July 30, 2014

Auto-injector needle length may be inadequate to deliver epinephrine intramuscularly in women with confirmed food allergy

Research


Open AccessGina Tsai1Laura Kim2Immaculate FP Nevis13Arunmozhi Dominic1Ryan Potts4Jack Chiu1 and Harold L Kim135*
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Allergy, Asthma & Clinical Immunology 2014, 10:39  doi:10.1186/1710-1492-10-39
Published: 22 July 2014

Abstract

Background

Epinephrine auto-injectors are the standard first aid treatment for anaphylaxis. Intramuscular delivery into the anterolateral aspect of the thigh is recommended for optimal onset of action of epinephrine. The most frequently prescribed auto-injector in North America and Canada is the EpiPen®, which has a needle length of 15.2 mm. Currently, it is unknown whether this needle length is adequate for intramuscular delivery of epinephrine in adult patients at risk of anaphylaxis.

Methods

One hundred consecutive adult patients with confirmed food allergy requiring an epinephrine auto-injector were recruited. Skin to muscle depth (STMD) at the right mid-anterolateral thigh was measured using ultrasound under minimal (min) and maximum (max) pressure. The EpiPen®needle length was considered adequate if STMDmax was ≤15.2 mm. Baseline characteristics including age, gender, ethnicity, and body mass index (BMI) were compared in patients with STMDmax -15.2 mm vs. >15.2 mm.

Results

The EpiPen® needle length of 15.2 mm was inadequate for intramuscular delivery in 19 of the 100 enrolled patients (19%), all of whom were female; 28% of women had a STMDmax >15.2 mm. The mean STMDmax in the ≤15.2-mm and >15.2-mm groups were 9 ± 4 mm and 20 ± 4 mm, respectively (p = 0.0001). Linear regression analysis found BMI to be significantly associated with STMDmax after adjusting for age (p - 0.001).

Conclusions

The needle length of the epinephrine auto-injectors may not be adequate for intramuscular delivery of epinephrine in a large proportion of women with food allergy; this may impact morbidity and mortality from anaphylaxis in this patient population.
Keywords: 
Food allergy; Anaphylaxis; Skin-to-muscle depth; Epinephrine; Auto-injector; Needle length 

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Middle East Consensus Statement on the Prevention, Diagnosis, and Management of Cow's Milk Protein Allergy

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Pediatr Gastroenterol Hepatol Nutr. Jun 2014; 17(2): 61–73.
Published online Jun 30, 2014. doi:  10.5223/pghn.2014.17.2.61
PMCID: PMC4107222

Abstract

Presented are guidelines for the prevention, diagnosis, and treatment of cow's milk protein allergy (CMPA) which is the most common food allergy in infants. It manifests through a variety of symptoms that place a burden on both the infant and their caregivers. The guidelines were formulated by evaluation of existing evidence-based guidelines, literature evidence and expert clinical experience. The guidelines set out practical recommendations and include algorithms for the prevention and treatment of CMPA. For infants at risk of allergy, appropriate prevention diets are suggested. Breastfeeding is the best method for prevention; however, a partially hydrolyzed formula should be used in infants unable to be breastfed. In infants with suspected CMPA, guidelines are presented for the appropriate diagnostic workup and subsequent appropriate elimination diet for treatment. Exclusive breastfeeding and maternal dietary allergen avoidance are the best treatment. In infants not exclusively breastfed, an extensively hydrolyzed formula should be used with amino acid formula recommended if the symptoms are life-threatening or do not resolve after extensively hydrolyzed formula. Adherence to these guidelines should assist healthcare practitioners in optimizing their approach to the management of CMPA and decrease the burden on infants and their caregivers.
Keywords: Allergy and immunology, Breast feeding, Hypersensitivity, Infant formula, Milk hypersensitivity

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An Overview of Leptin and the Th1/Th2 Balance

Review Paper
An Overview of Leptin and the Th1/Th2 Balance
DownloadDownload as PDF (Size:981KB)Download as PDF (Size:981KB) Full-Text HTML PP. 42-50   DOI: 10.4236/oji.2014.42006
Adipocytes produce hormones and adipokines, among others leptin, with metabolic and inflammatory responses. The role of leptin involves different subsets of the immune system. Low levels of serum leptin concentrations are associated with bacterial infections and produce susceptibility to allergic diseases and type Th2 autoimmune diseases. High levels of leptin are associated with Th1 autoimmune diseases via inflammatory responses. Leptin resistance, that happens in obesity, is characterized by the presence of high levels of serum leptin itself accompanied by a clinical situation of a Th2 response. There is a relationship between obesity, leptin resistance, altered immunity and sex hormones. Serum leptin concentration (Th1 response) in women is higher than in men maybe to achieve the balance Th1/Th2 because of the high level of estrogenic hormones (Th2 response) in women.
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Cite this paper
Brito Díaz, B. , Marcelino Rodríguez, I. , Almeida González, D. , Rodríguez Pérez, MC. and Cabrera de León, A. (2014) An Overview of Leptin and the Th1/Th2 Balance. Open Journal of Immunology4, 42-50. doi:10.4236/oji.2014.42006.

July 29, 2014

A prospective study comparing the efficacy and safety of two sublingual birch allergen preparations

Research

Open Access

Ludger KlimekAnnette SperlEsther van TwuijverRonald van ReeHuub KleinjansJohan Diderik Boot and Oliver Pfaar
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Clinical and Translational Allergy 2014, 4:23  doi:10.1186/2045-7022-4-23
Published: 23 July 2014

Abstract (provisional)

Background

SUBLIVAC FIX Birch (SUB-B) is a liquid oral preparation of Betula verrucosa pollen extract for the treatment of allergic rhinitis/rhinoconjuctivitis induced by birch pollen. The major allergen content of SUB-B and Staloral Birch (Stal-B) have been shown to be comparable. In order to compare the clinical efficacy and safety of both products, the present study was designed to investigate efficacy of treatment with SUB-B compared to Stal-B by means of reduction in allergy symptoms assessed by a titrated nasal provocation test (TNPT) in subjects suffering from IgE mediated allergy complaints triggered by birch pollen.

Methods

A prospective, randomized, open, blinded endpoint (PROBE), controlled, single-centre study in 74 birch allergic adults was performed. Treatment consisted of either SUB-B (10,000 AUN/ml) or Stal-B (initial phase 10 I.R./ml and maintenance phase 300 I.R./ml) for 16-20 weeks at maintenance dose. The primary efficacy outcome was defined by the difference in change of the TNPT-threshold dose between the two treatment groups at baseline and after completion of treatment. Secondary outcomes included determination of birch pollen specific IgE and IgG levels, safety lab and ECG. During the first 30 days of treatment, subjects were requested to fill out a diary concerning compliance with study medication, occurrence of AEs and the use of concomitant medication.

Results

Analysis of the primary efficacy parameter showed that the percentage of subjects showing a beneficial treatment effect was similar in both treatment groups, 33.3% for SUB-B vs. 31.4% for Stal-B in the intention to treat population. Evaluation of the immunologic response, showed that treatment with SUB-B and Stal-B induced similar increases (approximately 2 times) in IgE, IgG and IgG4 specific for Bet v 1.
In total, 143 related adverse events (AEs) were reported. The majority of the AEs was of mild intensity. The same pattern of AEs was observed for both products. No clinically relevant changes in other safety parameters, such as safety laboratory parameters, vital signs, physical examination and ECGs were observed.

Conclusion

Taken together, treatment with both products was effective by means of reduction in allergic symptoms during a TNPT. In addition, safety analysis revealed a good tolerability of both SLIT extracts.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011


Research

Open Access

Ya Sophia XuMonika KastnerLaurie HaradaAnna XuJane Salter and Susan Waserman
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Allergy, Asthma & Clinical Immunology 2014, 10:38  doi:10.1186/1710-1492-10-38
Published: 22 July 2014

Abstract (provisional)

Background

Examining deaths caused by anaphylaxis may help identify factors that may decrease the risk of these unfortunate events. However, information on fatal anaphylaxis is limited. The objectives of our study were to examine all cases of fatal anaphylaxis in Ontario to determine cause of death, associated features, co factors and trends in mortality. The identification of these factors is important for developing effective strategies to overcome gaps in monitoring and treatment of patients with food allergies and risk for anaphylaxis.

Methods

This was a retrospective case-series analysis of all causes of anaphylaxis-related deaths using data from the Ontario Coroner's database between 1986 and 2011. Quantitative data (e.g. demographic) were analyzed using descriptive statistics and frequency analysis using SPSS. Qualitative data were analyzed using content analysis of grounded theory methodology

Results

We found 92 deaths in the last 26 years related to anaphylaxis. Causes of death, in order of decreasing frequency, included food (40 cases), insect venom (30 cases), iatrogenic (16 cases), and idiopathic (6 cases). Overall, there appears to be a decline in the frequency of food related deaths, but an increase in iatrogenic causes of fatalities. We found factors associated with fatal anaphylaxis included: delayed epinephrine administration, asthma, allergy to peanut, food ingestion outside the home, and teenagers with food allergies.

Conclusions

Our findings indicate the need to improve epinephrine auto-injector use in acute reactions, particularly for teens and asthmatics with food allergies. In addition, education can be improved among food service workers and food industry in order to help food allergic patients avoid potentially fatal allergens. The increasing trend in iatrogenic related anaphylaxis is concerning, and requires monitoring and more investigation.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.


The potential mechanistic link between allergy and obesity development and infant formula feeding

Review

Open Access

Bodo C Melnik



Allergy, Asthma & Clinical Immunology 2014, 10:37  doi:10.1186/1710-1492-10-37
Published: 22 July 2014

Abstract

This article provides a new view of the cellular mechanisms that have been proposed to explain the links between infant formula feeding and the development of atopy and obesity. Epidemiological evidence points to an allergy- and obesity-preventive effect of breastfeeding. Both allergy and obesity development have been traced back to accelerated growth early in life. The nutrient-sensitive kinase mTORC1 is the master regulator of cell growth, which is predominantly activated by amino acids. In contrast to breastfeeding, artificial infant formula feeding bears the risk of uncontrolled excessive protein intake overactivating the infant’s mTORC1 signalling pathways. Overactivated mTORC1 enhances S6K1-mediated adipocyte differentiation, but negatively regulates growth and differentiation of FoxP3+ regulatory T-cells (Tregs), which are deficient in atopic individuals. Thus, the “early protein hypothesis” not only explains increased mTORC1-mediated infant growth but also the development of mTORC1-driven diseases such as allergy and obesity due to a postnatal deviation from the appropriate axis of mTORC1-driven metabolic and immunologic programming. Remarkably, intake of fresh unpasteurized cow’s milk exhibits an allergy-preventive effect in farm children associated with increased FoxP3+ Treg numbers. In contrast to unprocessed cow’s milk, formula lacks bioactive immune-regulatory microRNAs, such as microRNA-155, which plays a major role in FoxP3 expression. Uncontrolled excessive protein supply by formula feeding associated with the absence of bioactive microRNAs and bifidobacteria in formula apparently in a synergistic way result in insufficient Treg maturation. Treg deficiency allows Th2-cell differentiation promoting the development of allergic diseases. Formula-induced mTORC1 overactivation is thus the critical mechanism that explains accelerated postnatal growth, allergy and obesity development on one aberrant pathway.
Keywords: 
Allergy; Breastfeeding; FoxP3; Infant formula; mTORC1; Obesity; Postnatal growth acceleration; Regulatory T-cell 

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July 28, 2014

Prevalence, incidence and predictive factors for hand eczema in young adults - a follow-up study




Research article

Highly Accessed

Open AccessArne Johannisson1*Ann Pontén23 and Åke Svensson45

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BMC Dermatology 2013, 13:14  doi:10.1186/1471-5945-13-14
Published: 29 October 2013

Abstract

Background

Hand eczema is common in the general population and affects women twice as often as men. It is also the most frequent occupational skin disease. The economic consequences are considerable for society and for the affected individuals.

Methods

To investigate the prevalence and incidence of hand eczema and to evaluate risk factors for development of hand eczema in young adults. Subjects and methods; This is a prospective follow-up study of 2,403 young adults, 16 – 19 years old in 1995 and aged 29 – 32 years, 13 years later, in 2008. They completed a postal questionnaire that included questions regarding one-year prevalence of hand eczema, childhood eczema, asthma, rhino-conjunctivitis and factors considered to affect hand eczema such as hand-washing, washing and cleaning, cooking, taking care of small children and usage of moisturisers. These factors were evaluated with the multinominal logistic regression analysis.

Results

The one-year prevalence of hand eczema was 15.8% (females 20.3% and males 10.0%, p < 0.001). The incidence was 11.6 cases per 1000 person-years (females 14.3 and males 5.2, p < 0.001). Childhood eczema was the most important risk factor for hand eczema. The odds ratios were 13.17 when having hand eczema 1995 and 2008 compared to 5.17 in 2008 (p < 0.001). A high frequency of hand washing was important in predicting hand eczema only when having 1-year prevalence 2008, OR 1.02 (p = 0.038).

Conclusions

After 13 years an increased 1-year prevalence of hand eczema was found. The significant risk factors for hand eczema changed over time from endogenous to exogenous factors.
Keywords: 
Hand eczema; Childhood eczema; Prevalence; Incidence; Cohort; Gender; Skin care; Hand-wash 


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