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Tuesday, October 6, 2015

WHAT IS NEW IN ALLERGY & IMMUNOLOGY /

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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.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2015. | This topic last updated: Oct 01, 2015.
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
Investigational agent shows promise in asthma (June 2015)
GATA3 is a transcription factor that is essential for Th2 lymphocyte differentiation and activation. An investigational synthetic DNA molecule (SB010) has been developed that uniquely binds to GATA3 messenger RNA and cleaves it. The effect of SB010 was assessed in 43 patients with mild allergic asthma who were randomly assigned to inhalation of SB010 or placebo once daily for 28 days [1]. The early and late asthmatic responses to allergen bronchoprovocation were significantly attenuated by SB010. The degree of suppression of the late response was similar to that of inhaled glucocorticoids. This study supports a potential role for disruption of GATA3 (and thus Th2 cytokines) in asthma. (See "Alternative and experimental agents for the treatment of asthma", section on 'GATA3-specific DNAzyme'.)
Warning about use of non-prescription asthma treatments (April 2015)
The US Food and Drug Administration (FDA) released a consumer warning about the potential health risks of over-the-counter (OTC) homeopathic products for asthma [2]. The efficacy and safety of OTC products are not evaluated by the FDA. In addition, there is evidence that some non-prescription therapies, such as racemic epinephrine inhaler (sold as Asthmanefrin) and systemic ephedrine (sold as Bronkaid and Primatene tablets), are less effective than standard therapies for asthma and have a higher rate of side effects. Thus, OTC products are not recommended for the routine care of asthma, particularly acute asthma symptoms. These warnings are an important reminder for clinicians to ask their patients about use of OTC products. (See "Asthma in children younger than 12 years: Rescue treatment for acute symptoms", section on 'Nonstandard therapies' and "Alternative and experimental agents for the treatment of asthma", section on 'Risks associated with inhaled epinephrine' and "Alternative and experimental agents for the treatment of asthma", section on 'Homeopathic agents' and "Homeopathy", section on 'Specific diseases'.)
DRUG HYPERSENSITIVITY
Eosinophilia during prolonged antibiotic therapy (June 2015)
Eosinophilia is not uncommon in patients receiving prolonged intravenous (IV) antibiotics, but the prevalence and significance has not been extensively studied. In a prospective cohort study of 824 patients receiving prolonged intravenous antibiotic therapy, eosinophilia developed in 25 percent, appearing at a median of 15 days of therapy and peaking at a median absolute count of 726/mL (500 to 8610/mL) [3]. Although most patients with eosinophilia completed their courses without complications, one-third developed a hypersensitivity reaction involving rash or hepatic or renal involvement. Medication-associated eosinophilia does not mandate discontinuation of therapy but warrants close monitoring for evidence of hypersensitivity and consideration of alternative medications that could be substituted without compromising care. (See "Approach to the patient with unexplained eosinophilia", section on 'Medications and over the counter remedies'.)
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'.)
Immediate infusion reactions to leucovorin (April 2015)
Infusion reactions to leucovorin are rarely reported, but they may be under recognized because leucovorin is often administered simultaneously with other chemotherapy agents that are well known to cause reactions, such as oxaliplatin. In a series of 44 patients who had an immediate infusion reaction while receiving a leucovorin-containing regimen for metastatic colorectal cancer, five appeared related to leucovorin and not the coadministered drug (oxaliplatin, irinotecan) [5]. Leucovorin skin tests were negative, but challenge with leucovorin reproduced the symptoms in all five patients, while separate challenge with the co-administered agents produced no symptoms. All patients also reacted to subsequent challenge with LEVOleucovorin, suggesting that the L-isomer cannot necessarily be substituted for the more commonly used racemic leucovorin unless the patient has been specifically challenged and found to tolerate it. If continued leucovorin therapy is needed, it can be accomplished using a desensitization protocol. (See "Infusion reactions to systemic chemotherapy", section on 'Leucovorin'.)
FOOD ALLERGY AND INTOLERANCE
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 [6]. 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
Pulmonary manifestations in adults with chronic granulomatous disease (June 2015)
Pulmonary complications remain the most common manifestation of chronic granulomatous disease (CGD) in adulthood. In a series of 67 adults with CGD, two-thirds had at least one infectious or noninfectious pulmonary event, and about half had manifestations involving the gastrointestinal tract or skin [7]. Most patients with invasive pulmonary fungal infections were on itraconazole prophylaxis, although serum azole concentrations were low in the majority of the patients tested. One-third of patients with pulmonary complications, including invasive fungal infections, were asymptomatic. Serial screening for elevated inflammatory markers, such as C-reactive protein (CRP), followed by imaging of the suspected organ(s) involved if levels are elevated, are suggested to monitor for and diagnose infection. (See "Chronic granulomatous disease: Pathogenesis, clinical manifestations, and diagnosis", section on 'Sites of infection' and "Chronic granulomatous disease: Pathogenesis, clinical manifestations, and diagnosis", section on 'Pulmonary' and "Chronic granulomatous disease: Treatment and prognosis", section on 'Antifungal prophylaxis' and "Pulmonary complications of primary immunodeficiencies", section on 'Chronic granulomatous disease' and "Chronic granulomatous disease: Treatment and prognosis", section on 'Monitoring and diagnosis'.)
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 [8]. 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'.)
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 [9]. 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
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 [10]. 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) [11]. 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'.)
US ACIP recommendations for serogroup B meningococcal vaccination (June 2015)
In late 2014 and early 2015, the US Food and Drug Administration approved two serogroup B meningococcal vaccines (Trumenba, MenB-FHbp and Bexsero, MenB-4C). In June 2015, the Advisory Committee on Immunization Practices (ACIP) issued recommendations for serogroup B meningococcal vaccine for high-risk individuals aged 10 years or older; these include individuals with persistent complement component deficiencies, individuals with anatomic or functional asplenia, microbiologists routinely exposed to N. meningitidis isolates, and individuals at increased risk because of a serogroup B meningococcal disease outbreak [12]. These indications overlap with those for the quadrivalent meningococcal conjugate vaccine and are summarized in the table (table 1). Among patients with none of the above risk factors, the ACIP advises discussion between doctors and patients regarding vaccination against serogroup B meningococcus; routine vaccination has not been recommended [13]. (See "Meningococcal vaccines", section on 'Use in United States'.)
OTHER GENERAL ALLERGY AND IMMUNOLOGY
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 [14]. 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-associated SJS/TEN was reported in Colorado, likely related to high levels of M. pneumoniae infection in the region [15]. 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 [16]. 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 2)
(See "Seasonal influenza in children: Prevention with vaccines", section on 'Schedule' and "Seasonal influenza vaccination in adults", section on 'Overview'.)

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 [17]. 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'.)
Ease of use of different epinephrine autoinjectors for anaphylaxis (July 2015)
Epinephrine autoinjectors can be life saving for patients with serious allergies, but even with specific training, many people have trouble using the various devices properly. A randomized trial of mothers of food-allergic children, tested in simulated anaphylaxis scenarios, suggested that the Auvi-Q device, a rectangular cassette that has audible instructions to guide the user through the injection process, was easier to use than non-audible pen devices [18]. When prescribing an epinephrine autoinjector, ease of use, cost, the need for multiple injectors, and patient facility with self-injection should all be considered. (See "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Ease of use'.)
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) [19]. 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'.)
Unclear association between atopic dermatitis and lymphoma (May 2015)
The association between atopic dermatitis and lymphoma is controversial. A 2015 systematic review and meta-analysis of four cohort studies and 18 case-control studies found a modest increase in the risk of lymphoma in patients with atopic dermatitis compared with the general population [20]. The risk increase was significant in the meta-analysis of the cohort studies but not in the case-control studies. However, the large heterogeneity of case-control studies in study design and diagnostic criteria does not allow any definite conclusion. In particular, due to overlapping clinical features, cases of cutaneous T cell lymphoma may have been initially misdiagnosed and treated as severe atopic dermatitis. (See "Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)", section on 'Risk of lymphoma'.)
Depression and anxiety disorders in patients with atopic dermatitis (April 2015)
Several lines of evidence suggest that the incidence of psychiatric comorbidities, including major depression and anxiety disorders, is increased among patients with atopic dermatitis and may be influenced by factors such as perceived disease severity and quality of life. A longitudinal cohort study evaluated the risk of developing major depression or anxiety disorders later in life among more than 8000 adolescents and adults with atopic dermatitis and age- and sex-matched controls [21]. Patients with atopic dermatitis had a six- and fourfold increased risk of developing major depression or anxiety disorders, respectively. These findings suggest that the identification and treatment of psychiatric comorbidities are important aspects of the management of patients with atopic dermatitis. (See "Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)", section on 'Depression and anxiety disorder'.)
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REFERENCES

  1. Krug N, Hohlfeld JM, Kirsten AM, et al. Allergen-induced asthmatic responses modified by a GATA3-specific DNAzyme. N Engl J Med 2015; 372:1987.
  2. Over-the-Counter Asthma Products Labeled as Homeopathic: FDA Statement - Consumer Warning About Potential Health Risks. http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm439014.htm.
  3. Blumenthal KG, Youngster I, Rabideau DJ, et al. Peripheral blood eosinophilia and hypersensitivity reactions among patients receiving outpatient parenteral antibiotics. J Allergy Clin Immunol 2015.
  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. Ureña-Tavera A, Zamora-Verduga M, Madrigal-Burgaleta R, et al. Hypersensitivity reactions to racemic calcium folinate (leucovorin) during FOLFOX and FOLFIRI chemotherapy administrations. J Allergy Clin Immunol 2015; 135:1066.
  6. Ching JC, Lau W, Hannach B, Upton JE. Peanut and fish allergy due to platelet transfusion in a child. CMAJ 2015; 187:905.
  7. Salvator H, Mahlaoui N, Catherinot E, et al. Pulmonary manifestations in adult patients with chronic granulomatous disease. Eur Respir J 2015; 45:1613.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Folaranmi T, Rubin L, Martin SW, et al. Use of Serogroup B Meningococcal Vaccines in Persons Aged ≥10 Years at Increased Risk for Serogroup B Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep 2015; 64:608.
  13. http://www.cidrap.umn.edu/news-perspective/2015/06/acip-endorses-individual-choice-meningitis-b-vaccine (Accessed on June 25, 2015).
  14. 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.
  15. Olson D, Watkins LK, Demirjian A, et al. Outbreak of Mycoplasma pneumoniae-Associated Stevens-Johnson Syndrome. Pediatrics 2015; 136:e386.
  16. 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.
  17. 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.
  18. Umasunthar T, Procktor A, Hodes M, et al. Patients' ability to treat anaphylaxis using adrenaline autoinjectors: a randomized controlled trial. Allergy 2015; 70:855.
  19. 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.
  20. Legendre L, Barnetche T, Mazereeuw-Hautier J, et al. Risk of lymphoma in patients with atopic dermatitis and the role of topical treatment: A systematic review and meta-analysis. J Am Acad Dermatol 2015; 72:992.
  21. Cheng CM, Hsu JW, Huang KL, et al. Risk of developing major depressive disorder and anxiety disorders among adolescents and adults with atopic dermatitis: a nationwide longitudinal study. J Affect Disord 2015; 178:60.
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INFLUENZA / GRIPE / VACUNAS


Carlos E Mijares, MD former US Resident and Fellow at University of Kansas, USA, highly recommend to follow these guidelines!

www.centromedicodecaracas.com.ve
www.infoguia.com
www.paginasamarillascantv.com.ve


Especiales de los CDC

CDC en EspañolEspeciales CDCEnfermedades y afecciones

La temporada de la influenza está a la vuelta de la esquina

familia frente a la casaTodas las personas de 6 meses en adelante deben recibir la vacuna contra la influenza cada año. Después de recibir la vacuna, su cuerpo tarda unas dos semanas para producir protección completa contra la influenza (gripe). ¡Vacúnese para protegerse y proteger a sus seres queridos!
Los días se acortan y las noches se ponen más frías. Ya es otoño, y frecuentemente es el momento del año en que se comienza a ver que la gente se enferma de influenza (gripe). Si se vacuna y vacuna a toda su familia cada temporada de la influenza, puede ayudar a prevenir las enfermedades relacionadas con esta afección, y también evitar las faltas a la escuela o al trabajo.
La influenza es una enfermedad respiratoria contagiosa que afecta la nariz, la garganta y los pulmones, y que puede llevar a complicaciones graves, hospitalizaciones e incluso la muerte. La neumonía y la bronquitis son ejemplos de complicaciones graves relacionadas con la influenza. La influenza también puede agravar ciertas afecciones, como la diabetes, el asma y las enfermedades cardiacas o las pulmonares. Todas las personas, incluso las sanas, se pueden enfermar con la influenza y tener graves complicaciones. Pero aunque usted sea una de esas personas que se recupera rápidamente de un episodio de influenza, es posible que quienes lo rodean no tengan esa misma suerte. Vacunarse contra la influenza es la mejor manera de protegerse y de proteger a su familia de esta enfermedad grave.

Todos necesitan vacunarse contra la influenza cada vez que llegue la temporada de la influenza

Video: Todos necesitan vacunarse
Vea este divertido video para saber por qué TODOS necesitan la vacuna contra la influenza.
Los virus de la influenza cambian constantemente y cada temporada hay diferentes virus que circulan y causan esta enfermedad. Las vacunas contra la influenza se elaboran cada año para que protejan contra los virus de la influenza que, según indiquen las investigaciones, serán los más comunes. Por esta razón todos necesitan vacunarse cada vez que llega la temporada de la influenza.
Y aunque todas las personas de 6 meses en adelante, a excepción de unas pocas, se deben vacunar contra la influenza esta temporada, es particularmente importante para algunas personas.
Estas incluyen a las siguientes:
Para ver una lista completa de todas las personas para quienes se recomienda la vacuna, y también para quienes no se recomienda, visite Quién debe vacunarse.

Vacúnese cada vez que llegue la temporada de la influenza

  • Usted debe vacunarse todos los años por dos razones. Los virus de la influenza cambian de manera constante, por lo tanto, la vacuna contra la influenza frecuentemente se actualiza entre una temporada y la otra para que proteja contra los virus que, según indiquen las investigaciones, serán los más comunes la temporada entrante.
  • Además, la protección inmunitaria que brinda la vacuna se debilita con el tiempo, o sea que se necesita vacunar cada año para conseguir la mayor protección. Se recomienda la vacunación anual incluso para quienes recibieron la vacuna la temporada de influenza anterior.

Un recordatorio para los padres

Algunos niños de 6 meses a 8 años de edad necesitan dos dosis de la vacuna contra la influenza. Los niños en este grupo de edad que se vacunen por primera vez necesitarán dos dosis, igual que algunos que ya hayan sido vacunados anteriormente. El médico u otro profesional de salud de su hijo le podrán decir si su hijo necesita las dos dosis.

Opciones de vacunación

Las vacunas contra la influenza se elaboran para que protejan contra tres o cuatro virus de la influenza diferentes. Estas se llaman vacunas trivalentes o cuatrivalentes.
Las vacunas trivalentes protegen contra dos virus de la influenza A y uno de la influenza B. Las siguientes son las vacunas trivalentes contra la influenza disponibles:
Las vacunas cuatrivalentes contra la influenza protegen contra dos virus de la influenza A y dos de la influenza B. Las siguientes son las vacunas cuatrivalentes contra la influenza disponibles:

La seguridad de las vacunas

Las vacunas contra la influenza son seguras. Las personas las han estado recibiendo por más de 50 años. La seguridad de las vacunas es vigilada de cerca por los Centros para el Control y la Prevención de Enfermedades (CDC) y la Administración de Alimentos y Medicamentos (FDA). Se han administrado cientos de millones de vacunas contra la influenza de manera segura a personas en todos los Estados Unidos durante décadas.
Muchas personas creen que la vacuna contra la influenza causa la enfermedad, pero eso no es cierto. La vacuna no tiene esa capacidad. Los efectos secundarios más frecuentes de la vacuna inyectable son dolor o enrojecimiento en el lugar de la inyección y posiblemente fiebre o dolor general. La vacuna contra la influenza en atomizador nasal puede causar congestión nasal, moqueo, dolor de garganta o tos. Estos efectos secundarios NO son la influenza. Pero si se presentara alguno de ellos, suelen ser leves y de corta duración.

Dónde vacunarse

Debería encontrar la vacuna contra la influenza amplia y fácilmente disponible en muchos lugares. Visite a su médico u otro profesional de la salud para recibir la vacuna, o búsquela en otros lugares donde se ofrezca, como por ejemplo, en farmacias, departamentos de salud, tiendas de alimentos y muchos otros lugares. Use el Buscador de vacunas provisto por HealthMap para buscar lugares de vacunación cercanos.
* Los enlaces a sitios web pueden llevar a páginas en inglés o español.

Más información

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Thursday, October 1, 2015

PEDIATRIC ALLERGY / The Allergic Child



Publicado por C.A. Centro Medico De Caracas el: 24/01/2011
Ubicación
Distrito Capital
Caracas
San Bernardino
Tipo de vendedor Profesional Oferta
Descripción
Carlos E Mijares, MD Certified USA University of Kansas. School of Medicine. Asthma, Allergies & Immunology, pediatrician. Pediatra Alergólogo, Inmunólogo, Neumonólogo. Headquartes: C.A. Centro Médico de Caracas. San Bernardino. Caracas 1010. Venezuela. Phones +58 550 5238 555.9379 555.9522 Mobile: 0412 393.2265 0416 408.4342 0424 1525291 Web: www.centromedicodecaracas.com.ve, paginasamarillascantv.com.ve,infoguia.com,worldallergy.org,svaaai.org.ve

Our methods of diagnosis and care are those extensively proved, approved --and used by the FDA, WHO,WAO (World Allergy Organization).

Emergencies, Anaphylaxis. Keep and use Epipen as needed. Or Auvi-Q de Sanofi.

Send your resume or contact us (round the cloc'k) 0412 393.2265 0416 408.4342

We are Members of Who is Who in the World of Professionals, since 2002
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Wednesday, September 30, 2015

WHAT IS NEW IN DERMATOLOGY 2015 ?



What's new in dermatology
Disclosures: Abena O Ofori, MD Nothing to disclose. Rosamaria Corona, MD, DSc 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.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2015. | This topic last updated: Sep 24, 2015.
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.
ACNE AND ROSACEA
Serum potassium monitoring during spironolactone therapy for acne (March 2015)
Spironolactone is an androgen receptor antagonist that is effective for the treatment of acne in females. Although periodic monitoring of serum potassium levels is often performed during treatment with spironolactone, there is uncertainty about the need for monitoring in young, healthy acne patients. A large retrospective study comparing the rate of hyperkalemia during treatment with spironolactone with baseline rates of hyperkalemia in women with acne (ages 18 to 45) did not find increased rates of hyperkalemia during spironolactone therapy, suggesting that periodic monitoring of serum potassium in healthy women is not necessary [1]. These results cannot be applied to patients who may be at increased risk for hyperkalemia due to heart failure, renal disease, concomitant medical therapy, or other conditions. (See "Hormonal therapy for women with acne vulgaris", section on 'Side effects'.)
ATOPIC DERMATITIS AND OTHER DERMATITIS
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) [2]. 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'.)
Pimecrolimus for atopic dermatitis in infants and young children (May 2015)
Topical calcineurin inhibitors have been approved in the United States as second-line therapies for the treatment of mild to moderate atopic dermatitis (AD) in adults and children ≥2 years. However, they have been used off-label as first-line treatment for AD in younger children and infants, in the absence of long-term studies evaluating their efficacy and safety. A five-year randomized, open-label trial evaluated the safety and long-term efficacy of pimecrolimus 1% cream compared with low or mid-potency topical corticosteroids in over 2400 infants with mild to moderate AD [3]. After five years, overall treatment success was achieved in approximately 90 percent of children in both groups. Growth, immune function, and cancer rates were similar in the two groups, as were overall rates of adverse events. However, episodes of bronchitis, infected eczema, impetigo, and nasopharyngitis were slightly more frequent in the pimecrolimus group, and the rates of cutaneous adverse events (eg, skin irritation, atrophy, telangiectasias) were not reported. Thus, the advantage of using pimecrolimus rather than low to mid-potency topical corticosteroids in this age group remains unclear. (See "Treatment of atopic dermatitis (eczema)", section on 'Off-label use in infants'.)
Unclear association between atopic dermatitis and lymphoma (May 2015)
The association between atopic dermatitis and lymphoma is controversial. A 2015 systematic review and meta-analysis of four cohort studies and 18 case-control studies found a modest increase in the risk of lymphoma in patients with atopic dermatitis compared with the general population [4]. The risk increase was significant in the meta-analysis of the cohort studies but not in the case-control studies. However, the large heterogeneity of case-control studies in study design and diagnostic criteria does not allow any definite conclusion. In particular, due to overlapping clinical features, cases of cutaneous T cell lymphoma may have been initially misdiagnosed and treated as severe atopic dermatitis. (See "Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)", section on 'Risk of lymphoma'.)
Depression and anxiety disorders in patients with atopic dermatitis (April 2015)
Several lines of evidence suggest that the incidence of psychiatric comorbidities, including major depression and anxiety disorders, is increased among patients with atopic dermatitis and may be influenced by factors such as perceived disease severity and quality of life. A longitudinal cohort study evaluated the risk of developing major depression or anxiety disorders later in life among more than 8000 adolescents and adults with atopic dermatitis and age- and sex-matched controls [5]. Patients with atopic dermatitis had a six- and fourfold increased risk of developing major depression or anxiety disorders, respectively. These findings suggest that the identification and treatment of psychiatric comorbidities are important aspects of the management of patients with atopic dermatitis. (See "Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)", section on 'Depression and anxiety disorder'.)
AUTOIMMUNE AND SYSTEMIC DISEASES
Benefit of long-term management on risk for vulvar carcinoma in women with vulvar lichen sclerosus (June 2015)
Vulvar lichen sclerosus is a chronic disease associated with an increased risk for vulvar carcinoma. The findings of a prospective cohort study of 507 women with vulvar lichen sclerosus suggest that topical corticosteroid therapy, used both to achieve disease control and for long-term maintenance treatment, may reduce cancer risk [6]. Women who reported consistent adherence to treatment instructions had a lower incidence of vulvar carcinoma or vulvar intraepithelial neoplasia than women who reported less consistent adherence (0 versus 4.7 percent). In addition, patients who adhered to treatment had better symptom control and reduced risk for vulvar scarring. These findings suggest that consistent treatment rather than an "as needed" approach to the long-term management of vulvar lichen sclerosus may improve patient outcomes. (See "Vulvar lichen sclerosus", section on 'Topical corticosteroids'.)
Effects of rituximab in systemic sclerosis (May 2015)
In patients with systemic sclerosis (SSc), B cell infiltration has been demonstrated within skin and lung biopsies. Earlier case reports suggested that B cell depletion could attenuate skin and lung fibrosis, and now a larger study of 63 SSc patients and 25 matched controls has evaluated the therapeutic effects of rituximab [7]. After a follow-up period of approximately seven months, patients treated with a single course of rituximab demonstrated a significant improvement in the modified Rodnan skin score (mRss). Among SSc patients with interstitial lung disease, rituximab also prevented a further decline in forced vital capacity compared with matched controls. There were no serious adverse events among rituximab-treated patients. However, this study had many limitations, and additional studies are needed to establish the long-term efficacy of rituximab for skin and lung fibrosis in systemic sclerosis before routine use can be recommended. (See "Immunomodulatory and antifibrotic approaches to the treatment of systemic sclerosis (scleroderma)", section on 'Rituxumab'.)
Apremilast for oral ulcers in Behçet’s disease (April 2015)
There remains a need for effective therapy for recurrent oral ulcers in patients with Behçet’s syndrome. Preliminary data suggest that apremilast, an orally administered phosphodiesterase-4 inhibitor known to modulate several inflammatory pathways, is beneficial in treating oral ulcers. A randomized, phase II trial including over 100 patients with Behçet’s syndrome found that patients who received apremilast had a significant reduction in the number of oral ulcers at 12 weeks, as compared with those in the placebo group [8]. There was also a significant reduction in pain from oral ulcers. Nausea, vomiting, and diarrhea were more common than in the placebo group, which is similar to findings seen in previous studies of apremilast for the treatment of psoriasis and psoriatic arthritis. Additional studies are needed to determine the long-term efficacy and safety of apremilast for oral ulcers before routine use can be recommended. (See "Treatment of Behçet’s syndrome", section on 'Oral aphthae and genital ulcers'.)
INFECTIONS AND INFESTATIONS
Updated recommendations for pediatric head lice (May 2015)
Pediculosis capitis is a common condition that can lead to physical discomfort and social stigmatization. An update to the 2010 clinical report on head lice published by the American Academy of Pediatrics incorporates new therapies (spinosad and topical ivermectin), clarifies diagnosis and treatment protocols, and provides guidance for the management of children with pediculosis capitis in the school setting [9]. Examples of major points in the update include recommendations that no child should be excluded from school because of head lice or nits and that pyrethroids remain reasonable first-line therapies for primary treatment of pediculosis capitis in communities where resistance to pyrethroids is unproven. (See "Pediculosis capitis", section on 'Pediculicide selection'.)
The efficacy of an inactivated vaccine to prevent zoster (April 2015)
The live attenuated zoster vaccine reduces the risk of herpes zoster with a reported vaccine efficacy of 60 to 70 percent in adults 50 years and older, but it cannot be used in immunocompromised individuals and may have decreased efficacy in adults 70 years and older. A randomized, placebo-controlled trial evaluated the efficacy of HZ/su, an experimental recombinant inactivated zoster vaccine administered in two doses two months apart, among 15,411 adults 50 years and older [10]. After three years of follow-up, the overall vaccine efficacy against herpes zoster was 97.2 percent (95% CI 93.7-99.0), and efficacy among adults 70 years and older was similar to that seen in adults between 50 and 69 years of age. (See "Prevention of varicella-zoster virus infection: Herpes zoster", section on 'Inactivated vaccines'.)
PEDIATRIC DERMATOLOGY
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-associated SJS/TEN was reported in Colorado, likely related to high levels of M. pneumoniae infection in the region [11]. 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'.)
PSORIASIS AND OTHER PAPULOSQUAMOUS DISORDERS
Secukinumab, an anti-IL17A antibody, for psoriatic arthritis (August 2015, MODIFIED August 2015)
Secukinumab, an anti-interleukin (IL)-17A antibody, is available for the treatment of psoriasis in the United States and other countries, and has been evaluated for psoriatic arthritis (PsA) using various routes of administration and dosing regimens. In a multicenter randomized trial, involving almost 400 patients with active PsA, secukinumab (300, 150, or 75 mg administered subcutaneously weekly for four weeks and every four weeks thereafter, consistent with the regimen for psoriasis) was superior to placebo in achieving significant improvement in joint and skin disease, and in physical function and quality of life [12]. Responses by weeks 12 to 16 were similar to those at week 24 (ACR20 responses of 54, 51, and 29 versus 15 percent), and benefit was sustained at 52 weeks. The drug was well-tolerated and may have a future role in the treatment of psoriatic arthritis. (See "Treatment of psoriatic arthritis", section on 'IL-17 blockade'.)
Comparative efficacy of secukinumab and ustekinumab for plaque psoriasis (July 2015)
Secukinumab, a fully human anti-interleukin-17A monoclonal antibody, is a highly effective new treatment for psoriasis that was superior to etanercept in earlier trials. In the first randomized trial to compare secukinumab with ustekinumab, another established psoriasis therapy, secukinumab was more effective than ustekinumab for moderate to severe plaque psoriasis [13]. Safety profiles for the two drugs were similar. The expanding literature on the comparative efficacy of psoriasis therapies will provide valuable information for therapeutic decision making. (See "Treatment of psoriasis", section on 'Secukinumab'.)
Phase III trial support for oral tofacitinib for plaque psoriasis (July 2015)
Oral therapy for psoriasis is advantageous because of the ease of administration compared with topical medications, injected or infused medications, and phototherapy. Tofacitinib, an oral janus kinase (JAK) inhibitor used for the treatment of rheumatoid arthritis, is under investigation for the treatment of psoriasis. A phase III trial that compared two different doses of tofacitinib with etanercept and placebo found that the higher dose of tofacitinib (10 mg twice daily) was superior to placebo and non-inferior to etanercept in the treatment of moderate to severe plaque psoriasis [14]. Other phase III randomized trials also support the efficacy of tofacitinib therapy [15]. Tofacitinib represents a potential addition to the armamentarium for psoriasis therapy. (See "Treatment of psoriasis", section on 'Future therapies'.)
Risk for vascular complications of diabetes in patients with psoriasis (June 2015)
Psoriasis may be associated with increased risk for vascular complications of diabetes. A retrospective cohort study that compared risk for microvascular and macrovascular complications in diabetic patients with psoriasis with risk for these complications in diabetic patients without psoriasis found a modest increase in risk for both types of complications in patients with psoriasis [16]. Additional study is needed to confirm these findings. (See "Comorbid disease in psoriasis", section on 'Implications'.)
SKIN CANCER
Sonidegib approved for advanced basal cell carcinoma (July 2015)
Targeted inhibition of the Hedgehog pathway has antitumor activity against advanced basal cell carcinoma. Based upon the results of a phase II trial [17], sonidegib was approved at a dose of 200 mg orally once a day by the US Food and Drug Administration for patients with locally advanced basal cell carcinoma that has recurred following surgery or radiation therapy, or who are not candidates for surgery or radiation therapy [18]. Sonidegib provides an additional treatment option for these patients. (See "Systemic treatment of advanced cutaneous squamous and basal cell carcinomas", section on 'Sonidegib'.)
Weak association between citrus fruit and melanoma (July 2015)
An analysis of data from over 100,000 individuals participating in the Nurse’s Health Study found a modest 36 percent increase in melanoma risk associated with high dietary intake of citrus fruit or juice, after adjusting for known risk factors for melanoma, such as family history of melanoma, phenotypic characteristics, number of nevi, and lifetime number of blistering sunburns [19]. A potential explanation for this association is that citrus fruits are a source of psoralens, chemical compounds present in plants known to be photosensitizers. However, the results of this study need further confirmation, because, given the small increase in risk, residual confounding cannot be excluded. In the meanwhile, changes in dietary advice to the public are not warranted. (See "Risk factors for the development of melanoma", section on 'Other proposed risk factors'.)
Melanoma incidence in the United States (June 2015)
A report from the Centers for Disease Control and Prevention indicates that melanoma incidence rates doubled in the United States over the three decades from 1982 to 2011, while the mortality rates remained constant over time [20]. The annual number of cases is expected to double over the next 15 years. Based upon findings from SunSmart, an Australian community-wide skin cancer prevention program designed to raise awareness, change personal behaviors, and influence institutional policy and practices, the report estimates that a comprehensive skin cancer prevention program in the United States could prevent 20 percent of melanoma cases between 2020 and 2030. (See "Risk factors for the development of melanoma", section on 'Incidence'.)
Topical 5-fluorouracil for the long-term control of actinic keratoses (May 2015)
Topical 5-fluorouracil (5-FU) is used as a field treatment in patients with multiple actinic keratoses (AKs) and may be effective for the long-term control of AKs. In a randomized trial, 932 participants with multiple AKs on the face and ears were treated with 5% 5-FU cream or vehicle twice daily for four weeks and followed-up for an average time of 2.6 years [21]. Compared with the control group, patients in the 5-FU group had a significantly higher rate of complete clearance at six months and fewer AKs at 42 months. (See "Treatment of actinic keratosis", section on 'Topical 5-fluorouracil'.)
SURGICAL AND COSMETIC DERMATOLOGY
Effect of needle diameter on patient discomfort during facial injection of botulinum toxin (September 2015)
Although previous data on the impact of injection needle diameter on patient discomfort has been equivocal, studies evaluating this issue have had various methodological flaws. A small randomized trial designed to minimize such flaws found that patients receiving facial injections of botulinum toxin A for forehead wrinkles were less likely to experience clinically significant pain when injected with a 32-gauge needle than with a 30-gauge needle [22]. This finding suggests that use of a smaller diameter needle may benefit patients who experience significant pain during facial injections. (See "Overview of botulinum toxin for cosmetic indications", section on 'During treatment'.)
Cyanoacrylate glue for the ablation of incompetent superficial veins (March 2015)
Several methods are available for the ablation of incompetent superficial veins. A system that ablates the treated vein using a cyanoacrylate adhesive agent has been approved for use in the United States [23]. The procedure is performed like radiofrequency and laser ablation, but without the need for tumescent anesthesia. In a randomized trial comparing this system with radiofrequency ablation, short-term outcomes at three months were similar [24]. Longer term follow-up is needed to determine the durability of the results. (See "Liquid, foam, and glue sclerotherapy techniques for the treatment of lower extremity veins", section on 'Cyanoacrylate glue'.)
OTHER DERMATOLOGY
Afamelanotide for protoporphyria (August 2015)
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are cutaneous porphyrias that present in childhood with painful, non-blistering photosensitivity within minutes of sun exposure. Affected individuals must avoid sunlight, often with substantial reduction in their quality of life. Afamelanotide is a new therapy for EPP and XLP that is administered as a subcutaneous implant every other month. The mechanism involves increased melanin production; there are no effects on porphyrin levels. Two multicenter randomized trials in adults with EPP or XLP (168 patients total) found that afamelanotide substantially reduced photosensitivity and improved sunlight tolerance, with minimal toxicities [25]. Thus, for adults with EPP or XLP, we suggest afamelanotide. This therapy is available in Europe but not in the United States. Dosing and safety data in children have not been reported. (See "Erythropoietic protoporphyria and X-linked protoporphyria", section on 'Afamelanotide'.)
Eosinophilia during prolonged antibiotic therapy (June 2015)
Eosinophilia is not uncommon in patients receiving prolonged intravenous (IV) antibiotics, but the prevalence and significance has not been extensively studied. In a prospective cohort study of 824 patients receiving prolonged intravenous antibiotic therapy, eosinophilia developed in 25 percent, appearing at a median of 15 days of therapy and peaking at a median absolute count of 726/mL (500 to 8610/mL) [26]. Although most patients with eosinophilia completed their courses without complications, one-third developed a hypersensitivity reaction involving rash or hepatic or renal involvement. Medication-associated eosinophilia does not mandate discontinuation of therapy but warrants close monitoring for evidence of hypersensitivity and consideration of alternative medications that could be substituted without compromising care. (See "Approach to the patient with unexplained eosinophilia", section on 'Medications and over the counter remedies'.)
Sunscreen use among adults in the United States (June 2015)
Although regular sunscreen use is a key message of sun-safety campaigns worldwide, data on the pattern of sunscreen use in the general population are limited. In the United States, a survey of over 4000 adults found that approximately 14 percent of men and 30 percent of women regularly used sunscreen on the face and other exposed skin when outside in the sun for more than one hour [27]. Regular use of sunscreen was associated with having sun-sensitive skin, higher annual household income, performing aerobic activity, and having children younger than 18. However, the use of sun protection measures other than sunscreen (eg, wearing hat or protective clothing) was not investigated. The results of this study indicate a need for sun-safety interventions targeting men, individuals with a lower perceived susceptibility to sun damage, and those for whom cost may be a barrier to sunscreen use. (See "Selection of sunscreen and sun-protective measures", section on 'Patterns of use'.)
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REFERENCES

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