Fairfield County Allergy, Asthma & Immunology Associates, PC (FCAAIA)

FOOD ALLERGIC PATIENTS: Be careful during Passover! Passover foods often contain nuts or eggs. Recipes and information for about foods kosher for Passover food-allergic patients, please go to this link: http://www.kidswithfoodallergies.org/search.php?zoom_query=passover&zoom_per_page=10&zoom_and=0&zoom_sort=0.  A PDF version of the booklet is available if you prefer...just call and give your email address to Dr. Lester.

Students going to summer camp programs will need Medication Authorization forms.  Don't wait until the last minute to get this important information in to the program!

Do you have asthma?  What happens in asthma? What else can you do to decrease exposure to your triggers? What should you do at the earliest onset of your symptoms? Call to set up an in-depth ASTHMA TEACHING SESSION with Audrey.  You will get even more information than we can provide during your regular office visits (when you receive information overload!). Receive a personalized and computerized asthma action plan and a free peak flow meter (while supplies last). Dr. Lester has a PDF copy of "The Essential Guide to the Management of Asthma" that he is happy to send you.

Please scroll down to any of the articles below. To access any web site cited, please copy the URL and paste it in to your browser.
(For Medscape articles: User name: FCAAIA, Password: allergies).  Updated April 1, 2012.

1. Asthma Remains Largely Uncontrolled in the United States
2. Systemic Effects of Inhaled Corticosteroids
3. Does body mass index influence responsiveness to inhaled corticosteroids in persistent asthma?
4. High Copays Cut Asthma Drug Use in Older Kids
5. Oral Treatment Mows Down Grass Allergy

Archived articles (Please contact Dr. Lester if you would like a complete copy of an archived article):
6. Topical and Systemic Therapies for Nickel Allergy
7. Allergy Tests Should Only Confirm Diagnosis
8. The Introduction of Allergenic Foods and the Development of Reported Wheezing and Eczema in Childhood.
9. Gluten Sensitivity: Problems of an Emerging Condition Separate From Celiac Disease5. ACAAI: Oral Tx for Peanut Allergy a Viable Option
10. ACAAI: Oral Tx for Peanut Allergy a Viable Option
11. Food Allergy in Kids Not Being Optimally Diagnosed
12. Allergen Immunotherapy: A History of the First 100 Years
13. Asthma Patients Feel Gloomy, Stay Sedentary
14. Are Saline Irrigations Effective in Relieving Chronic Rhinosinusitis Symptoms: A Review of the Evidence
15. Allergic to Eggs?  It’s OK to Get a Flu Shot
16. Controversies Regarding Long-Acting Beta 2-Agonists
17. Respiratory and Allergic Health Effects of Dampness, Mold, and Dampness-Related Agents
18. Asthma-Related Comorbidities
19. Helping Families Manage Food Allergy in Schools
20. Air Cleaners Do Not Sufficiently Reduce Secondhand Smoke
21. Obesity Complicates Asthma Diagnosis
22. My Asthma Is Under Control...Not!
23. Food-induced Anaphylaxis
24. “Hypoallergenic” Dogs May Not Protect Against Allergies
25. Prenatal or Early-Life Exposure to Antibiotics and Risk of Childhood Asthma
26. Early Pet Exposure May Help Kids Avoid Allergies.
27. Swimming Pool Attendance, Asthma, Allergies, and Lung Function in the Avon   Longitudinal Study of Parents and Children Cohort
28. Food Allergies and Asthma
29. The Indoor Environment and its Effects on Childhood Asthma
30. Pesticides and Asthma
31. Hymenoptera Venom Immunotherapy
32. Pollen Counts from Popular Commercial Web Sites Unreliable
33. Injection Allergen Immunotherapy for Asthma
34. FDA Pulls Unapproved Cold, Cough, and Allergy Drugs from Market
35. No Increased Risk for Cataracts in Asthmatics Taking Inhaled Steroids
36. Flu Shots OK for People with Egg Allergy
37. NIAID Releases First Guidelines for Managing Food Allergies
38. Connecticut Doctors Open a Food Allergy Treatment Center
(Information about oral peanut desensitization research)
39. CDC: Asthma rate in US up a little to 8.2%.
40. Docs get guide for ID'ing food allergies
41. What’s the story on allergy “drops?”

1. ASTHMA REMAINS LARGELY UNCONTROLLED IN THE UNITED STATES
Lara C. Pullen, PhD

FCAAIA NOTES: For those of us who treat asthma every day, the findings of this study are not surprising.  Many patients are hesitant to use a controller medication long-term.  However, controller medications have an extraordinary safety profile.  For patients with persistent asthma for whom controllers are recommended, the disease is more of a risk to long term health than the medications are. Controllers are just that; they control the symptoms by controlling the underlying bronchial inflammation.  They are not curative however.  They are designed to stay on for a long time, even if you are doing well.  It is important to “step down” to the lowest controlling daily dose with a plan described by your allergist. If you have ANY concerns about regular use of controller medications, you should discuss them with your allergist.

(Source: http://www.medscape.com/viewarticle/759344?src=mp&spon=38  February 28, 2012)

Asthma control falls far short of US national asthma management targets, according to a new survey. This study is noteworthy because it takes into account both asthma control and asthma severity, using methods from the Expert Panel Report III (EPR 3). The results from the Comprehensive Survey of Healthcare Professionals and Asthma Patients Offering Insight on Current Treatment Gaps and Emerging Device Options (CHOICE) survey were published by Gene L. Colice, MD, from Washington Hospital Center and the George Washington University School of Medicine in Washington, DC, and colleagues in the March issue of the Annals of Allergy, Asthma and Immunology.

The CHOICE survey incorporated the EPR 3 recommendations to assess asthma severity before the use of long-term controllers. The survey also revealed that although a respondent may indicate a high burden of disease via the answers to survey questions, that same respondent often described their disease as either completely or well-controlled. Perhaps because of this, many of the asthma patients surveyed (49%) were not using controller medication, despite the presence of persistent disease.

"According to survey results, 79 percent of these patients had persistent asthma and should have been on controllers," said Dr. Colice in a news release. "Of the 51 percent on controllers, 86 percent were inadequately treated as their asthma was not well or very poorly controlled." The CHOICE survey was a telephone survey of 1000 patients who were diagnosed with asthma. As such, it was vulnerable to the limitations of responder bias and inaccurate recall. Asthma is a common illness, affecting 7 million children (10% of children in the United States) and 17.5 million adults (8% of adults in the United States). Direct and indirect asthma costs are substantial.

Visits to Allergists Can Reduce Asthma Failures
Michael Foggs, MD, an American College of Allergy, Asthma, and Immunology board member, spoke with Medscape Medical News about the survey results. He acknowledged that he was not surprised by the findings, but he commended the authors for publishing a "very important paper." He went on to explain that "all of this is solvable...if the right thing is done."

Dr. Foggs pointed to Asthma Management and the Allergist: Better Outcomes at Lower Cost, which he co-edited, and explained that the data in the document indicate that the number of asthma failures can be dramatically decreased if patients with asthma are referred to allergists. He advised primary care physicians to read the EPR 3 asthma guidelines, and to refer patients to an allergist if there are any issues. He also pointed out the importance of patient education, explaining that many patients, especially those in the vulnerable inner city, consider asthma to be an event. They think that asthma medicine can cure them and that an exacerbation is actually asthma returning. Because of this, patients may not be compliant with controller medication.

2. SYSTEMIC EFFECTS OF INHALED CORTICOSTEROIDS
Suissa. Curr Opin Pulm Med. 2012;18(1):85-89.

FCAAIA Notes: Apropos to the article preceding this one, the safety profile of the inhaled steroids is reviewed.  The authors stress the importance of gradually decreasing to the lowest daily dose that controls symptoms.  The “step-down” is in accordance with national and international guidelines for the care of asthma, but must be done gradually, with regards for the seasonality of the patient’s asthma symptoms. (Source: http://www.medscape.com/viewarticle/755185?sssdmh=dm1.765144&src=journalnl January 12, 2012)

PURPOSE OF REVIEW: Although inhaled corticosteroids (ICSs) are the mainstay of therapy in asthma, their use raises certain safety concerns. We review the articles appearing in the last year which have addressed the safety of ICSs when used in the treatment of asthma and chronic obstructive pulmonary disease (COPD).
RECENT FINDINGS: Recent studies suggest that patients with asthma as opposed to COPD do not experience an excess risk of pneumonia with ICS use. Patients with respiratory diseases are at increased risk of developing active tuberculosis and this excess risk is exacerbated by the use of high doses of ICSs. ICSs have systemic effects and one result appears to be an increase in the risk of diabetes onset and progression, especially at high doses of ICSs. When examining cases of glaucoma requiring therapy, there was no increase in risk with ICSs even at high current and cumulative doses. Finally, use of even high doses of ICSs during pregnancy does not appear to affect foetal adrenal function.
Summary: ICSs are a highly effective therapy in asthma and have an excellent safety profile at the low doses usually required in asthma. Adverse effects appear mostly at higher doses.
The full review article may be found at its source.

3. DOES BODY MASS INDEX INFLUENCE RESPONSIVENESS TO INHALED CORTICOSTEROIDS IN PERSISTENT ASTHMA?
William J. Anderson, MBChB AND Brian J. Lipworth, MD

FCAAIA Notes: As you read the abstract below, you should know that FeNO is a marker of bronchial inflammation, the underlying physiologic problem in asthma. Inhaled corticosteroids, decrease the inflammation, lower the FeNO, and help control asthma symptoms. No other commentary is necessary here…just another good reason to slim down!

(Source: http://www.annallergy.org/article/S1081-1206(11)00948-3/abstract  March 28, 2012)

BACKGROUND: Although the relationship between asthma and obesity has been extensively explored, the effect of body mass index (BMI) on the dose–response relationship to inhaled corticosteroids (ICS) has received little attention.
OBJECTIVE: To assess the dose–response of inhaled budesonide on outcome measures of asthma between overweight and normal weight patients with persistent asthma.
METHODS: Seventy-two patients with mild to moderate persistent asthma from a post hoc analysis of previously reported trial data were divided into 2 groups: overweight, BMI 25 kg/m2 or higher; normal weight, BMI less than 25 kg/m2. Each group received 4 weeks' treatment with inhaled (hydrofluoroalkane) budesonide 200 μg/day then 800 μg/day with ICS washout pretreatment. Outcome measures forced expiratory volume in 1 second (FEV1), fractional exhaled nitric oxide (FeNO), methacholine PC20, total daily asthma symptom score, and overnight urinary cortisol/creatinine ratio were performed at baseline and after each dose.
RESULTS: Significantly greater improvements were seen in the normal weight group for both FeNO and symptom responses at 0 to 200 μg and 0 to 800 μg ICS doses (as change from baseline), compared with the overweight group: FeNO 0 to 200 μg, P = .002; 0 to 800 μg, P = .045; symptoms 0 to 200 μg, P = .002; 0 to 800 μg, P = .013. A trend also was seen toward attenuated cortisol suppression in overweight subjects at 0 to 800 μg (P = .06), but no significant difference was seen at either dose in FEV1 and methacholine PC20 between weight groups.
CONCLUSION: Overweight patients with persistent asthma may have attenuated symptom and FeNO dose responses to inhaled budesonide compared with normal weight patients with asthma, with no differences in FEV1 or methacholine PC20 between groups. Attenuated cortisol suppression in the overweight group may be the clue to this difference, alluding to reduced peripheral lung deposition or absorption in overweight patients with asthma.

4. HIGH COPAYS CUT ASTHMA DRUG USE IN OLDER KIDS
Michael Smith, Senior Writer, MedPageToday

FCAAIA Notes: This study demonstrates the great risk of not using your asthma medications because of high copays. Rather than not taking your medications, please call us if your individual cost is too high. At FCAAIA, we recognize that your insurance carrier might require you to pay high out-of-pocket costs for your medications. In fact, we face the same issues when filling prescriptions for ourselves and our family members. Your health is paramount.  Therefore, please let us know if your costs are prohibitive!  We will always try to find you a medication that is as effective for you, as well tolerated, and costs you less. 

(Source: https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=100&topic_id=31883&puid=6559&flag=1 March 27, 2012)

Higher copayments for asthma drugs were associated with reduced use of the medications by older children, researchers reported. Children ages 5 to 18 whose families' out-of-pocket costs were highest also were more likely to be admitted to hospital because of their asthma, according to Dana Goldman, PhD, of the University of Southern California in Los Angeles, and colleagues.
But neither effect was seen in children younger than 5, Goldman and colleagues reported in the March 28 Journal of the American Medical Association.

Previous research has shown that, in adults, increased cost-sharing – imposed by private insurance companies to help control costs – leads to lower medication use and increases in emergency department (ED) visits and hospital admissions, Goldman and colleagues noted.
But research in children -- where any additional costs are borne by parents -- has been limited, they added. To help fill the gap, they undertook a retrospective study of insurance claims for 8,834 American children with asthma who started control therapy between 1997 and 2007.
They created a fixed "basket" of asthma medications and used variation in out-of-pocket costs across 37 employers to examine differences in asthma medication use, asthma-related hospital admissions, and ED visits.

In multivariable analyses, they found: 1) On average, the annual out-of-pocket asthma drug cost was $154 among children 5 to 18 and $151 among those younger than 5, 2) Among the 5,913 children 5 to 18 years, filled asthma prescriptions covered 40.9% of days, on average, and during a year of follow-up, 121 children were admitted to hospital and 220 visited an ED for asthma, 3) Among the younger 2,921 children, average medication use was 46.2% of days, 136 children had inpatient care for asthma, and 231 went to the ED, 4) Among older children, a cost increase from the 25th to the 75th percentile was associated with a small reduction in medication use – from 41.7% to 40.3% of days (P=0.02). There was no such change among younger children, 5) Among the older children, the rate of asthma-related admission was higher for those in the top quartile of out-of-pocket costs compared with the bottom quartile -- 2.4 versus 1.7 admissions per 100 children (P=0.004). Again, there was no such change among younger children, and 6) Annual rates of emergency department use didn't vary across out-of-pocket quartiles for either age group.

The researchers cautioned that the study lacked measures of clinical severity, so that overall asthma control could not be investigated. In addition, they noted, the sample was not representative of all privately insured children and could have included children with seasonal asthma who would not be expected to use medication year-round. Nonetheless, the findings emphasize that there is often a "misalignment" between the need for a medication and its price, according to Wendy Ungar, PhD, of the Hospital for Sick Children in Toronto.

In an accompanying editorial, Ungar argued that "cost-sharing levels of necessary drugs need to remain low enough so as not to deter acquisition and shift program costs to families." Various ideas have been floated to achieve those ends, she noted, including such things as tiered formularies and value-based insurance design, which would "set copayment levels in proportion to potential health benefit." A key insight, she concluded, is that "fully covering services and interventions that promote child health may deter or prevent serious or chronic diseases in the adult years." "The best form of value in drug policy reform," Ungar said, would be to base changes on that understanding.

5. ORAL TREATMENT MOWS DOWN GRASS ALLERGY
Nancy Walsh,  MedPageToday

FCAAIA Notes: On the surface, the use of tablets under the tongue for grass pollen seems like a great idea.  However, in Connecticut, there are very few patients so allergic to grass pollen and ONLY grass pollen that they require any kind of immunotherapy. In addition, in this study, the degree of improvement for allergy symptoms (12-34%) is quite modest and for many would not even be clinically significant. Furthermore, the amount given over one month of treatment was between 17 and 170 times more than is given by injection immunotherapy (allergy shots). Tablet therapy is not yet available in the United States for anything (including grass pollen) and the “drops” given by some doctors are PROVEN to be no more effective than placebo (sugar water). Nonetheless, many practitioners in the US give allergy “drops” (see archived articles below). However, just because a lot of people believe something, does not necessarily make it true!

(Source: https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=156&topic_id=31505&puid=6559&flag=1 March 6, 2012)

Oral immunotherapy successfully controlled the symptoms of allergic rhinoconjunctivitis in both adults and children, researchers reported at the AAAAI meeting in Orlando. Among adults given immunotherapy against Timothy grass pollen, there was a decrease in symptom scores of −0.48 points for nasal symptoms and −0.38 points for ocular symptoms, which represented reductions of 15% (P=0.02) and 25% (P<0.01), according to David Skoner, MD, of Allegheny General Hospital in Pittsburgh, and colleagues.

For children, the reductions were −0.81 points for nasal symptoms and −0.39 points for ocular symptoms, for decreases of 23% (P=0.03) and 28% (P=0.03), respectively, Skoner reported in a poster session at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. "And these results were seen during the year 2009, which was a bad pollen season," he told MedPage Today.

Some 8% to 10% of the population is affected by allergic rhinoconjunctivitis. Patients typically report that the sneezing, itching, and runny nose are moderately to severely bothersome, and many express dissatisfaction with currently available symptomatic treatments. Previous immunotherapy approaches have involved injections and are generally effective, but sublingual tablets -- easier and more convenient for patients -- have now been developed against Timothy grass pollen, which is cross-reactive against other grasses such as rye, meadow fescue, and bluegrass.

The adult trial included 439 patients who were randomized to receive 2,800 bioequivalent units of the allergen or placebo daily beginning 16 weeks before the onset of the grass pollen season and continuing throughout the season, which lasted for more than 50 days. During the peak of the season, when pollen levels reached the highest level, the oral immunotherapy was associated with greater reductions compared with placebo in symptoms for both nasal and ocular symptoms, with between group differences of −0.64 points and −0.45 points, respectively. Reductions in scores also were seen on specific nasal symptoms: Runny nose, 17% (P<0.05), Sneezing, 15% (P<0.05), Itchy nose, 16% (P<0.05), and Congestion, 12% (not statistically significant)

The pediatric study included 345 children ages 5 to 17. At the peak of the pollen season, the differences between the immunotherapy and placebo groups on nasal and ocular symptoms were −1.01 points and −0.47 points, respectively. These reductions were seen for specific nasal symptoms: Runny nose, 23% (P<0.05), Sneezing, 21% (P<0.05), Itchy nose, 34% (P<0.05), and Congestion, 16% (not statistically significant)

Adverse events seen in both studies included application-site effects, such as oral itching in more than one-third of both children and adults, along with irritation of the throat and ear pruritus.
There were no serious treatment-related serious adverse events or cases of anaphylaxis. This was in contrast to previous experiences with immunotherapy injections, where adverse reactions have occurred, Skoner said. In addition, no changes in vital signs, pulmonary function tests, or laboratory values were seen.

ARCHIVED ARTICLES (Please contact Dr. Lester if you would like a complete copy of any archived article):

6. TOPICAL AND SYSTEMIC THERAPIES FOR NICKEL ALLERGY
Dermatitis. 2011;22(05):251-255.

FCAAIA Notes: The form of contact dermatitis (or delayed-type hypersensitivity) with which most people are familiar is poison ivy. Nickel is also one of the most contact sensitizers and frequently manifests as an itchy, weepy rash where nickel touches the skin (jewelry, snaps from pants, belt buckles).  The history is frequently enough to identify the cause of a contact “sensitizer”.  However, patch testing may be necessary.  Patch testing is different from skin testing for immediate-type hypersensitivity that allergists do.  Sometimes, patients with contact sensitivity to nickel develop a diffuse rash from “systemic contact dermatitis” related to ingestion of nickel-containing foods. Patients with nickel sensitivity who require joint replacement might have patch testing done to other metals first.

(Source: http://www.medscape.com/viewarticle/753985?src=mp&spon=38 January 9, 2012)

ABSTRACT: Nickel allergy can result in both cutaneous and systemic manifestations, and can range from mild to severe symptoms. A severe form of this allergy is the Systemic nickel allergy syndrome, clinically characterized by cutaneous manifestions (contact dermatitis, pompholyx, hand dermatitis dyshydrosis, urticaria) .....

INTRODUCTION: Allergic contact dermatitis (ACD) from nickel is an inflammatory skin condition...that manifests itself after recurrent contact with the metal. The prevalence of ACD from nickel is increasing worldwide....The acute phase can be characterized by itching, erythema, edema, vesicles, and scaling with visible borders, and the chronic phase by lichenification and itching. Risk factors are the sensitizing potential of the allergen, high frequency of exposure, occlusion, prolonged time of contact, presence of penetration-enhancing factors, and altered skin barrier function.... 
    ....Nickel allergy is more common among women than among men (17% and 3%, respectively). This difference is due to different rates of exposure of skin to this substance; such exposure (from jewelry, leathers, etc).....Furthermore, nickel is present in a large number of foods (mainly vegetables), another source of exposure for sensitized patients.[3]
     Nickel allergy can result in both cutaneous and systemic manifestations, and its signs and symptoms can range from mild to severe. A more severe form is systemic nickel allergy syndrome (SNAS), which is clinically characterized by cutaneous manifestations (such as contact dermatitis, pompholyx, hand dermatitis, dyshydrosis, and urticaria), a long-term course, and systemic symptoms....      The full review article may be found at its source.

7. ALLERGY TESTS SHOULD ONLY CONFIRM DIAGNOSIS
Ricki Lewis, PhD, Medscape Medical News

FCAAIA Notes: This summary relates to some of the archived articles below.  Its main points are that allergy tests should not generally be done as a “screening” test.  Rather, testing should most often only be done to things considered to be possible triggers to a problem that has already occurred. Testing should be directed to relevant allergens and not to a “panel” of allergens chosen by the laboratory. Nothing is black and white; because many “false positive” and “false negative tests” occur, a thorough history should be done before tests are ordered and the tests should be interpreted by someone with an expertise in their meaning. The full article is a report from the American Academy of Pediatrics Section on Allergy and Immunology Executive Committee written during Dr. Lester’s tenure on the Committee (Pediatrics. 2012;129:193-97.).

(Source: http://www.medscape.com/viewarticle/756552?src=mp&spon=38 January 6, 2012)

     Allergy tests should be used only to confirm a diagnosis that has already been made on the basis of symptoms and medical history....Scott Sicherer, MD...Robert Wood, MD,...reviewed the benefits and limitations of blood tests and skin-prick tests in the detection of allergic diseases.
     .....Both the skin-prick test (SPT) and (blood tests) detect a sensitized state. "However, detection of sensitization to an allergen is not equivalent to a clinical diagnosis. In fact, many children with positive tests have no clinical illness when exposed to the allergen," Dr. Sicherer and Dr. Wood write.
     They further point out that testing for allergens that do not make sense (because they would never be encountered in the patient's environment or because the patient is obviously not allergic to them) could lead to "detrimental actions of unnecessary allergen avoidance." .....
    The allergists identify circumstances in which SPT and sigE are warranted: to confirm a suspected allergic trigger after observing a child react, to monitor the course of a food allergy to detect when it might be waning or outgrown, to confirm allergy to an insect after an anaphylactic response, and to identify allergies to vaccines (SPT only).
     SPT and (blood) tests should not be used...to screen for allergies in nonsymptomatic children or to diagnose food allergies or drug allergies. Food allergies should be assessed with food challenges..... 
    The tests might be useful for identifying the trigger of a respiratory allergy (allergic asthma or seasonal or perennial allergic rhinitis) that is ubiquitous but not obvious in the patient's environment....

8. THE INTRODUCTION OF ALLERGENIC FOODS AND THE DEVELOPMENT OF REPORTED WHEEZING AND ECZEMA IN CHILDHOOD.
Arch Pediatr Adolesc Med. 2011; 165(10):933-8 (ISSN: 1538-3628)

FCAAIA Notes: For years, the American Academy of Pediatrics and other groups recommended delaying the introduction of solid foods until 6 months of age if possible.  These recommendations were based more on theory, hypothesis, and tradition than actual hard data. Because of emerging data and its desire to have its recommendations as evidence-based as possible, the AAP re-examined the issue and revised its recommendations a few years ago (Pediatrics 2008;121(1):183-91;also from the Section on Allergy and Immunology). Parents should discuss feeding solids to their infants with their pediatricians.  They should consider using somewhat more caution when an older sibling is known to have food allergy.

(Source: http://www.medscape.com/medline/abstract/21646571 January 10, 2012)

OBJECTIVE: To examine whether the timing of introduction of the allergenic foods cow's milk, hen's egg, peanuts, tree nuts, soy, and gluten is associated with eczema and wheezing in children 4 years of age or younger.....
....RESULTS: Of 6905 children, wheezing was reported in 31% at age 2 years and in 14% at ages 3 and 4 years. Eczema was reported in 38%, 20%, and 18% of children at the ages of 2, 3, and 4 years, respectively. The introduction of cow's milk, hen's egg, peanuts, tree nuts, soy, and gluten before the age of 6 months was not significantly associated with eczema or wheezing at any age after adjustment for potential confounders (P > .10 for all comparisons). The results did not alter after stratification according to the child's history of cow's milk allergy and parental history of atopy.
CONCLUSION: This study does not support the recommendation for delayed introduction of allergenic foods after age 6 months for the prevention of eczema and wheezing.

9. GLUTEN SENSITIVITY: PROBLEMS OF AN EMERGING CONDITION SEPARATE FROM CELIAC DISEASE
Expert Rev Gastroenterol Hepatol. 2012;6(1):43-55.

FCAAIA Notes: What is “gluten sensitivity?”  Well, that’s the real issue here, isn't it?  Celiac Disease (gluten enteropathy) is certainly under-recognized in mild cases, but relatively easy to diagnose.  However, numerous people are labeled “gluten sensitive” with out any diagnostic criteria or objective test that can be measured. Some people might have an exaggerated but normal physiologic response in which they feel full and tired after a large carbohydrate meal (such as pasta, bread, etc.).  Others have different reproducible symptoms when they eat gluten-containing grains (wheat, rye, barley, oat, and spelt).  Some might get a “placebo effect” by merely by eliminating a food or foods that are a big part of their diets. Many are “diagnosed” by alternative practitioners who do tests that have been proven to have no diagnostic, clinical, or predictive value. So what do you do?  Frankly, if you completely eliminate gluten containing grains and otherwise maintain a balanced, nutritional diet, nothing bad is likely happen.  If gluten seems to cause a problem, you should be tested for Celiac Disease, which has other clinical implications.  But, if you do not have celiac disease, at this point we also have no reason for concern if you eat gluten “as tolerated.”

(Source: http://www.medscape.com/viewarticle/757916?src=mp&spon=38 February 9, 2012)

....INTRODUCTION: The aim of this perspective is to address some of the fundamental problems associated with the condition known as gluten sensitivity or nonceliac gluten sensitivity. Specific problems addressed include lack of a standard definition for gluten sensitivity, lack of diagnostic criteria, difficulty determining rising gluten sensitivity rates, identifying possible factors contributing to the gluten sensitivity problem (human genetics, plant genetic modifications, gluten as a food additive, environmental toxins, hormonal influences, intestinal infections and autoimmune diseases), and treatment.
     The rest of this review may be found at its source.

10. ACAAI: ORAL TX FOR PEANUT ALLERGY A VIABLE OPTION
John Gever, Senior Writer, MedPageToday

FCAAIA Notes: This article reports research from The New England Food Allergy Treatment Center presented at the recent American College of Allergy, Asthma, and Immunology annual meeting. Oral peanut desensitization (or desensitization to any food for that matter) is not a risk-free procedure.  Specific, safe, and well-studied protocols are essential. It should not be undertaken outside of a facility with extensive experience monitoring patients being desensitized. Therefore, it is not to be done at home or at routine office visits with your allergist. The New England Food Allergy Treatment Center is not affiliated with Fairfield County Allergy, Asthma, and Immunology Associates, PC.

(Source: https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=328&topic_id=29542&puid=6559&flag=1 November 10, 2011)

     Oral desensitization therapy for severe peanut allergy is feasible ....as long as patients are counseled appropriately and precautions are rigorously observed.... At a clinic in central Connecticut, 103 children and adolescents have been treated with slowly escalating daily doses of peanut protein -- including 56 now considered tolerant enough for maintenance dosing ....according to Glenda Noumon, DO, of the New England Food Allergy Treatment Center in West Hartford, Conn.
     Preliminary data from interviews with patients and their families indicated that the oral immunotherapy has reduced patients' anxiety about accidental exposure to peanuts and the resulting consequences,...She suggested that a key factor in the successful results achieved to date has been to limit expectations among patients and their families. "Our goal is not [complete] tolerance, they understand that," she said. "It is not a cure." Rather, the intent is to allow patients to ingest small quantities of peanuts without experiencing severe systemic reactions, so that an incidental exposure....does not land them in a hospital, or worse.....The center's protocol starts with a one-day escalation regimen during which patients are closely monitored. Each subsequent escalation also takes place in the center, which is equipped to treat anaphylactic reactions.... When patients are able to tolerate 450 mg of peanut protein.... they begin daily maintenance dosing with whole peanuts or chocolate candies containing peanut products.....
     Nevertheless, side effects are common...Of the 103 patients treated with the protocol thus far, 34% have experienced moderate abdominal pain at least occasionally, sometimes with vomiting. Another 30% have had mild abdominal pain. Just under 40% have complained of oral pruritus. Other notable adverse effects include hives in 8% of patients and respiratory symptoms in 7%. Only 28% experienced no untoward symptoms at all.
     Quality of life data are being systematically collected as part of the IRB-sanctioned research protocol.....A preliminary review suggested that patients and their families, "felt more comfortable in situations where peanut exposure could occur," she said.  "Their goal is to improve the quality of life, so they can go to a baseball game and go get ice cream without being super concerned that there is going to be cross-contamination somewhere and they'll anaphylax,"  
    At the same time, she said, the center makes clear to patients that they will remain peanut-sensitive for the rest of their lives. The message is that the effects of treatment do not last very long after the last dose, so daily maintenance dosing is essential.....

11. FOOD ALLERGY IN KIDS NOT BEING OPTIMALLY DIAGNOSED
Fran Lowry

FCAAIA Notes: More news from the ACAAI meeting…Far too often, patients are labeled allergic to a food based solely on the result of a blood test.  Without a supportive history to indicate a specific food was a trigger to an allergic reaction, a positive blood test generally has a low predictive value.  It is essential that physicians correlate the history with test results and only test for foods that are suspected to be relevant.  Even then, oral food challenges are often necessary to confirm or refute that a suspect food is the cause of an allergic reaction.  This study is consistent with recently published guidelines for the diagnosis and management of food allergies (see articles #28 and 31).

(Source: http://www.medscape.com/viewarticle/753505?src=mp&spon=38 November 22, 2011)

     Oral food challenges are the gold standard for diagnosing food allergies in children, but only a small fraction of kids in the United States are getting them, researchers reported....As a result, it is likely that childhood food allergy is seriously under diagnosed....  "Guidelines just came out in March of this year from the National Institutes of Health NIAID [National Institute of Allergy and Infectious Diseases] stating that oral food challenge is the proper test to diagnose food allergy, along with medical history and positive skin and blood testing." 
     "Oral food challenge solidifies the fact that the child does indeed have that particular food allergy..... 
     Dr. Gupta and her colleagues conducted a randomized cross-sectional survey of American households from June 2009 to February 2010.....A formal physician diagnosis of food allergy was made in 61.5% of these children. Of these, 47% had a skin test and 40% had a blood test for food allergy. However, an oral food challenge was done in just 15.6% of children; it was done more commonly if the child had a severe food allergy or had multiple food allergies, Dr. Gupta said.  Formal diagnoses were most frequently confirmed by oral food challenge for milk allergy (22.4%), soy (19.2%), peanut (16.1%), wheat (15.5%), shellfish (14.4%), tree nut (12.6%), egg (12.4%), sesame (11.2%), and fin fish (9.1%). "Overall, what this tells us is that food allergy is not being diagnosed optimally and oral food challenges are definitely not being done enough."
     ....The test can be cumbersome for busy practitioners to do. This might be one reason why oral challenge is not used as often as it should be.  "This lack of use is understandable because oral food challenges take a long time for physicians to do. A test can take a couple of hours, and that ties up a room for a long time. Plus, reimbursements are poor, so there are lots of reasons why allergists are not able to do as many as they probably would like to do," Dr. Gupta said.....
     "Presently, some over rely on blood or skin testing, but the gold standard is the ability to ingest a full serving of a food," Dr. Oppenheimer said.  "Blood and skin tests have a very high false-positive rate. This abstract reminds us that in some patients...oral food challenge can aid in determining a true allergy."  "Despite the fact that it is almost 2012, we have no perfect test to determine if a patient is allergic to a specific food," Dr. Oppenheimer continued.
     "Both the blood and skin tests are solely confirmatory tools, based upon history. They function very poorly as a screening tool. Thus, the allergist is left to rely upon history and to layer these confirmatory tests to determine the best move forward. When it appears reasonable, from the standpoint of risk, they can then perform a food challenge.....There is no better time to determine the likelihood of food allergy than just after the sentinel reaction," he said.....

12. ALLERGEN IMMUNOTHERAPY: A HISTORY OF THE FIRST 100 YEARS
Curr Opin Allergy Clin Immunol. 2011;11(6):554-559.

FCAAIA Notes:  Allergy shots change the way your body sees what you are allergic to from an allergic to a non-allergic immune response. This “immune deviation” is in essence the only potential “cure” for allergic airway disease which includes asthma and nasal allergies.   There are only two 100% natural and PROVEN effective treatments for asthma: Allergy shots and avoidance of triggers. It surprises allergists (including this editor) that more primary care physicians and pulmonologists do not recognize the role that allergy shots play in the care of asthma.  In fact, the most recent national guidelines for the diagnosis and management of asthma, written by pulmonologists, allergists, and primary care physicians published in 2007 indicates the importance of allergy shots (http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm). It recommends that ANYONE with persistent asthma and allergies who is 5 or older should be considered for injection therapy.

The full review article may be found at its source: http://www.medscape.org/viewarticle/743269?src=cmemp  November 15, 2011.

PURPOSE OF REVIEW:To provide a historical perspective on the development of allergen immunotherapy and to describe the progress that has been made in both the clinical application and the scientific understanding of this therapeutic technique in the 100 years since its inception.

RECENT FINDINGS: Although allergen immunotherapy has been part of allergy practice for a century, it is only in relatively recent years that the cellular and molecular mechanisms which underlie its clinical efficacy have been elucidated. ......

SUMMARY: After 100 years of clinical application, allergen immunotherapy remains the only treatment modality with the potential for long-term immunologic amelioration of atopic diseases. Future treatment advances in allergen immunotherapy will likely harness the increasing power of molecular and genomic medicine to achieve greater allergen specificity, while improving overall efficacy and minimizing the potential for systemic reactions.

13. ASTHMA PATIENTS FEEL GLOOMY, STAY SEDENTARY
Nancy Walsh, Senior Writer, MedPageToday

FCAAIA Notes: The relationship between poor asthma control and psychological morbidity probably works both ways.  People with poorly controlled asthma are more likely to have symptoms of depression (NOT the same as clinical depression).  Conversely, those with symptoms of depression are more likely to sabotage their own asthma control by exercising less, smoking more and generally not taking as good overall care of themselves. As we enter the holiday season, we tend to eat more, exercise less, and some patients are subject to seasonal affective disorder.  Take good care of yourself, follow the asthma plan provided by your allergist, and let us know if you are not as well as you should be.

(Source: https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=100&topic_id=29309&puid=6559&flag=1  October 28, 2011)

     Depressive symptoms along with unhealthy behaviors are common among individuals with asthma...  Among responders reporting current asthma, 37.4% had symptoms of depression compared with 21.8% of those without asthma...
     ...Goral and colleagues reported that asthmatic individuals with depressive symptoms were at increased risk for unhealthy behaviors, including: Physical inactivity, smoking, and less than six hours' sleep at night. Adults with asthma experience increased rates of psychiatric disorders, such as depression, which in turn can have an adverse impact on their asthma control. And inadequate asthma control in these patients not only can worsen the morbidity and mortality risks associated with their pulmonary disorder, but also can lead to greater psychiatric morbidity, the researchers explained....
     Among those with asthma, depressive symptoms were associated with these factors: Ages 40 to 59, female sex, and presence of medical comorbidities.
     Those with higher household income were less likely to report depressive symptoms (OR 0.18, 95% CI 0.11 to 0.30, P<0.001).
     ...."Engagement in routine physical activity is an important component of optimal asthma management as well as in the management of mental disorders," the researchers observed.  In addition, smoking cessation and regular sleep should be addressed using systematic approaches for individuals with asthma and depression, even as these behaviors can be particularly challenging for these patients, they advised.

14. ARE SALINE IRRIGATIONS EFFECTIVE IN RELIEVING CHRONIC RHINOSINUSITIS SYMPTOMS: A REVIEW OF THE EVIDENCE
J Nurse Pract. 2011;7:680-686

FCAAIA Notes: There is no symptom reliever that is effective for everyone.  This review shows just that.  If nasal saline rinses help you, use them.  If they don’t help you, don’t use them.  It’s a cheap thrill; the simplicity, safety, and cost certainly make nasal rinses worth trying if you never have before.  In fact, you can make your own saline solution at home for free!  There are some data indicating that nasal rinses containing xylitol (a sugar) are even more effective than saline rinses. Xylitol enhances killing of bacteria, perhaps contributing to its mechanism of action.

(Source: http://www.medscape.com/viewarticle/750905?src=mp&spon=38  October 18, 2011)

BACKGROUND Chronic rhinosinusitis (CRS) is a common disorder that affects 14% of the adult population....CRS, typically caused by a virus, is frequently treated with antibiotics, contributing to the growing problem of antibiotic resistance. For this reason, both patients and healthcare providers have increasingly turned to alternative therapies including nasal saline irrigation....

METHODOLOGY. Numerous databases, including Cochrane, MEDLINE, and CINAHL, were searched for studies that answered the research question: In adult primary care patients, does the use of saline irrigations (compared with no treatment) improve the symptoms of CRS? A total of 7 studies met the inclusion criteria of having been conducted since 2000 and examining saline irrigations for rhinosinusitis.

RESULTS The investigators concluded that the evidence for efficacy of saline irrigations was contradictory. No conclusion could be drawn as to type of solution (isotonic, hypotonic, or hypertonic) that produced consistently positive results or was best tolerated....Equally, best delivery method, including volume and pressure of the irrigation, cannot be determined. However, few adverse effects were noted and those that did occur, including stinging and, rarely, epistaxis, were self-limited. No serious adverse effects were found and the treatment appeared to pose no significant health risks, but data were insufficient to support a conclusion that irrigation was of some benefit with minimal side effects.

VIEWPOINT Clearly, an alternative to the widespread use of antibiotics to treat this predominantly viral condition must be found....Saline irrigation fulfills the mandate to "first, do no harm," so it should be included in the armamentarium of therapies for this common condition.

15. ALLERGIC TO EGGS? IT’S OK TO GET A FLU SHOT
Sandra A. Fryhofer, MD

FCAAIA Notes: Patients with egg allergy may safely receive influenza vaccine in either a single shot or a dose split in to two shots.  Influenza vaccine testing and desensitization is rarely if ever needed. The first indication of the safety of this method came in 1997 in a study published by Dr. Lester and others (James JM, et al. J Pediatr 1998;133(5):624-8.)

(Source: http://www.medscape.com/viewarticle/748449?src=mp&spon=38  [See this link for video] August 24, 2011)

     Twenty percent of the US population comes down with influenza every year. So every year people should be vaccinated against it. But until now patients with egg allergy couldn't be vaccinated because chicken eggs are used in making vaccine, and there were theoretical concerns that traces of egg protein could trigger a serious allergic reaction.
     But the data indicate differently. At least 17 studies of more than 2600 egg-allergic patients showed no serious reactions, including respiratory distress and hypotension. The only reactions were minor, such as hives and mild wheezing.
     The likeliest reason for this surprising lack of reaction is the tiny amount of leftover egg protein in the vaccine. There is also good news for the healthcare professional who administers flu vaccines. No skin tests are needed. The results aren't predictive, and there is no need to divide the dose.
     Single-dose studies support giving the entire vaccine dose at one time. There are some special caveats. Egg-allergic patients must get the inactivated flu shot because this is what has been used in studies. They cannot get the nasal flu vaccine. Anyone giving vaccinations should be familiar with egg allergy.
     After administering the shot, patients should be observed for 30 minutes.
     The bottom line is that allergy experts have changed their tune. They now say it is safer for egg-allergic patients to get vaccinated than to risk getting the flu. 

16. CONTROVERSIES REGARDING LONG-ACTING BETA 2-AGONISTS
Curr Opin Allergy Clin Immunol. 2011;11(4):345-354.

FCAAIA Notes: The long-acting Beta 2-agonists are long-acting cousins of albuterol.  They are found in such combination medications as Advair, Symbicort, and Dulera.  These medications are very useful; and are required for many patients with asthma.  However, they are not indicated for EVERY patient with asthma or for “as needed” symptom relief. Patients should have their inhaled steroid dose optimized.  In addition, many patients requiring the combination medications can later be “stepped down” to the inhaled steroid alone.

(Source: http://www.medscape.com/viewarticle/746137?sssdmh=dm1.718622&src=journalnl  July 22, 2011)

PURPOSE OF REVIEW: This review examines the literature regarding the efficacy and safety of long-acting Beta 2-agonists as add-on therapy to inhaled corticosteroids.

RECENT FINDINGS: The Global Initiative for Asthma (GINA) 2009 guidelines and the National Heart, Lung, and Blood Institute (NHLBI) 2007 asthma guidelines recommend adding long-acting Beta 2-agonists to patients inadequately controlled on inhaled corticosteroids. These recommendations must be balanced against published data which demonstrate a signal of increased morbidity and mortality with use of long-acting Beta 2-agonists. These conflicting data raise the question of whether or not there may be genotypic or phenotypic discriminators leading to disparate responses to long-acting Beta 2-agonists.

SUMMARY: The combination of long-acting Beta 2-agonists and inhaled corticosteroids demonstrates improvement in asthma control and exacerbation rates; however, long-acting Beta 2-agonists are not recommended for use as monotherapy or without optimization of inhaled corticosteroid dose. Although the majority of asthmatic patients appear to benefit from the addition of long-acting Beta 2-agonists, there are concerns that a small proportion of patients, including steroid-naïve patients and African Americans, may not obtain such benefits. Thus far, studies have not clearly demonstrated genotypic or phenotypic differences explaining the variability in response.

17. RESPIRATORY AND ALLERGIC HEALTH EFFECTS OF DAMPNESS, MOLD, AND DAMPNESS-RELATED AGENTS: A Review of the Epidemiologic Evidence
Mendell, MJ, et al. Environmental Health Perspectives. 2011;119(6):748-756.

FCAAIA Notes: MOLD!!!! The very word strikes fear in the hearts and minds of people with allergies (and some people without allergies). First of all, mold can, but rarely does cause anything more than allergy and asthma symptoms.  Secondly, you are breathing mold with every breath you take except when you are out side and there is snow on the ground. This review reveals that dampness, water damage, and visible mold are the most reliable predictors that mold MIGHT be contributing to symptoms.  Having your home tested is rarely necessary (and can be costly).  Even if the tests reveal a particular mold in your home, it only tells you that you are exposed, not that the mold causes symptoms. Positive skin tests to mold only tell us that you mounted an immune response to the mold, not that the mold is necessarily a problem.  The test results must be correlated with your symptom pattern.  A detailed history and review of tests results with your allergist will help you put all your potential triggers in perspective.

(Source: http://www.medscape.com/viewarticle/744420 June 28, 2011)

OBJECTIVES: Many studies have shown consistent associations between evident indoor dampness or mold and respiratory or allergic health effects, but causal links remain unclear. Findings on measured microbiologic factors have received little review. We conducted an updated, comprehensive review on these topics.

DATA SOURCES: We reviewed eligible peer-reviewed epidemiologic studies or quantitative meta-analyses, up to late 2009, on dampness, mold, or other microbiologic agents and respiratory or allergic effects.

DATA EXTRACTION: We evaluated evidence for causation or association between qualitative/subjective assessments of dampness or mold (considered together) and specific health outcomes. We separately considered evidence for associations between specific quantitative measurements of microbiologic factors and each health outcome.

DATA SYNTHESIS: Evidence from epidemiologic studies and meta-analyses showed indoor dampness or mold to be associated consistently with increased asthma development and exacerbation, current and ever diagnosis of asthma, dyspnea, wheeze, cough, respiratory infections, bronchitis, allergic rhinitis, eczema, and upper respiratory tract symptoms. Associations were found in allergic and nonallergic individuals. Evidence strongly suggested causation of asthma exacerbation in children. Suggestive evidence was available for only a few specific measured microbiologic factors and was in part equivocal, suggesting both adverse and protective associations with health.

CONCLUSIONS: Evident dampness or mold had consistent positive associations with multiple allergic and respiratory effects. Measured microbiologic agents in dust had limited suggestive associations, including both positive and negative associations for some agents. Thus, prevention and remediation of indoor dampness and mold are likely to reduce health risks, but current evidence does not support measuring specific indoor microbiologic factors to guide health-protective actions.

18. ASTHMA-RELATED COMORBIDITIES
Louis-Philippe Boulet, MD; Marie-Ève Boulay, BSc

FCAAIA Notes: There are many and varied conditions related to asthma.  For some, there is a “chicken and egg” question.  That is, which came first?  In many cases it does not matter because each exacerbates the other and both require treatment.  The first section of this review addresses the most common condition related to asthma: Rhinitis.  In fact, allergic rhinitis (nasal allergies) and asthma are essentially the same disease, affecting opposite ends of a single, unified airway. Discuss with your allergist if conditions other than asthma might be contributing to your symptoms, especially if you do not feel well-controlled.

(Source: http://www.medscape.org/viewarticle/744555   June 24, 2011)

ABSTRACT: Asthma is often associated with various comorbidities. The most frequently reported asthma comorbid conditions include rhinitis, sinusitis, gastroesophageal reflux disease, obstructive sleep apnea, hormonal disorders and psychopathologies. These conditions may, first: share a common pathophysiological mechanism with asthma; second: influence asthma control, its phenotype and response to treatment; and third: be more prevalent in asthmatic patients but without obvious influence on this disease. For many of these, how they interact with asthma remains to be further documented, particularly for severe asthma. If considered relevant, they should, however, be treated appropriately. Further research is needed on the relationships between these conditions and asthma.

INTRODUCTION: Asthma is a common airway inflammatory disorder characterized by variable airway obstruction and hyperresponsiveness. Asthma is of variable severity and is increasingly recognized as a condition presenting as various phenotypes. Asthma control is the main goal of therapy and is achieved when the disease results in minimal or no symptoms, normal sleep and activities, and optimal pulmonary function. Such control can be obtained with patient education, avoidance of environmental triggers, individualized pharmacotherapy and regular follow-up.
     Numerous comorbidities can be associated with asthma and influence its clinical expression, although their specific influence remains to be characterized. They are, however, increasingly recognized as important factors to document in asthma patients as they may influence disease management and control.
     Among the most frequently contributing comorbid conditions reported in asthmatic patients are rhinitis, sinusitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), hormonal disorders and psychopathologies, although other conditions, sometimes without an evident link with asthma, have been found to be highly prevalent in asthmatic patients. Indeed, analyses of large databases have shown an increased prevalence of a variety of conditions in asthmatic patients, which either influence or do not influence asthma outcomes. These large-scale analyses may, however, be biased due to contamination with, for example, patients with chronic obstructive pulmonary disease (COPD) or other conditions.

19. HELPING FAMILIES MANAGE FOOD ALLERGY IN SCHOOLS: Tips and Tools for the Allergist and Nonallergist
Matthew J. Greenhawt, MD, MBA

FCAAIA Notes: Several years ago, guidelines for Connecticut schools management of food allergy were published.  These days, most schools are very accommodating and work closely with children with food allergies and their parents.  This article has accurate and up-to-date information that parents will find useful.  In addition, it will answer many school/food allergy related concerns that parents have.  We encourage parents of children with food allergy to read this article, particularly if they are sending their child off to kindergarten and his or her first public school experience. 

(Source: http://www.medscape.com/viewarticle/746589?src=mp&spon=382    August 2, 2011)

     Food allergy is a growing epidemic in the United States. The Centers for Disease Control and Prevention estimate that nearly 3 million children younger than 18 years are affected by food allergy; over the past 10 years, the number of new cases of food allergy has increased 10-fold. 
     Food allergy can have a wide-ranging, negative effect on children and their families, affecting not only life at home but also work, education, vacation, and entertainment. Virtually no life activity remains unaffected by the presence of a potentially fatal allergy.... The chances are high that an individual parent or child will interact with a food-allergic person every day. Although much work has been accomplished in spreading the message that food allergens can potentially be life-threatening, a clear lack of understanding about this issue in many persons without food allergy remains. The main management strategy for food allergy -- avoidance -- is difficult to implement, a fact often underappreciated by unaffected individuals. Food allergy has become a global social issue, and protecting the health and self-esteem of affected children as well as the quality of life of the family, is a responsibility that must be shared by the entire community.
     Sending a food-allergic child to school, camp, or child care can be a daunting task for a parent and may be associated with much anxiety. Increasingly, allergists and nonallergists are being asked to help prepare students and their families to make a safe transition. This involvement consists of ensuring the following:
     • Each student has a self-injectable epinephrine device;
     • The family and child (if age-appropriate) know how and when to use the device;
     • The family can train others to use the device; and
     • The student has an emergency action plan for the facility to follow in case of a reaction.

     Often, more detailed involvement is requested in guiding classroom and/or facility-wide policies, such as the establishment of section 504 plans or other individualized health plans that afford protection and services for food-allergic children at school. Understanding real vs perceived risks of a potential food-induced reaction at school or child care can be helpful in planning.
Let's review the published evidence to gain a better understanding of this situation….

20. AIR CLEANERS DO NOT SUFFICIENTLY REDUCE SECONDHAND SMOKE 
Arch Pediatr Adolesc Med. 2011;165:741-748.

FCAAIA Notes: Air cleaners have some utility for control of indoor asthma and allergy triggers.  They are useful for particulates matter and irritant dusts.  They have some utility in reducing indoor mold and animal dander levels.  They actually are not that useful for dust mites or pollen that comes in through open windows, both of which are relatively heavy so they settle and do not remain air-borne very long.  As far as second-hand smoke goes, there is a 100% effective control measure: Convince your loved ones to stop smoking…..for everyone’s health, including theirs!

(Source: http://www.medscape.org/viewarticle/747596?src=cmemp   August 15, 2011)

Clinical Context
     Secondhand smoke exposure is a daily health risk encountered by too many children in the United States, with more than 30% of all children exposed to secondhand smoke in their homes....

STUDY SYNOPSIS AND PERSPECTIVE: Air cleaners significantly reduce PM levels but are not enough to reduce exposure to secondhand smoke in inner-city children with asthma residing with a smoker, a new study has found....."Despite parental awareness that second-hand smoke exacerbates asthma, 40% to 67% of inner-city children with asthma reside in a household with at least 1 smoker."
      The current study sought to test the ability of an air cleaner only, an air cleaner plus a health coach, or delayed air cleaners in reducing PM, air nicotine, and urine cotinine concentrations. The number of symptom-free days was also evaluated.....
      "Use of air cleaners in homes of children with asthma was associated with a significant reduction in indoor PM concentrations and increase in symptom-free days," the study authors note. "However, the reduced indoor PM levels were not sufficiently decreased to meet EPA [Environmental Protection Agency] standards for outdoor air quality," they add....

CLINICAL IMPLICATIONS: More than 30% of all children in the United States are exposed to secondhand smoke in their homes, with a higher rate among children living in poverty. Smoking increases airborne PM levels substantially more than activities such as indoor sweeping or cooking, and non-nicotine PM can increase the risk for asthma symptoms among children with asthma.....The current study finds that air cleaners can reduce the concentrations of PM in the homes of smokers and the number of symptom-free days among children with asthma in these homes. However, these cleaners failed to reduce air nicotine levels, children's urine cotinine levels, or healthcare utilization for acute asthma events. The addition of asthma health coaches did not improve the efficacy of air cleaners.

21. OBESITY COMPLICATES ASTHMA DIAGNOSIS
Scott S, et al "Risk of misdiagnosis, health-related quality of life, and body mass index in overweight patients with doctor-diagnosed asthma" Chest 2011; epub.

FCAAIA Notes: In addition to obesity causing shortness of breath (a “restrictive” lung disease), it increases the risk of gastroesophageal reflux (GERD).  GE reflux can cause cough in and of itself, further complicating diagnosis.  If you are overweight, you should discuss weight loss strategies with your primary care physician.  As you know, eating appropriate amounts of the right foods and exercise will be a part of that regimen.  A good nutritionist can help you design a healthy and nutritionally adequate diet that contains foods you enjoy eating.

(Source: https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=637&topic_id=28104&puid=6559&flag=1   August 22, 2011)

     More than a third of obese asthmatic patients had no evidence of bronchial hyper-responsiveness, suggesting frequent misdiagnosis of breathlessness.....The charts also revealed significant associations between body mass index (BMI) and health-related quality of life, a relationship that can lead to more clinic visits and further increase the likelihood of asthma misdiagnosis, according to an article published online in Chest……."We have shown a consistent negative correlation of increasing BMI and health-related quality of life measured by both generic and disease-specific instruments....."
……"These data emphasize the complex problems of identifying respiratory disease accurately in obese subjects".………
     Obesity adversely affects health-related quality of life....."Since health-related quality of life and asthma control are related, it is easy to see how health impairments arising from obesity could be attributed to asthma, further increasing the likelihood of a misdiagnosis"  …….. 
     Participants completed generic, respiratory, and obesity-related quality-of-life questionnaires. They also underwent atopy testing, methacholine challenge for bronchial hyper-responsiveness, and assessment of airway inflammation as reflected by the fraction of exhaled nitric oxide (FeNO)......
      "The variable that correlated strongest with degree of health impairment was BMI rather than other traditional markers of asthma severity ... or airway inflammation," the authors wrote in their discussion…….
 
22. MY ASTHMA IS UNDER CONTROL…NOT!
Britto MT, et al. Overestimation of impairment-related asthma control by adolescents.
J Pediatr. 2011; 158(6):1028-1030.e1

FCAAIA Notes: Among the many ways to assess asthma control, but self-perception is one of the least accurate, in part because patients often have lower standards of acceptable control than we as allergists do.  In addition, patients with asthma are notoriously bad at identifying what their pulmonary function is. It is important that patients with asthma continue their daily “controller” medications and see their allergist for regular follow-up visits with pulmonary function testing.  If you feel like you “don’t need” your controller any more, talk to your allergist before you just stop it on your own.

(Source: http://www.medscape.com/viewarticle/745273?src=mp&spon=38  July 5, 2011)

STUDY SUMMARY:
          Previous studies have demonstrated that adults overestimate the degree to which their asthma is controlled. This study evaluated whether adolescents similarly overestimate their level of asthma control. The participants were adolescents and young adults, age 12-22 years old.....The adolescents completed self-assessment questionnaires that evaluated their motivation to control their asthma. The questionnaires collected data on the adolescents' perceived control.....and on objective measures of asthma impairment, such as nighttime symptoms, frequency of rescue inhaler use, and whether the adolescents experienced activity limitations......         
     An adolescent was considered well-controlled if he or she experienced cough, shortness of breath, wheezing, or reduced activity during the day fewer than 3 times per week; experienced nighttime awakenings fewer than 3 times per month; and experienced no asthma-related interference with normal activity. Adolescents with controlled asthma also used short-acting beta agonists fewer than 3 times per week......In addition to evaluating how the adolescents' perceptions of control compared with their level of impairment as measured by responses to the impairment questions, the investigators evaluated, on a scale of 1-10, how confident the adolescents were in their ability to manage their asthma......
     Twenty-eight percent of the adolescents reported experiencing nighttime asthma-related symptoms at least 3 nights per week. However, daytime symptoms were even more prevalent. Only 28.5% of the adolescents experienced daytime symptoms fewer than 3 days per week......Only 27% of the adolescents experienced no asthma-related activity limitations, 65.5% reported that asthma affected activity "some" or "a little" of the time, and 7.5% reported that asthma limited their activity "all" or "most" of the time. The factor that most commonly placed adolescents in the "not controlled" category was self-reported activity limitations......
           Only 8% of the adolescents were considered well-controlled. In comparing the adolescents' perceptions of control vs actual control, only 25% of the adolescents were accurate in their perception of their degree of asthma control. Most (all but 2) adolescents overestimated their asthma control.....An increase in confidence in one's ability to manage asthma was associated with an increased probability that the adolescent would overestimate his or her level of control. Many adolescents overestimate their asthma control, and the relationship between confidence in self-management and overestimation of asthma control is inverse......

23. FOOD-INDUCED ANAPHYLAXIS
Järvinen KM. Curr Opin Allergy Clin Immunol. 2011;11(3):255-261. 

FCAAIA Notes:  There is more information in this article than most patients need, some sections gloss over or omit important points and some contain conjecture and a lot of “food allergy” trivia, it is a thorough and well written review.  We are certain it leaves many of your questions unanswered, so please do not hesitate to call or ask those questions at your next office visit.

(Source: May 25, 2011 http://www.medscape.com/viewarticle/741823?sssdmh=dm1.702843&src=journalnl )

ABSTRACT:
PURPOSE OF REVIEW: Food-induced anaphylaxis is the leading single cause of anaphylaxis treated in emergency departments and increasing in prevalence.

RECENT FINDINGS: Food allergy is an increasing problem in westernized countries around the world, with a cumulative prevalence of 3–6%. Peanut, tree nuts, and shellfish are the most commonly implicated foods in anaphylaxis, although milk is a common trigger in children. Asthmatics, adolescents, and those with a prior reaction are at increased risk for more severe reactions. Most first reactions and reactions in children most commonly occur at home, whereas most subsequent reactions and reactions in adults occur outside home. Studies on schools have identified inadequate management plans and symptom recognition whereas those on restaurants report lack of prior notification by allergic individuals and lack in staff education. Epinephrine, although underutilized is the drug of choice with multiple doses needed in up to one-fifth of reactions. Diagnosis is currently based on convincing history and allergy testing supported by elevated serum tryptase, if available. Long-term management includes strict avoidance and emergency action plan.

SUMMARY: With a growing population of food-allergic children and adults, markers to predict which individuals are at increased risk for anaphylaxis as well as new therapies are vigorously sought.

24. “HYPOALLERGENIC” DOGS MAY NOT PROTECT AGAINST ALLERGIES.
Nicholas C, et al.  Am J Rhinol Allergy 2011; DOI: 10.2500/ajra.2011.25.3606.

FCAAIA Notes:  One can propose immunologic theory that might make one breed of dog more or less allergenic that another breed for an individual.  However, there are no data to support that one breed is likely to be more or less allergenic than another breed for everyone.  There are data indicating that even for people not allergic to dogs, those with asthma or allergies who live dogs might have worsening control of their symptoms triggered by a different, non-allergenic mechanism (increased airway inflammation from endotoxin exposure). The safest bet for people with allergy to dog is to not get a dog.  Contact your allergist with questions about this common issue.

(Source: July 13, 2011 https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=99&topic_id=27503&puid=6559&flag=1 )

          Choosing a breed dubbed "hypoallergenic" may not be enough to avoid triggering a dog allergy, researchers found......
          Homes with a hypoallergenic dog were no less likely to have detectable levels of dog allergen or to have lower average levels of allergen than homes with a nonhypoallergenic breed.....The findings did not differ based on whether the dog was allowed into the area where dust samples were taken. 
          "Clinicians should advise patients that they cannot rely on breeds deemed to be 'hypoallergenic. Additional scientific investigation into dog-specific factors and whether hypoallergenic breeds truly exist is warranted."
          Although there is increasing interest in hypoallergenic dogs -- perhaps spurred by the selection of a breed touted as such (the Portuguese water dog) by President Barack Obama and his family -- there are few studies assessing whether those breeds actually produce less allergen......
           Dust samples -- which were analyzed for the presence of Canis familiaris 1, the major dog allergen -- were collected from the floors of the babies' bedrooms.....The researchers conducted an Internet search to identify hypoallergenic breeds, and included those listed in more than 25% of the references as hypoallergenic.....Nicholas and her colleagues then developed four classification schemes using combinations of purebred and mixed-breed dogs for the analyses on home allergen levels......
           There were no significant differences for any of the four classification schemes in the percentage of homes with detectable allergen based on the hypoallergenic status of the dogs (P>0.05 for all)......
           The findings remained consistent after adjusting for whether the dog was allowed in the baby's bedroom, the dog's weight, length of dog ownership, the time the dog spent indoors, the floor surface assessed for dog allergen, and the home's location......

25. PRENATAL OR EARLY LIFE EXPOSURE TO ANTIBIOTICS AND RISK OF CHILDHOOD ASTHMA: A SYSTEMATIC REVIEW.
Murk W, Risnes KR, Bracken MB. (published on line)

FCAAIA Notes:  Studies such as these are often difficult to interpret.  Is it the chicken or the egg?  That is, are children and their parents who need antibiotics more likely to have or be prone to having allergic diseases including asthma?  Or is more frequent use of antibiotics an independent risk for developing asthma?  It is hard to say, but there is still an important lesson in this study: Only patients with a proven bacterial infection or those HIGHLY suspected of having one should be prescribed antibiotics.  At very least, decreasing the indiscriminate use of antibiotics will decrease the risk of bacteria becoming resistant to antibiotics and decrease the cost of medical care.  As indicated here, it might also decrease the one’s risk of developing asthma.
     More details and a summary of this study may be found at: http://www.medscape.org/viewarticle/743269?src=cmemp 

(Source: http://pediatrics.aappublications.org/content/early/2011/05/19/peds.2010-2092.abstract?sid=67d67dff-e599-4a78-945a-660909d6c854  Published on line May 23, 2011)

ABSTRACT
CONTEXT: The increasing prevalence of childhood asthma has been associated with low microbial exposure as described by the hygiene hypothesis. 

OBJECTIVE: We sought to evaluate the evidence of association between antibiotic exposure during pregnancy or in the first year of life and risk of childhood asthma.....

.....CONCLUSIONS: Antibiotics seem to slightly increase the risk of childhood asthma. Reverse causality and protopathic bias seem to be possible confounders for this relationship. 

26. EARLY PET EXPOSURE MAY HELP KIDS AVOID ALLERGY.
Wegienka G, et al. Clinical & Experimental Allergy. Clin Exp Allergy 2011; DOI: 10.1111/j.1365-2222.2011.03747.x.

FCAAIA Notes:  Well, this is another chicken/egg question, isn’t it?  Are families with allergies less likely to have pets in the first place, making their children less likely to grow up with a pet?  Or, does the presence of pets in the home early in life decrease one’s risk of getting allergies?  Or both?  The prevalent “Hygiene Hypothesis” for risk of developing allergic airway disease (nasal allergies and asthma) supports the notion that early life exposure to animals in the home may convey a lesser risk on susceptible populations.  Even so, we are talking about DECREASED risk, not NO risk!  So, no one should assume that buying a pet for their yet-to-be-born child will eliminate the chance that that child will develop allergies and/or asthma. 

(Source: MedNews, June 13, 2011 https://stamford.mednewsplus.com/html/topicdetails.asp?pid=72&section_id=99&topic_id=27024&puid=6559&flag=1

Children raised in homes with cats during their first year of life have about half the relative risk of developing allergies to these animals in adulthood, researchers found.....

 .....The researchers also found that boys and girls delivered by cesarean section also showed significant reduction in risk for sensitization to dog allergy if they had a dog during their first year (RR 0.33, 95% CI 0.07 to 0.97).....

....."This research provides further evidence that experiences in the first year of life are associated with health status later in life, and that early life pet exposure does not put most children at risk of being sensitized to these animals later in life," Wegienka wrote in a release issued with the study.

The study consisted of 566 participants that had been enrolled in the Detroit Childhood Allergy Study birth cohort in 1987 to 1989. Participants provided blood samples and information on their pet histories at an 18-year follow-up interview.....

.....Blood tests determined if a participant was sensitized to dog or cat exposure as defined by an animal-specific immunoglobulin E (IgE) of greater than or equal to 0.35 kU/L. Exposure to an animal was defined as living with an animal for at least two weeks, and also included measures for the first year of life, ages one to five, ages six to 12, and 13 and older.

Cumulative exposure was not associated with risk of dog or cat allergy development overall in any group.

Wegienka and colleagues noted the significant effect in cat and dog sensitization for children born by cesarean section, which is consistent with previous studies that have found a relationship between cesarean birth and development of allergies. The group hypothesized that cesarean section babies acquire a higher proportion of their microbes from household exposures -- such as dust and pet dander -- during their formative years, allowing for a different immune response.....

27. SWIMMING POOL ATTENDANCE, ASTHMA, ALLERGIES, AND LUNG FUNCTION IN THE AVON LONGITUDINAL STUDY OF PARENTS AND CHILDREN COHORT 
Font-Ribera L, Villanueva CM, Nieuwenhuijsen MJ, Zock JP, Kogevinas M, Henderson J. Am J Respir Crit Care Med. 2011;183:582-588.

FCAAIA Notes:  Better physical conditioning can lead to improved overall asthma control. Swimming is often a great way for children with asthma to exercise.  The humid air of indoor pools can lessen the risk of exercise-induced asthma symptoms. On the other hand, a small proportion of patients with asthma will tolerate only brominated, but not chlorinated pools.  In those instances, the thin layer of chloramines that forms just above the water surface creates an irritant to the airway and triggers asthma symptoms. There is no reason to avoid chlorinated pools unless you always have problems when swimming in them.

(Source: Medscape, May 17, 2011, http://www.medscape.com/viewarticle/741805?src=mp&spon=38 )

STUDY SUMMARY: Concerns have been raised that regular swimming in chlorinated indoor swimming pools may lead to asthma and nasal symptoms in children, possibly because chlorine and related products are irritating to the respiratory mucosae. These concerns have been based on epidemiologic evidence[1] and a body of observational studies. However, results of those studies have been inconsistent and inconclusive.
To throw a clearer light on the issue, a prospective longitudinal study (the best way to address the question) was performed in the United Kingdom. Children were enrolled soon after birth. Respiratory symptoms were assessed by a standard questionnaire at regular intervals until aged 10 years. The questionnaire also inquired about the frequency of indoor swimming. At age 7, data were available for 5537 children; at age 10, the number was 4770 children. The frequencies of ever having had asthma, current asthma, the use of asthma medications, wheezing, and nasal or ocular allergies were the primary outcomes. Each of these was similar or lower in children with the highest exposure to indoor swimming compared with children who had little or no exposure to swimming.......Font-Ribera and colleagues concluded that, contrary to some previous studies, children who were regular swimmers had less asthma, better lung function, and were less likely to have nasal symptoms.

VIEWPOINT:..... Although highly suggestive that swimming does not increase the risk of developing asthma or nasal symptoms, its limitations need to be considered. Children were not prospectively randomly assigned to swimming and nonswimming groups, so an element of self-selection may have unbalanced the groups. For example, children with a tendency for respiratory symptoms might have been disproportionately kept from swimming....These limitations notwithstanding, it seems safe to say that regular swimming in indoor pools is not a risk factor for the development of asthma or other respiratory problems in children up to the age of 10. Indeed, to the contrary, children who swim regularly may even obtain some protection from asthmatic and allergic-type respiratory disorders.

28. FOOD ALLERGIES AND ASTHMA
Wang J, Liu AH. Curr Opin Allergy Clin Immunol. 2011;11(3):249-254.

FCAAIA Notes:  The more that is learned about the relationship between various allergic conditions (asthma, nasal allergies, food allergies, atopic dermatitis, etc.), the more complex things seem to become.  It is clear that children with any allergic disease are at greater risk of another. It is of utmost importance that your allergist closely monitors the natural history of any child’s allergic disease, keeping his eyes open for even subtle hints of progression.  The “atopic (or allergic) march” from eczema in infancy to asthma and allergic rhinitis by early school age is a well described phenomenon.  Children with chronic or recurrent upper or lower airway symptoms should see an allergist for evaluation.

(Source: Medscape, May 24, 2011, http://www.medscape.com/viewarticle/741822?src=mp&spon=38 )

ABSTRACT
PURPOSE OF REVIEW: To consider the possible links between food allergy and asthma.

RECENT FINDINGS: Food allergy and asthma coexist in many children, and recent studies demonstrate that having these comorbid conditions increases the risk for morbidity. Children with food allergies and asthma are more likely to have near-fatal or fatal allergic reactions to food and more likely to have severe asthma.

SUMMARY: Although a causal link has not been determined, increased awareness of the heightened risks of having both of these common childhood conditions and good patient/parent education and management of both conditions can lead to improved outcomes

29. THE INDOOR ENVIRONMENT AND ITS EFFECTS ON CHILDHOOD ASTHMA
Ahluwalia SK, Matsui EC. Curr Opin Allergy Clin Immunol. 2011;11(2):137-143.

FCAAIA Notes: Irritants to the airway include air pollution (indoor and outdoor), strong odors from paints, cleaning products, etc., particulates (such as dusty areas), and even the odors from indoor molds and mustiness.  People with allergy and/or asthma are particularly susceptible, in that their airways are already hyperreactive (“twitchy”). Allergic inflammation of the upper airway (nose) or lower airway (asthma) makes that “twitchiness” worse.  In essence, airway irritants have a synergistic (that is, the total effect is greater than the sum of the individual parts) effect with airway inflammation. Controlling and preventing the allergic airway inflammation with daily controller medications reduces the effect of irritants on the airway.

(Source: Medscape, May 10, 2011, http://www.medscape.com/viewarticle/738958?src=mp&spon=38 )

ABSTRACT
PURPOSE OF REVIEW: Indoor pollutants and allergens cause asthma symptoms and exacerbations and influence the risk of developing asthma. We review recent studies regarding the effects of the indoor environment on childhood asthma.
RECENT FINDINGS: Exposure to some indoor allergens and second hand smoke are causally related to the development of asthma in children. Many recent studies have demonstrated an association between exposure to indoor pollutants and allergens and airways inflammation, asthma symptoms, and increased healthcare utilization among individuals with established asthma. Genetic polymorphisms conferring susceptibility to some indoor exposures have also been identified, and recent findings support the notion that environmental exposures may influence gene expression through epigenetic modification. Recent studies also support the efficacy of multifaceted environmental interventions in childhood asthma.
SUMMARY: Studies have provided significant evidence of the association between many indoor pollutants and allergens and asthma morbidity, and have also demonstrated the efficacy of multifaceted indoor environmental interventions in childhood asthma. There is also a growing body of evidence suggesting that some indoor pollutants and allergens may increase the risk of developing asthma. Future studies should examine mechanisms whereby environmental exposures may influence asthma pathogenesis and expand the current knowledge of susceptibility factors for indoor exposures.

30. PESTICIDES AND ASTHMA
Hernández AF, Parrón T, Alarcón R. Curr Opin Allergy Clin Immunol. 2011;11(2):90-96.

FCAAIA Notes: Pesticides are for the most part, another airway irritant (see article above) and can act much as outdoor air pollution can, with a direct effect on the airway. Exposure to pesticides can exacerbate pre-existing problems like asthma or allergy, and intense exposure may irritate the airways making one more likely to develop allergies to pollens or indoor allergens.  Pesticides are not IMMUNOGENIC, however.  That is, it is rare to mount an abnormal immune response to them or truly become “allergic”.

(Source: Medscape, March 23, 2011, http://www.medscape.com/viewarticle/738955?sssdmh=dm1.683790&src=journalnl )

ABSTRACT
PURPOSE OF REVIEW: Several clinical and epidemiological studies have reported an association between exposure to pesticides, bronchial hyper-reactivity and asthma symptoms. This article reviews the mechanistic evidence lending support to the concept that either acute or chronic low-level inhalation of pesticides may trigger asthma attacks, exacerbate asthma or increase the risk of developing asthma.
RECENT FINDINGS: Pesticide aerosols or gases, like other respiratory irritants, can lead to asthma through interaction with functional irritant receptors in the airway and promoting neurogenic inflammation. Cross-talk between airway nerves and inflammatory cells helps to maintain chronic inflammation that eventually damages the bronchial epithelium. Certain organophosphorus insecticides cause airway hyper-reactivity via a common mechanism of disrupting negative feedback control of cholinergic regulation in the lungs. These pesticides may interact synergistically with allergen sensitization rendering individuals more susceptible for developing asthma.
SUMMARY: Many pesticides are sensitizers or irritants capable of directly damaging the bronchial mucosa, thus making the airway very sensitive to allergens or other stimuli. However, most pesticides are weakly immunogenic so that their potential to sensitize airways in exposed populations is limited. Pesticides may increase the risk of developing asthma, exacerbate a previous asthmatic condition or even trigger asthma attacks by increasing bronchial hyper-responsiveness.

31. HYMENOPTERA VENOM IMMUOTHERAPY
Bilò BM, Bonifazi F .Immunotherapy. 2011;3(2):229-246.

FCAAIA Notes: Stinging flying insect allergy is one of the most curable things allergists treat. ANYONE and EVERYONE who has had anaphylaxis after a wasp, honey bee, yellow jacket, hornet, or fire ant sting should be seen by an allergist. In addition, people older than 15 years who are stung and get diffuse hives or swelling should be seen. In accordance with well-established research, all those patients should receive venom immunotherapy to dramatically decrease their likelihood of another life-threatening reaction after a sting. The bees will be out soon!  Call to set up an evaluation for yourself or a loved one with a history of bee-sting allergy.

(Source: Medscape, March 29, 2011  http://www.medscape.com/viewarticle/739777?src=mp&spon=38 )

ABSTRACT: Subcutaneous venom immunotherapy is the only effective treatment for patients who experience severe hymenoptera sting-induced allergic reactions, and the treatment also improves health-related quality of life. This article examines advances in various areas of this treatment, which include the immunological mechanisms of early and long-term efficacy, indications and contraindications, selection of venom, treatment protocols, duration, risk factors for systemic reactions in untreated and treated patients as well as for relapse following cessation of treatment. Current and future strategies for improving safety and efficacy are also examined. However, although progress in the past few years has been fruitful, much remains to be accomplished. (see link above for full article).

32. POLLEN COUNTS FROM POPULAR COMMERCIAL WEB SITES UNRELIABLE.

FCAAIA Notes: An accurate pollen count can only be made AFTER the fact. That is, how much pollen was in the air for a preceding period of time (usually 24 hours). Commercial web sites try to predict in advance, what the pollen count will be in the ensuing day by factoring predicted weather conditions including wind, temperature and precipitation. For patients interested in following pollen counts, we recommend a source more likely to be accurate, such as the National Allergy Bureau (http://pollen.aaaai.org/nab/ ).

(Source: Medscape, March 31, 2011 http://www.medscape.com/viewarticle/739988?src=mp&spon=38 )

A new study provides scientific support for what allergists have long suspected — pollen count information available from popular commercial television channels and online sites is often unreliable ....For many years, Dr. Dalan.. performed the pollen counts ...found that his counts differed from those provided for his area on popular commercial Web sites and television channels. .

Yet many patients, and even many physicians, do not realize that television channels and online sites often base their pollen counts on prediction models that take into account weather forecasts and pollen counts at a similar time period in previous years....

Charles Barnes, PhD, ... commented .... "This study is the first to formally examine what we have long suspected — that patients are altering their lives based on pollen counts that may be inaccurate."

Thus, it is important to caution patients not to rely on pollen counts they get from television channels or online commercial Web sites, and crucial to tell them not to restrict their activities simply based on these counts, Dr. Barnes said....

33. INJECTION ALLERGEN IMMUNOTHERAPY FOR ASTHMA
Abramson MJ, Puy RM, Weiner JM. Cochrane Database Syst Rev. 2010; (8):CD001186

FCAAIA Notes: Allergy shots change the way your body sees what you are allergic to from an allergic to a non-allergic immune response. This “immune deviation” is in essence the only potential “cure” for allergic airway disease which includes asthma and nasal allergies. For all intents and purposes, asthma and allergies are the same disease, affecting different ends of a unified airway. It surprises allergists (including this editor) that more primary care physicians and pulmonologists do not recognize the role that allergy shots play in the care of asthma. In fact, the most recent national guidelines for the diagnosis and management of asthma, written by pulmonologists and allergists published in 2007 (http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm) indicates the importance of allergy shots. It recommends that ANYONE with persistent asthma and allergies who is 5 or older should be considered for injection therapy.

(Source: Medcape, January 26, 2011 http://www.medscape.com/medline/abstract/20687065?cid=med&src=nlbest )

BACKGROUND: Allergen specific immunotherapy has long been a controversial treatment for asthma. Although beneficial effects upon clinically relevant outcomes have been demonstrated in randomised controlled trials, there remains a risk of severe and sometimes fatal anaphylaxis. The recommendations of professional bodies have ranged from cautious acceptance to outright dismissal. With increasing interest in new allergen preparations and methods of delivery, we updated the systematic review of allergen specific immunotherapy for asthma.

OBJECTIVES: The objective of this review was to assess the effects of allergen specific immunotherapy for asthma.

SEARCH STRATEGY: We searched the Cochrane Airways Group Trials Register up to 2005, Dissertation Abstracts and Current Contents.

SELECTION CRITERIA: Randomised controlled trials using various forms of allergen specific immunotherapy to treat asthma and reporting at least one clinical outcome.

DATA COLLECTION AND ANALYSIS: Three authors independently assessed eligibility of studies for inclusion. Two authors independently performed quality assessment of studies.

MAIN RESULTS: Eighty-eight trials were included (13 new trials). There were 42 trials of immunotherapy for house mite allergy; 27 pollen allergy trials; 10 animal dander allergy trials; two Cladosporium mould allergy, two latex and six trials looking at multiple allergens. ... Overall, there was a significant reduction in asthma symptoms and medication, and improvement in bronchial hyper-reactivity following immunotherapy. There was a significant improvement in asthma symptom scores (standardised mean difference -0.59, 95% confidence interval -0.83 to -0.35) .... Allergen immunotherapy significantly reduced allergen specific bronchial hyper-reactivity, with some reduction in non-specific bronchial hyper-reactivity as well....

AUTHORS' CONCLUSIONS: Immunotherapy reduces asthma symptoms and use of asthma medications and improves bronchial hyper-reactivity. One trial found that the size of the benefit is possibly comparable to inhaled steroids. The possibility of local or systemic adverse effects (such as anaphylaxis) must be considered.

34. FDA PULLS UNAPPROVED COLD, COUGH, AND ALLERGY DRUGS FROM MARKET

FCAAIA Notes: The Food and Drug Administration did note state that these medications were not effective or safe. The announcement indicates that the manufacturers have not registered their products. “Domestic and foreign establishments that manufacture, repack, or re-label drug products in the United States are required to register and list all of their commercially marketed drug products with the FDA.” Many of the individual components of these medications are still available individually or in combination over-the counter. You should read the label of your favorite one and try to find the the same components in another product.

(Source: Medscape, March 2, 2011, http://www.medscape.com/viewarticle/738277?sssdmh=dm1.669916&src=nl_newsalert )

March 2, 2011 — The US Food and Drug Administration (FDA) is taking action against companies that manufacture, distribute, or market oral agents that are not approved by the FDA. The drugs are prescribed for the treatment of coughs, colds, and allergies in the United States.

According to the FDA, companies that have previously listed products subject to today's action are required to stop manufacturing the products within 90 days and to stop shipping the products within 180 days. Companies that have not previously listed products subject to today's action with FDA are expected to stop manufacturing and shipping their products immediately.....

 FDA officials advised clinicians that the FDA database of approved drugs can be searched, and if no number is associated with the product, it is an indication that the drug is not approved, and that the clinician should check with the manufacturer. The complete list of unapproved products is available on the FDA Web site. (http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/EnforcementActivitiesbyFDA/SelectedEnforcementActionsonUnapprovedDrugs/ucm245106.htm )

(Please contact Dr. Lester if you would like a complete copy of this article).

35. NO INCREASED RISK FOR CATARACTS IN ASTHMATICS TAKING INHALED STEROIDS.

FCAAIA Notes: Study after study has demonstrated the great safety profile of inhaled steroids for asthma or nasal steroids for allergies.  These medications work directly in the airway with minimal systemic absorption. While nothing is 100% risk free (even ibuprofen!), these medications are the first line preventive choices for patients with persistent asthma or allergies.  They are certainly safer than poorly controlled disease and should not be withheld only because of “steroid-phobia” (fear of steroids).  The safety of these topical medications is also much greater than even a single course of oral steroids (the treatment of choice for a severe asthma flare). Once a patient achieves control of her or his asthma and allergies, it is important to gradually “step down” to the lowest controlling dose.

(Source: Medscape April 12, 2011 http://www.medscape.com/viewarticle/740220?src=mp&spon=38 )

There is no increased risk for either cataracts or elevated intraocular pressure (IOP) with the inhaled steroid budesonide, which can lead to glaucoma, ...In adulthood, all enrollees underwent a slit-lamp examination, and the same certified ophthalmologist took retroillumination images and IOP measurements....

...During the study period, subjects received inhaled budesonide at a dose adjusted to achieve asthma control (mean daily dose, 385 mg). Patients were followed for 2 to 32 years, and in adulthood (while still taking the study medication) they underwent ophthalmological exams. ....

Results indicated that mean IOP was similar in the intervention and control groups, although 5 of 148 patients in the intervention group and 1 of 53 patients in the control group had an IOP higher than 21 mm Hg. This difference was not significant, Dr. Pedersen said. There were also no significant differences between the 2 groups in the incidence of posterior subcapsular cataracts; none of these cataracts occurred in the intervention group and 2 occurred in the control group, he reported....

"There seemed to be no adverse effects on cataracts or [IOP] from the use of inhaled budesonide," .....

36. FLU SHOTS OK FOR PEOPLE WITH EGG ALLERGY

FCAAIA Notes: Influenza vaccine contains such minute amounts of egg protein that it is not a risk for egg allergic patients. The first evidence to this effect came in 1997 in a study in which Dr. Lester participated. More recently, it has been shown that virtually all lots of seasonal and H1N1 influenza vaccine contain as little egg protein as in the original study. As a comparison, an egg contains 20,000-26,000 times more egg protein than is in a dose of influenza vaccine that would be given to a child 3 or younger). The measles-mumps-rubella vaccine (MMR) does not contain egg protein and may safely be given all patients with egg allergy. Only patients who have had a previous allergic reaction to a flu shot or MMR require vaccine testing. Yellow fever vaccine contains egg protein.

(Source: Medscape, March 3, 2011. http://www.medscape.com/viewarticle/730694 )

October 18, 2010 — For years, people with egg allergy were told to avoid the flu vaccine because it contains egg protein and could trigger a reaction, but this advice no longer stands. People with egg allergies can -- and should -- get the flu shot this year, according to a new report by the American Academy of Allergy, Asthma & Immunology....

Why the change? "We now know with confidence that most people with egg allergy can receive the flu shot without reaction," says the report’s author, James T. Li, MD, PhD, an allergist at the Mayo Clinic in Rochester, Minn....

Skin testing is not necessary either unless the person with egg allergy has had a reaction to the flu vaccine in the past, Li says....

See an Allergist for Proper Evaluation
"If you have egg allergy or suspected egg allergy, see your doctor, and there is a very high probability that you can receive the influenza vaccine without reaction and derive the benefits," Li says....

37. NIAID RELEASED FIRST GUIDELINES FOR MANAGING FOOD ALLERGIES

FCAAIA Notes: The diagnosis of food allergy goes far beyond a simple blood test or skin test. Test results must always be interpreted in the context of the patient’s individual history. Tests for food are usually not “black and white.” Many practitioners do tests for allergy that are proven to have no diagnostic validity whatsoever. A good source of information as to what tests for are proven useful is www.quackwatch.org . This web site has numerous well-written and well-referenced articles about many aspects of health.

(Source: Medscape, December 14, 2010, http://www.medscape.com/viewarticle/733634?src=mp&spon=38 )

The first food allergy guidelines were issued today by the National Institutes of Health's National Institute of Allergy and Infectious Diseases (NIAID). According to the new guidelines, avoiding the ingestion of specific allergens is the main strategy suggested for managing food allergies, and no medications are currently recommended.

Developed over 2 years, the guidelines are intended for use by both family practice physicians and medical specialists and were published online today by the Journal of Allergy and Clinical Immunology. The full text of the guidelines is now available on the NIAID Web site (http://www.niaid.nih.gov/topics/foodallergy/clinical/Pages/default.aspx ).....

FOOD ALLERGIES INCREASING IN US
The natural history of the most common food allergens in the United States — including egg, milk, peanut, tree nuts, wheat, crustacean shellfish, and soy — was reviewed and summarized. ...According to the literature summary in the new guidelines, most children with allergies to milk, egg, soy, and wheat will eventually be able to tolerate these allergens, while tree nut and peanut allergies are less likely to resolve with time. Likewise, food allergies that begin in adulthood are likely to persist....

GUIDELINES RECOMMEND CONFIRMATION OF ALLERGIES
The guidelines also describe conditions that should raise clinical suspicion of food allergies. In addition, they suggest that food allergies should be confirmed, because studies indicate that 50% to 90% of presumed food allergies are, in fact, not allergies. The new guidelines will help physicians to know which tests have been scientifically evaluated to diagnose food allergy.....

VACCINES IN EGG-ALLERGIC POPULATIONS
The guidelines also suggest that patients allergic to eggs should receive the measles, mumps, and rubella vaccine despite it being egg-based. Administering the egg-based yellow fever and rabies vaccines to these patients was not supported by a summary of the literature, and insufficient evidence was found to recommend the egg-based influenza vaccine for these patients.....

DELAYING OF FOODS NOT WARRENTED
The guidelines do not recommend restricting maternal diet during pregnancy or lactation to prevent the development or clinical course of food allergies, but they do recommend exclusive breast-feeding of all infants until age 4 to 6 months, unless medical reasons contraindicate breast-feeding. According to Dr. Sampson, the guidelines concur with current American Academy of Pediatrics guidelines. "There is no evidence that delaying certain foods, even foods that are considered allergenic, (is) going to have any significant effect on the development of allergy," he said.....

EPINEPHRINE THE FIRST CHOICE FOR ANAPHYLAXIS
The recommended therapy for anaphylaxis is described in the guidelines. Dr. Sampson stressed that "epinephrine is the first choice for the treatment of anaphylaxis and many of the other drugs, such as antihistamines, corticosteroids, and such, are secondary medications."

38. CONNECTICUT DOCTORS OPEN A FOOD ALLERGY TREATMENT CENTER

FCAAIA NOTES: The New England Food Allergy Treatment Center (www.nefoodallergy.org ) is not affiliated with Fairfield County Allergy, Asthma, and Immunology Associates, PC. Oral peanut desensitization (or desensitization to any food for that matter) is a research tool and should not be undertaken outside of a research facility. Therefore, it is not to be done at home or at routine office visits with your allergist.

(Source: http://www.acorn-online.com/joomla15/thereddingpilot/news/localnews/81130-connecticut-doctors-open-a-food-allergy-treatment-center-.html ) December 28, 2010.

Peanut allergy is one of the most common food allergies in children and adults and is often associated with serious, potentially life-threatening reactions. The only treatment of peanut allergy has been to strictly avoid peanut ingestion and patients must be extremely careful about potential exposure in foods. Peanut allergy can result in patients or their parents feeling trapped because of the many foods that they are prohibited from eating and the fear that they will mistakenly eat something that contains peanut products....

The New England Food Allergy Treatment Center, located in West Hartford, CT has initiated a new, investigational treatment that may desensitize patients with peanut allergy with the hope that if an allergic individual were to eat something with peanuts they would much less likely experience an allergic reaction. ..... "The research we are conducting will hopefully result in substantial improvement in the quality of life of many peanut allergic patients."

ORAL IMMUNOTHERAPY
The center is conducting a clinical study with peanut protein, using a procedure called oral immunotherapy.…..

39. CDC: ASTHMA RATES IN US UP A LITTLE TO 8.2%.

FCAAIA NOTES: Treatment for asthma is effective and safer than poorly controlled asthma. In a way, asthma and nasal allergies are the same disease affecting different ends of a unified airway. Having either greatly increases your risk of having the other. Treatment of nasal allergies and asthma must be considered together. You should discuss this with your allergist if you have not done so already.

(Source: Yahoo News, January 12, 2011, http://news.yahoo.com/s/ap/20110112/ap_on_he_me/us_med_asthma)

ATLANTA – Asthma seems to be increasing a little and nearly one in 12 Americans now say they have the respiratory disease, federal health officials said Wednesday. About 8.2 percent of Americans had asthma in a 2009 national survey of about 40,000 individuals. That's nearly 25 million people with asthma, according to a Centers for Disease Control and Prevention report.

The rate had been holding steady at a little under 8 percent for the previous four years. Better diagnostic efforts could be part of the reason for the increase. They were believed to be a main reason for an increase in asthma seen from 1980 through 1995, said Dr. Lara Akinbami, a medical officer at the CDC's National Center for Health Statistics….

40. DOCS GET GUIDE FOR ID’ING FOOD ALLERGIES

FCAAIA Notes: The diagnosis of food allergy goes far beyond a simple blood test or skin test. Test results must always be interpreted in the context of the patient’s individual history. Tests for food are usually not “black and white.” These Many practitioners do tests for allergy that are proven to have no diagnostic validity whatsoever. A good source of information as to what tests for are proven useful is www.quackwatch.org. This web site has numerous well-written and well-referenced articles about many aspects of health.

(Source: CNN Health, December 6, 2010 http://pagingdrgupta.blogs.cnn.com/2010/12/06/docs-get-guide-for-iding-food-allergies/ )

The first guidelines for diagnosing and managing food allergies were released Monday by The American Academy of Allergy, Asthma and Immunology (AAAAI). Designed by and for allergists, immunologists and other health care professionals, the guidelines represent the best practices for management of a disease where there is no current treatment. It's a framework intended to help doctors make appropriate decisions about treating patients, but not fixed rules that must be followed. Doctors and patients still need to develop individual treatment plans based on the circumstance of the patient.

The most common food allergens in this country are milk, eggs, peanuts, tree nuts, shellfish, wheat and soy. Milk and eggs are the two most common allergies seen in pediatric patients, but 80 percent of children outgrow them. Peanuts, tree nuts and shellfish allergies more often last a lifetime–less than 10-20 percent of kids outgrow them according to Dr. Hugh Sampson, Professor of Pediatrics at Mount Sinai School of Medicine and a member of the Guidelines Coordinating Committee.

Sampson says food allergy is often over-diagnosed……

41. WHAT’S THE STORY ON ALLERGY “DROPS”?
• Scientific studies from Europe in the last few years show that patients allergic to only one of the several things (e.g., grass, dust mite, ragweed, or cat) may benefit from sublingual immunotherapy (in which the substance is placed under the tongue rather than given by shots). The under-the-tongue method is nicknamed “SLIT”. In Europe, SLIT is given with very high dose dissolvable tablets that melt away over about a minute; they don’t give any drops at all!
• Recent studies show SLIT is not very effective for patients with allergies to numerous things. With increased use of SLIT, there are now reports of patients having anaphylaxis at home after taking their doses.
• The European studies indicate that for SLIT to be effective, the total dose given in a month should be 300-500 times higher than the dose given by injection (allergy shots)…….

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