the treatment of recurrent wheezing/asthma has been considered, given their antiinflammatory properties and antimicrobial effects against Mycoplasma pneumonia and Chlamydia pneumonia, although there is a paucity of data supporting their use in this setting. One multicenter trial examined whether the early use of azithromycin prevented lower respiratory tract illness (LRTI) in 607 preschool children with a history of severe recurrent wheezing [1]. Treatment was initiated at the onset of respiratory illness in conjunction with signs/symptoms that usually preceded the development of a severe LRTI specific to each child. Children were randomly assigned to oral azithromycin or placebo for five days in addition to albuterol. The risk of progressing to severe LRTI was significantly lower in the treatment group compared with the control, although there was no difference in urgent care utilization, emergency department visits, or hospitalizations. Although this study provides some evidence for the early use of azithromycin, given concerns regarding antibiotic resistance and adverse effects with widespread use, further study is warranted to define subpopulations who could most benefit from preventive therapy before recommendations can be made. (See "Treatment of recurrent virus-induced wheezing in young children", section on 'Antibiotics'.)
New biologic therapy approved for severe eosinophilic asthma (November 2015)
Mepolizumab, a monoclonal antibody to interleukin (IL)-5, has been approved by the US Food and Drug Administration for add-on, maintenance treatment of severe asthma in patients who are age 12 or older, have frequent asthma exacerbations, and have an eosinophilic phenotype [2]. One marker of an eosinophilic phenotype is an absolute eosinophil count in peripheral blood of ≥150/microL. Studies in patients with severe eosinophilic asthma have shown that mepolizumab reduces the rate of exacerbations [3] and enables a reduction in the oral glucocorticoid dose. Mepolizumab is administered subcutaneously at four-week intervals. Based on a small increase in herpes zoster in treated adults, we suggest that patients who meet criteria for the varicella-zoster vaccine be immunized at least four weeks prior to initiation of mepolizumab. Mepolizumab will likely be commercially available in early 2016. (See "Treatment of severe asthma in adolescents and adults", section on 'Anti-IL-5 therapy'.)
DRUG HYPERSENSITIVITY
Low allergic cross-reactivity between penicillins and carbapenems (May 2015)
Carbapenems (eg, imipenem, meropenem) share a common beta-lactam ring with penicillins and hence the potential for allergic cross-reactivity, and some drug information systems list penicillin allergy as a contraindication to the use of carbapenems (figure 1). In the largest study to date, 212 patients with allergy to penicillins, confirmed by skin testing, were then tested with carbapenems [4]. All subjects were negative to carbapenem skin testing and tolerated graded challenges to three different carbapenems. Based on this and other series, the rate of reactivity to carbapenems in patients with confirmed penicillin allergy is estimated at <1 percent. This supports our current recommendations on administration of carbapenems to patients reporting immediate-type penicillin allergy: Perform penicillin skin testing when available. If negative, patients may safely receive penicillins and carbapenems. If penicillin skin testing is positive or not available, carbapenems may be administered via a graded challenge. (See "Penicillin-allergic patients: Use of cephalosporins, carbapenems, and monobactams", section on 'Carbapenems'.)
FOOD ALLERGY AND INTOLERANCE
Omalizumab and oral immunotherapy for food allergy (January 2016)
Investigational protocols of oral immunotherapy (OIT) for food allergy have been complicated by high rates of allergic reactions during treatment. There has been interest in co-treating patients with anti-IgE (omalizumab) to prevent these reactions, although omalizumab is expensive. Results from a randomized, multicenter trial suggest that treatment with anti-IgE before and during the build-up phase of OIT may be a more cost-effective approach than continuing anti-IgE for the duration of OIT therapy. In this trial, 57 children and adults were assigned to omalizumab or placebo for four months before and throughout the build-up and maintenance phases of open-label milk OIT [5]. The median percentages of doses per subject to cause symptoms in the omalizumab and placebo groups were 2.1 and 16.1 during build-up, and 0 and 3.4 during maintenance, respectively. There were no significant differences in the percent of patients desensitized (>70 percent) or with sustained unresponsiveness to milk (>36 percent). Thus, omalizumab treatment improved the safety, but did not impact the efficacy of OIT. Because most reactions occurred during the build-up phase, omalizumab could be limited to that phase of treatment to reduce cost. (See "Future therapies for food allergy", section on 'Oral immunotherapy combined with anti-IgE'.)
Genetic modification of foods to reduce allergen content (December 2015)
There has been interest in genetically modifying foods to lower the content of specific allergenic proteins, and an apple line has been modified by RNA interference to reduce the content of Mal d 1, an allergen important in pollen-food allergy syndrome (PFAS, also called oral allergy syndrome). In a proof-of-concept study of 21 adults with PFAS, single-blind oral challenges of two lines containing the lowest amount of this allergen produced no symptoms in 43 and 63 percent of subjects, respectively, and only mild symptoms in nearly all the others [6]. The apple lines produced for this study are not commercially available. (See "Management and prognosis of oral allergy syndrome (pollen-food allergy syndrome)", section on 'Genetically-modified foods'.)
n-3 LCPUFA supplementation in pregnancy and allergies in offspring (November 2015)
It has been hypothesized that maternal intake of long chain polyunsaturated fatty acids (n-3 LCPUFA) during pregnancy may prevent development of allergies in offspring. However, a recent systematic review of randomized trials assessing the effect of n-3 LCPUFA supplementation during pregnancy and/or breastfeeding on allergy outcomes in offspring found supplementation did not significantly reduce childhood allergic disease (food allergy, atopic dermatitis, allergic rhinitis, asthma) at 36 months of age compared with no treatment/placebo [7]. (See "Fish consumption during pregnancy", section on 'Other outcomes'.)
Transient transfer of food allergies in a blood product (September 2015)
A recent case report highlights the possibility of acquiring food allergies following transfusion of a blood product such as platelets [8]. This may also occur after solid organ or hematopoietic cell transplantation. In the former case, the allergy is transient and is due to food-specific immunoglobulin E (IgE) in the blood product. In the latter case, the potential mechanism depends upon the type of transplant and can range from temporary allergy due to transferred mast cells or allergen-specific IgE, to longer-lasting or permanent allergy due to transfer of food allergen-specific lymphocytes or hematopoietic stem cells from the donor. Finally, an allergic reaction to a food can occur in an allergic recipient after receiving a blood product that contains intact allergen consumed by the donor. (See "History and physical examination in the patient with possible food allergy", section on 'Questions related to contributory factors'.)
IMMUNODEFICIENCY
Updated guidelines for the diagnosis and management of primary immunodeficiency (November 2015)
A revised “Practice parameter for the diagnosis and management of primary immunodeficiency,” developed by the three national allergy and immunology societies in the United States, has been published to aid allergy/immunology specialists and other practitioners in the recognition, diagnosis, and general management of these disorders [9]. Highlights include screening and advanced laboratory tests for the different components of immune function, characteristic clinical manifestations and laboratory findings for a number of disorders, internet resources, antibiotic prophylaxis, and indications for hematopoietic cell transplantation or gene therapy. There are now more than 200 genetically distinct disorders of immune function that are classified using the system devised by the World Health Organization (WHO) and International Union of Immunological Societies (IUIS). Consultation with an immunology specialist with experience in diagnosing and managing primary immunodeficiencies is recommended. Our approach is consistent with that outlined in this practice parameter. (See"Approach to the child with recurrent infections" and "Laboratory evaluation of the immune system" and "Medical management of immunodeficiency".)
Dedicator of cytokinesis 2 deficiency (June 2015)
Dedicator of cytokinesis 2 (DOCK2) deficiency is a newly recognized combined immunodeficiency (CID). Biallelic (homozygous or compound heterozygous) mutations in the DOCK2 gene were identified through whole-exome sequencing in a group of unrelated patients with early-onset invasive bacterial and viral infections, lymphopenia, and defective T, B, and NK cell responses [10]. DOCK2 deficiency results in impaired activation of RAC1 that leads to defects in actin polymerization, lymphocyte proliferation and migration, natural killer cell degranulation, and response to viral infections in fibroblasts and peripheral blood mononuclear cells. Other CIDs that are the result of defects in actin regulation include Wiskott-Aldrich syndrome and DOCK8 deficiency. (See "Combined immunodeficiencies", section on 'Dedicator of cytokinesis 2 deficiency'.)
RHINITIS AND RHINOSINUSITIS
Systematic review of medical therapies for adults with chronic rhinosinusitis (September 2015)
A new systematic review of medical therapies for adults with chronic rhinosinusitis (CRS, both with and without nasal polyposis) concluded that topical glucocorticoids and high-volume nasal saline irrigations were the two therapies best supported by evidence [11]. Evidence for the effectiveness of other therapies was conflicting, but the review supports the use of short courses (one to three weeks) of oral glucocorticoids, doxycycline, and leukotriene receptor antagonists for CRS with nasal polyposis, with which UpToDate largely agrees. The review also suggests a trial of long-term macrolide therapy for CRS without polyposis, although evidence for this is weak and UpToDate authors do not agree that benefits outweigh risks (drug resistance, costs, adverse effects) for most patients. More high-quality studies are needed for the optimal treatment of CRS. (See "Chronic rhinosinusitis: Management", section on 'Oral glucocorticoids'.)
URTICARIA AND ANGIOEDEMA
Mechanism proposed for hereditary angioedema with normal C1 inhibitor and FXII mutations (August 2015)
Hereditary angioedema with normal C1 inhibitor is a rare disorder; normal complement studies distinguish this from other forms of hereditary angioedema. Defects in the gene for coagulation factor XII (FXII) are seen in some patients with hereditary angioedema with normal C1 inhibitor but a mechanism linking FXII defects and angioedema has been lacking. A new study proposes that one FXII mutation found in these patients affects a glycosylation site, resulting in increased autoactivation of FXII [12]. Increased FXII autoactivation could lead to enhanced activation of the kallikrein-kinin pathway and excessive bradykinin formation. Thus, a potential mechanism has been identified for the pathogenesis of the hereditary angioedema in patients with normal complement studies and a FXII mutation. (See "Hereditary angioedema with normal C1 inhibitor (type III HAE)", section on 'Mutations in the FXII gene'.)
VACCINES AND VACCINE HYPERSENSITIVITY
Adjuvanted influenza vaccine approved for elderly adults in the United States (November 2015)
There has been interest in using adjuvants in influenza vaccines in elderly individuals, who have reduced immune responses to influenza vaccines; adjuvants are substances that amplify the immune response to an antigen. In November 2015, an adjuvanted trivalent inactivated influenza vaccine (Fluad) was approved for use in individuals ≥65 years of age in the United States [13]. It is the first adjuvanted seasonal influenza vaccine to be approved in the United States, but it has been approved already in >35 other countries. The vaccine is formulated with the adjuvant MF59, an oil-in-water emulsion of squalene oil. Studies have shown that the MF59-adjuvanted vaccine has comparable [13] or higher immunogenicity compared with unadjuvanted vaccines [14-16]. Until further data are available, we continue to suggest the non-adjuvanted high-dose inactivated vaccine for individuals ≥65 years of age. (See "Seasonal influenza vaccination in adults", section on 'Adjuvanted vaccine' and "Seasonal influenza vaccination in adults", section on 'Vaccine formulations'.)
Statins and influenza vaccine immunogenicity and effectiveness (November 2015)
Statins are used commonly in older adults with hyperlipidemia and are known to have immunomodulatory effects, which could affect vaccine responses. In an observational study conducted in the context of a randomized trial that evaluated influenza vaccines in individuals >65 years of age, hemagglutination inhibition (HAI) geometric mean titers to various influenza strains were substantially lower in those receiving chronic statin therapy than in those not receiving it [17]. In addition, in the adjusted analysis of a large retrospective cohort study, statin use was associated with reduced influenza vaccine effectiveness against medically attended acute respiratory illness [18]. The observed associations between statin use and vaccine effectiveness could be due to confounding, as patients receiving statins are likely to be at differing baseline risk of influenza from those not receiving statins. Although these studies raise the possibility that older patients receiving statins are less likely to be protected by the influenza vaccine, such individuals should still receive statins, when indicated, as well as an influenza vaccine annually. (See "Seasonal influenza vaccination in adults", section on 'Efficacy'.)
Revised schedule for pneumococcal vaccination in older adults (September 2015)
The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for many years in the United States for all adults ≥65 years of age. In 2014, the United States Advisory Committee on Immunization Practices (ACIP) began also recommending the 13-valent pneumococcal conjugate vaccine (PCV13) for adults ≥65 years of age [19]. In September 2015, the ACIP changed the recommended interval between administration of PCV13 and PPSV23 for immunocompetent adults ≥65 years of age from 6-12 months to ≥1 year to simplify the administration schedule (algorithm 1) [20]. In patients who have already received PPSV23, at least 1 year should elapse before they are given PCV13. (See "Pneumococcal vaccination in adults", section on 'Schedule for dual vaccination'.)
OTHER GENERAL ALLERGY AND IMMUNOLOGY
Classification of cutaneous manifestations of mastocytosis (December 2015)
Mastocytosis is characterized by the expansion of a clonal mast cell population and can be limited to the skin or systemic. Skin lesions may be present in the systemic form of the disease. An international consensus report proposed revised definitions and diagnostic criteria for different skin lesions [21]. The most common skin finding, urticaria pigmentosa, is now called maculopapular cutaneous mastocytosis (MPCM). MPCM is divided into two types: a monomorphic type typically seen in adults, consisting of multiple uniform, small, brownish-red lesions; and a polymorphic type usually seen in infants and children, consisting of larger, more heterogeneous lesions. Childhood polymorphic MPCM usually improves or regresses by puberty, but children who present with monomorphic MCPM appear to have a higher risk of the disease persisting into adulthood and involving extracutaneous organs. (See "Mastocytosis (cutaneous and systemic): Evaluation and diagnosis in adults" and "Mastocytosis (cutaneous and systemic): Evaluation and diagnosis in children", section on 'Skin examination'.)
Dupilumab for moderate to severe atopic dermatitis in adults (November 2015)
Dupilumab is an investigational monoclonal antibody directed against the IL-4 receptor alpha subunit, which blocks the downstream signaling of IL-4 and IL-13. These cytokines are believed to be drivers of the Th2-mediated inflammation in atopic dermatitis. In an industry-sponsored phase IIb randomized trial, over 300 adult patients with chronic moderate to severe atopic dermatitis were treated with dupilumab, at five different doses and schedules, or placebo [22]. At 16 weeks, patients in all the dupilumab treatment groups had a greater improvement in the eczema area and severity score (EASI) compared with baseline than patients in the placebo group, and improvement was dose-dependent. The most common adverse events associated with dupilumab were upper respiratory tract infection and exacerbation of atopic dermatitis. These results suggest that dupilumab may be a promising treatment for long-standing atopic dermatitis in adults. However, due to both the high attrition rate in the dupilumab groups and the short duration of the trial, further studies are needed to evaluate the long-term efficacy and safety of dupilumab for the treatment of atopic dermatitis. (See "Treatment of atopic dermatitis (eczema)", section on 'Experimental agents'.)
Auvi-Q and Allerject epinephrine autoinjectors recalled by manufacturer (October 2015)
A manufacturer's recall was issued in October 2015 of all Auvi-Q epinephrine autoinjectors in the United States, as well as all Allerject devices in Canada, including both the 0.15 and 0.3 mg strengths, due to potentially inaccurate dose delivery [23,24]. Patients should be provided with a prescription for an alternate epinephrine device and return Auvi-Q and Allerject autoinjectors to their pharmacy for replacement and instruction on how to use the new device. Patients should only use Auvi-Q or Allerject if no other device is available in a severe allergic reaction and then immediately contact 9-1-1 or emergency medical services. (See "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Types of autoinjectors'.)
Prediction model for eosinophilic esophagitis (September 2015)
The distinction between eosinophilic esophagitis and gastroesophageal reflux disease is often difficult to make. A prediction model that incorporated eight clinical and endoscopic features (younger age; male sex; presence of dysphagia and food allergies; presence of esophageal rings, furrows, and plaques; and lack of a hiatal hernia) predicted eosinophilic esophagitis with an accuracy, sensitivity, and specificity of 84, 97, and 92 percent, respectively [25]. However, additional studies are needed to validate this model. (See "Clinical manifestations and diagnosis of eosinophilic esophagitis", section on 'Distinction from GERD'.)
Stevens-Johnson syndrome outbreak associated with M. pneumoniae (August 2015)
Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a rare, severe blistering mucocutaneous reaction, most commonly triggered by medications, characterized by extensive necrosis and detachment of the epidermis and mucosa.Mycoplasma pneumoniae and cytomegalovirus infections are the next most common trigger of SJS/TEN, particularly in children. Between September and November 2013, an outbreak of eight pediatric cases of M. pneumoniae-associatedSJS/TEN was reported in Colorado, likely related to high levels of M. pneumoniae infection in the region [26]. All children had severe oropharyngeal mucositis; the conjunctiva was involved in seven children and the genital mucosa in five. (See"Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis", section on 'Infection'.)
Influenza vaccine recommendations for 2015-2016 influenza season (August 2015)
In August 2015, the Advisory Committee on Immunization Practices released recommendations for the prevention and control of influenza during the 2015-2016 influenza season in the United States. As in previous seasons, seasonal influenza vaccination is recommended for everyone ≥6 months of age [27]. Changes for the 2015-2016 season include:
Different influenza A H3N2 and influenza B (Yamagata lineage) antigens than were in the 2014-2015 vaccines
A simplified dosing algorithm for children six months through eight years (algorithm 2)
Availability of a quadrivalent intradermal vaccine for adults 18 through 64 years of age (table 1)
Predictors of the need for repeat epinephrine doses in anaphylaxis (August 2015)
Epinephrine is the first-line therapy for anaphylaxis, and retrospective studies suggest that up to one-third of patients may require a second dose. However, predictive factors for requiring more than one dose are not well defined. In a prospective cohort study of over 500 patients (all ages) treated for anaphylaxis in a tertiary care emergency department, 14 percent of those requiring any epinephrine required more than one dose [28]. Patients with a history of previous anaphylaxis, and those presenting with flushing, diaphoresis, or dyspnea, were more likely to require multiple doses of epinephrine to control symptoms. Anaphylaxis is an inherently unpredictable disorder, but this study provides some insight into predictors of a more complicated treatment course and may help clinicians managing such patients. (See "Anaphylaxis: Rapid recognition and treatment", section on 'Dosing and administration'.)
Acute worsening of atopic dermatitis due to aeroallergen exposure (July 2015)
Environmental allergens are a trigger of atopic dermatitis (AD) in a small subset of children and adults. Patients who have environmental allergies as a trigger of AD have persistent disease with chronic exposure to an allergen in the environment. A small study of adults with AD demonstrated that exposure to grass pollen in an environmental challenge chamber for two consecutive days resulted in a significant worsening of AD on exposed skin for the five days after challenge compared with exposure to clean air (placebo) [29]. This study shows that an isolated exposure to an aeroallergen can cause an acute flare of AD in sensitized individuals. (See "Role of allergy in atopic dermatitis (eczema)", section on 'Aeroallergens'.)
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REFERENCES

  1. Bacharier LB, Guilbert TW, Mauger DT, et al. Early Administration of Azithromycin and Prevention of Severe Lower Respiratory Tract Illnesses in Preschool Children With a History of Such Illnesses: A Randomized Clinical Trial. JAMA 2015; 314:2034.
  2. US Food and Drug Administration. http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm471031.htm (Accessed on November 05, 2015).
  3. Powell C, Milan SJ, Dwan K, et al. Mepolizumab versus placebo for asthma. Cochrane Database Syst Rev 2015; 7:CD010834.
  4. Gaeta F, Valluzzi RL, Alonzi C, et al. Tolerability of aztreonam and carbapenems in patients with IgE-mediated hypersensitivity to penicillins. J Allergy Clin Immunol 2015; 135:972.
  5. Wood RA, Kim JS, Lindblad R, et al. A randomized, double-blind, placebo-controlled study of omalizumab combined with oral immunotherapy for the treatment of cow's milk allergy. J Allergy Clin Immunol 2015.
  6. Dubois AE, Pagliarani G, Brouwer RM, et al. First successful reduction of clinical allergenicity of food by genetic modification: Mal d 1-silenced apples cause fewer allergy symptoms than the wild-type cultivar. Allergy 2015; 70:1406.
  7. Gunaratne AW, Makrides M, Collins CT. Maternal prenatal and/or postnatal n-3 long chain polyunsaturated fatty acids (LCPUFA) supplementation for preventing allergies in early childhood. Cochrane Database Syst Rev 2015; 7:CD010085.
  8. Ching JC, Lau W, Hannach B, Upton JE. Peanut and fish allergy due to platelet transfusion in a child. CMAJ 2015; 187:905.
  9. Bonilla FA, Khan DA, Ballas ZK, et al. Practice parameter for the diagnosis and management of primary immunodeficiency. J Allergy Clin Immunol 2015; 136:1186.
  10. Dobbs K, Domínguez Conde C, Zhang SY, et al. Inherited DOCK2 Deficiency in Patients with Early-Onset Invasive Infections. N Engl J Med 2015; 372:2409.
  11. Rudmik L, Soler ZM. Medical Therapies for Adult Chronic Sinusitis: A Systematic Review. JAMA 2015; 314:926.
  12. Björkqvist J, de Maat S, Lewandrowski U, et al. Defective glycosylation of coagulation factor XII underlies hereditary angioedema type III. J Clin Invest 2015; 125:3132.
  13. FDA news release. FDA approves first seasonal influenza vaccine containing an adjuvant. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm474295.htm (Accessed on November 25, 2015).
  14. Black S. Safety and effectiveness of MF-59 adjuvanted influenza vaccines in children and adults. Vaccine 2015; 33 Suppl 2:B3.
  15. De Donato S, Granoff D, Minutello M, et al. Safety and immunogenicity of MF59-adjuvanted influenza vaccine in the elderly. Vaccine 1999; 17:3094.
  16. O'Hagan DT, Rappuoli R, De Gregorio E, et al. MF59 adjuvant: the best insurance against influenza strain diversity. Expert Rev Vaccines 2011; 10:447.
  17. Black S, Nicolay U, Del Giudice G, Rappuoli R. Influence of Statins on Influenza Vaccine Response in Elderly Individuals. J Infect Dis 2015.
  18. Omer SB, Phadke VK, Bednarczyk RA, et al. Impact of Statins on Influenza Vaccine Effectiveness Against Medically Attended Acute Respiratory Illness. J Infect Dis 2015.
  19. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2014; 63:822.
  20. Kobayashi M, Bennett NM, Gierke R, et al. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2015; 64:944.
  21. Hartmann K, Escribano L, Grattan C, et al. Cutaneous manifestations in patients with mastocytosis: Consensus report of the European Competence Network on Mastocytosis; the American Academy of Allergy, Asthma & Immunology; and the European Academy of Allergology and Clinical Immunology. J Allergy Clin Immunol 2015.
  22. McGregor S, Farhangian ME, Feldman SR. Dupilumab for the treatment of atopic dermatitis: A clinical trial review. Expert Opin Biol Ther 2015; 15:1657.
  23. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm470010.htm (Accessed on October 29, 2015).
  24. http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2015/55620a-eng.php (Accessed on October 29, 2015).
  25. Dellon ES, Rusin S, Gebhart JH, et al. A Clinical Prediction Tool Identifies Cases of Eosinophilic Esophagitis Without Endoscopic Biopsy: A Prospective Study. Am J Gastroenterol 2015; 110:1347.
  26. Olson D, Watkins LK, Demirjian A, et al. Outbreak of Mycoplasma pneumoniae-Associated Stevens-Johnson Syndrome. Pediatrics 2015; 136:e386.
  27. Grohskopf LA, Sokolow LZ, Olsen SJ, et al. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 Influenza Season. MMWR Morb Mortal Wkly Rep 2015; 64:818.
  28. Campbell RL, Bashore CJ, Lee S, et al. Predictors of Repeat Epinephrine Administration for Emergency Department Patients with Anaphylaxis. J Allergy Clin Immunol Pract 2015; 3:576.
  29. Werfel T, Heratizadeh A, Niebuhr M, et al. Exacerbation of atopic dermatitis on grass pollen exposure in an environmental challenge chamber. J Allergy Clin Immunol 2015; 136:96.

Topic 8363 Version 6012.0

Tuesday, December 22, 2015

FLU VACCINE for All: A Critical Look at the Evidence

Of note, Immunization, Obesity, Illiteracy and High School drop out are actual priorities worldwide!

Allergy & Clinical Immunology

Flu Vaccine for All: A Critical Look at the Evidence

Eric A. Biondi, MD, MS; C. Andrew Aligne, MD, MPH
Disclosures | December 21, 2015

When Vaccination Became Routine

Vaccine proponents felt that the failure of the vaccine was explained by the immunization campaign being too little, too late. As a result, in 1960, national health experts recommended, for the first time, routine annual vaccination, with emphasis on high-risk groups, including those over the age of 65 years and individuals with chronic illness.[13] By the early 1960s, routine influenza vaccination was generally adopted as a policy, with very little supporting evidence.
After several years of this policy, the CDC decided to evaluate its impact. In 1964, Alexander Langmuir, MD, MPH, then the chief epidemiologist at the CDC, published a paper[13] that "reluctantly concluded that there is little progress to be reported. The severity of the epidemic of 1962-1963...demonstrates the failure to achieve effective control of excess mortality." The paper questioned whether widespread influenza immunization "should be continued without better evidence to justify the major costs to the general public." Despite this, annual vaccination campaigns were continued.
In 1968, the CDC finally performed a randomized, double-blind trial[14] to examine the effect of vaccination on morbidity and mortality. The authors concluded that "Despite extensive use of influenza vaccines...attainment of [improved morbidity and mortality] has never been demonstrated." Nevertheless, flu immunization continued.
In 1976, H1N1 "swine flu" appeared, and a large-scale effort to immunize as many Americans as possible was launched.[15] However, the anticipated levels of disease did not appear, and an epidemic of paralytic Guillain-Barré syndrome in recipients of vaccine led to the program's cancellation. An analysis in 1977[16] by the CDC concluded that influenza control had been "generally ineffective" and that statistically valid community trials were needed.
In 1995, a major review from the US Food and Drug Administration acknowledged the ongoing "paucity of randomized trials" and warned about serious methodological flaws in many existing flu vaccine studies.[17]
In 2000, the CDC performed a placebo-controlled trial and found that "vaccination [when compared to placebo] may not provide overall economic benefit in most years."[18]
Nonetheless, in 2004, the AAP recommended annual influenza immunization for young children, household contacts, and healthcare providers.[19]
Vaccination coverage recommendations continued to expand, and now during every flu season, we watch commercials by retail pharmacies telling us about the importance of getting the flu shot. The fact that the AAP recommends "mandatory" flu vaccination for healthcare providers[20] means that eventually clinicians could be fired for not getting vaccinated.

Summing Up the Data

A 2012 systematic review and meta-analysis[21] examined the efficacy and effectiveness of licensed influenza vaccines in patients with confirmed influenza illness. The authors confirmed that the original "recommendation to vaccinate the elderly was made without data for vaccine efficacy or effectiveness." The main message was that we need a better vaccine and better studies to demonstrate its effectiveness.
Despite the lack of high-quality data supporting the value of the flu shot, widespread vaccination policy might still be reasonable if observational studies consistently showed a benefit. However, the observational studies cited by flu shot proponents are frequently flawed.[22-28] In many studies, relevant clinical outcomes are ignored in favor of immunogenicity (ie, the ability to elicit an antibody response). "Influenza-like illness" (ie, cold symptoms) is frequently measured instead of serious outcomes, such as pneumonia or death. When these more serious outcomes are examined, there is often a failure to control for healthy user bias—the propensity for healthier people to do such things as receive annual check-ups, eat healthier foods, and get the flu shot. So, although it's true that people who get flu shots live longer, it may have nothing to do with actually getting the flu shot.
A 2005 study of a 33-season, national data set attempted to reconcile the reduced all-cause morbidity and mortality found in some observational studies of influenza vaccination with the fact that "national influenza mortality rates among seniors increased in the 1980s and 1990s as the senior vaccination coverage quadrupled."[29] In this study, the authors conclude that:
"[Our] estimates, which provide the best available national estimates of the fraction of all winter deaths that are specifically attributable to influenza, show that the observational studies must overstate the mortality benefits of the vaccine...[even during two pandemic seasons] the estimated influenza-related mortality was probably very close to what would have occurred had no vaccine been available."
The rationale for flu immunization as a national health priority is that influenza is a disease with serious complications, such as pneumonia, hospitalization, and death.[5,13,28] If the reason for influenza vaccination is that flu is such a serious disease, then the relevant outcomes are whether vaccination improves morbidity and mortality from flu. However, after decades of vaccine use, it is hard to detect any public health impact. This is in stark contrast to other routine vaccinations, such as polio and Haemophilus influenzae type b, where introduction of the vaccine led to obvious decline of the disease.
We are pediatricians, and we believe in childhood immunizations. Many vaccines have provided immense public health value. We simply question whether the policy of routine influenza vaccination has outpaced the data supporting its use.
Influenza vaccination now supersedes many other priorities of public health (such as obesity, illiteracy, and high school dropout), and we question whether so much time, effort, and money should be dedicated to flu vaccination while these other national healthcare priorities remain on the back burner.
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Tuesday, November 24, 2015

ANAFILAXIA INDUCIDA POR EJERCICIO EN ALERGIA ALIMENTARIA / PRESENTACION DE UN CASO




Allergy & Clinical Immunology

Food-Dependent Exercise-Induced Anaphylaxis to Chickpea in a 17-Year-Old Female: A Case Report

Hannah Roberts; Moshe Ben-Shoshan
Disclosures
J Med Case Reports. 2015;9(186) 

Abstract and Introduction

Abstract

Introduction: Food-dependent exercise-induced anaphylaxis is a subtype of anaphylaxis and, although rare, it is an important condition to be familiar with as it can ultimately lead to death.
Case presentation: We present a case of food-dependent exercise-induced anaphylaxis in a 17-year-old white girl due to chickpea. She had a history of anaphylaxis after eating crackers and hummus before exercising. Skin prick testing and serum-specific immunoglobulin E level confirmed chickpea to be the causative allergen.
Conclusions: This case demonstrates the challenge in identifying specific causative food allergens when foods are eaten in combination, when the food is processed, and when cross-reactivity is possible. These challenges add complexity to a condition that is already rare and unfamiliar to some health care providers. We hope that this case will serve as an important reminder that although rare, food-dependent exercise-induced anaphylaxis exists and making a diagnosis can lead to life-saving preventative strategies. As legumes are not a common food associated with food-dependent exercise-induced anaphylaxis, this will add to our current knowledge base in the field of allergy.

Introduction

Anaphylaxis is a systemic allergic reaction that is rapid in onset and has the potential to cause death.[1] Once diagnosed, avoidance of allergen and carrying an epinephrine auto-injector is recommended.[2] Most anaphylactic reactions are immunoglobulin E (IgE) mediated and the major triggers include food, medication, venom, latex, exercise, and transfusions.[3] It is reported that anaphylaxis affects at least 1.6% of the general population.[4]
Food-dependent exercise-induced anaphylaxis (FDEIA) is a subtype of anaphylaxis and is rare.[5] FDEIA is more commonly described in adolescents and adults versus younger children.[6] The condition is characterized by anaphylaxis that develops in association with physical exertion and ingestion of a causative food within a certain timeframe. In an analysis of 167 Japanese cases of FDEIA, 80% of the patients developed symptoms within 2 hours of eating the causative food.[7] Neither the food allergen nor exercise alone triggers anaphylaxis. Typical symptoms seen in FDEIA include skin manifestations (urticaria, erythema, edema, and pruritus), dyspnea, abdominal pain, and fatigue.[8] The pathogenesis is not fully understood yet. Based on skin prick testing (SPT) and specific IgE results for causative foods, an IgE mechanism is likely. The exact mechanism that results in a transient disruption in immune tolerance to causative foods is not known and different theories exist.[9] It is thought that exertion triggers physiological change that enhances absorption of undigested, immunoreactive forms of allergen from the gastrointestinal tract. Specific co-triggers such as non-steroidal anti-inflammatory drugs (NSAIDS), aspirin, extreme temperatures, a second food, menstruation, and stress, have also been theorized to aid in the development of FDEIA.[5], [6] The primary foods reported to trigger FDEIA are wheat and shellfish,[10] although in Europe tomatoes appear to be more common in FDEIA than wheat.[6] A variety of other foods have been identified in FDEIA including vegetables, fruits, nuts, egg, mushrooms, rice, and meat.[7]
Diagnosis relies on a thorough history to identify food allergen exposure, along with the combination of exercise and possible co-triggers. SPT and specific IgE levels can reveal the food allergen(s) and exclude other suspected allergens. A positive oral-food exercise challenge would further confirm a diagnosis, but is unnecessary if the history is suggestive and SPT and/or IgE levels are consistent.[5]
We present a case of FDEIA to chickpea in a 17-year-old girl with a convincing clinical history, positive SPT to fresh chickpea and hummus extract, along with an elevated serum-specific IgE level to chickpea. To the best of our knowledge, this is the first case demonstrating FDEIA to chickpea in an adolescent. This case describes the challenge in identifying specific causative food allergens when foods are eaten in combination, when the food is processed, and when cross-reactivity is possible.
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