Allergic Diseases

Question: Does pimecrolimus cream 1%, effective and safe in patients with Atopic Dermatitis?

October 28th, 2007

Answer:

Pimecrolimus cream 1% is effective in patients with head and neck dermatitis intolerant of, or dependent on, TCS. Reversion of skin atrophy may occur during TCS-free intervals.

There is a need for alternative treatments for atopic dermatitis (AD) of the face and neck as long-term use of topical corticosteroids (TCS) is associated with skin atrophy and telangiectasia and some patients develop allergy, intolerance or other side-effects. The authors assessed the efficacy and safety of pimecrolimus cream 1% in patients with AD of the face and neck who are either dependent on, or intolerant of, TCS. They did a 12-week study comprising a 6-week, double-blind, randomized, vehicle-controlled phase was conducted, followed by a 6-week, open-label phase. Two hundred patients aged 12 years or over with mild to moderate head and neck AD, intolerant of, or dependent on, TCS were randomized to either pimecrolimus cream or vehicle cream. The primary efficacy criterion was the facial investigator’s global assessment score at 6 weeks. Secondary efficacy criteria were head and neck Eczema Area and Severity Index (EASI), pruritus score and eyelid dermatitis. Facial skin atrophy and telangiectasia were assessed with dermatoscopy. A significantly higher percentage of patients treated with pimecrolimus was cleared or almost cleared of facial AD compared with vehicle (47% vs. 16%, respectively). A statistically significant difference was also seen on head and neck EASI and pruritus score. Significantly more pimecrolimus-treated patients than vehicle-treated patients achieved clearance of eyelid dermatitis (45% vs. 19%, respectively). Among the 77 patients with skin atrophy at baseline, treatment with pimecrolimus was associated with a reversal in skin thinning. Of the 112 patients with telangiectasia at baseline, no statistically significant difference was seen between treatment groups. Adverse events occurred with similar frequency in both groups.

Br J Dermatol. 2007 Nov;157(5):954-9.

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Question: Does early Supplementation of Prebiotic Oligosaccharides Protects Formula-Fed Infants against Infections during the First 6 Months of Life?

October 28th, 2007

Answer:

Oligosaccharide prebiotics reduced the number of infectious episodes and the incidence of recurring, particularly respiratory, infections during the first 6 mo of life. Although the exact mechanism of action is under investigation, it is very likely that the immune modulating effect of this prebiotic mixture through intestinal flora modification is the principal mechanism for the observed infection prevention early in life.

A mixture of neutral short chain galactooligosaccharides and long chain fructo-oligosaccharides (scGOS/lcFOS) has been shown to have prebiotic and immunomodulatory effects comparable to human milk oligosaccharides. The authors studied was that this specific prebiotic mixture could have a preventive effect against infections during the first 6 mo of life. In a prospective, randomized, double-blind, placebo-controlled trial, healthy term infants with a parental history of atopy were fed either prebiotic-supplemented (8 g/L scGOS/lcFOS) or placebo-supplemented (8 g/L maltodextrin) hypoallergenic formula during the first 6 mo of life. The primary outcome measures were infectious episodes, number of infections requiring antibiotics, and incidence of infections. During the study period, infants in the scGOS/lcFOS group had fewer episodes of all types of infections combined (P = 0.01). They also tended to have fewer upper respiratory tract infection episodes (P = 0.07) and fewer infections requiring antibiotic treatment (P = 0.10). Similarly, the cumulative incidence of recurring infections was significantly lower in the scGOS/lcFOS group. The cumulative incidence of any recurring infection and recurring respiratory infections was 3.9 and 2.9% in the scGOS/lcFOS group and 13.5 and 9.6% in the placebo group, respectively (P < 0.05).

J Nutr. 2007 Nov;137(11):2420-4

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Question: Does grass allergen tablet immunotherapy (Grazax) relieves individual seasonal eye and nasal symptoms, including nasal blockage?

October 23rd, 2007

Answer:

Grazax has effects on multiple allergic symptoms, including nasal blockage, and is an effective treatment of rhinoconjunctivitis, thereby reducing the need for topical anti-allergic drugs.

Symptoms of allergic rhinitis have a considerable impact on the quality of life of the sufferer. Sneezing, runny nose, blocked nose and headache are some of the most common symptoms of allergic rhinitis, which affects work, home and social life for many patients. Sublingual immunotherapy has shown to induce a protective immune response and provide sustained symptom prevention for allergic patients.

Experts investigated the efficacy and safety of a sublingual grass allergen tablet (Grazax) 75 000 SQ-T; ALK-Abelló A/S, Denmark). The data reported are the effects of Grazax on individual eye and nasal symptoms. The trial was a double-blind placebo-controlled trial including 634 participants with significant rhinoconjunctivitis because of grass pollen. Participants were randomized 1 : 1 to Grazax (a fast dissolving, once daily immunotherapy tablet for home administration) or placebo and received treatment for at least 16 weeks prior to and continuing during the grass pollen season of 2005. Four nasal symptoms and two eye symptoms were scored on a scale from 0 (no symptoms) to 3 (severe symptoms) every day during the entire grass pollen season. Nasal symptoms included runny nose, blocked nose, sneezing and itchy nose; eye symptoms included gritty feeling/red/itchy eyes and watery eyes. Consistent and highly significant reductions in individual eye and nasal symptoms (from 22 to 44%) were observed following treatment with Grazax as compared with placebo (P < 0.0001).

Allergy. 2007 Aug;62(8):954-7

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Question: Is short course corticosteroids (oral, intramuscular, or intravenous) beneficial for preventing relapse after an acute exacerbation of asthma?

October 22nd, 2007

Answer:

A short course of corticosteroids following assessment for an asthma exacerbation significantly reduces the number of relapses to additional care, hospitalizations and use of short-acting beta(2)-agonist without an apparent increase in side effects. Intramuscular and oral corticosteroids are both effective.

Acute asthma is responsible for many emergency department (ED) visits annually. Between 12 to 16% will relapse to require additional interventions within two weeks of ED discharge. Treatment of acute asthma is based on rapid reversal of bronchospasm and reducing airway inflammation.

Expert determined the benefit of corticosteroids (oral, intramuscular, or intravenous) for the treatment of asthmatic patients discharged from an acute care setting (i.e. usually the emergency department) after assessment and treatment of an acute asthmatic exacerbation. They searched the Cochrane Airways Group Specialised Register and reference lists of articles. In addition, authors of all included studies were contacted to locate unpublished studies. The most recent search was run in October 2006. They only selected randomized controlled trials articles comparing two types of corticosteroids (oral, intra-muscular, or inhaled) with placebo for outpatient treatment of asthmatic exacerbations in adults or children. To make it more accurate 2 review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. What they got 6 trials involving 374 people were included. One study used intramuscular corticosteroids, five studies used oral corticosteroids. The review was split into two reviews and although the latest search yielded no additional placebo controlled trials an additional IM study was included. Significantly fewer patients in the corticosteroid group relapsed to receive additional care in the first week (Relative risk (RR) 0.38; 95% confidence interval (CI) 0.2 to 0.74). This favourable effect was maintained over the first 21 days (RR 0.47; 95% CI 0.25 to 0.89) and there were fewer subsequent hospitalizations (RR 0.35; 95% CI 0.13 to 0.95). Patients receiving corticosteroids had less need for beta(2)-agonists (mean difference (MD) -3.3 activations/day; 95% CI -5.6 to -1.0). Changes in pulmonary function tests (SMD 0.045; 95% CI -0.47 to 0.56) and side effects (SMD 0.03; 95% CI -0.38 to 0.44) in the first 7 to 10 days, while rarely reported, showed no significant differences between the treatment groups. Statistically significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. From these results, as few as ten patients need to be treated to prevent relapse to additional care after an exacerbation of asthma.

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Question: Is swimming beneficial in patient with mild persistent asthma?

October 21st, 2007

Answer:

Engagement of patients with mild persistent asthma in recreational swimming in nonchlorinated pools, combined with regular medical treatment and education, leads to better improvement of their parameters of lung function and also to more significant decrease of their airway hyperresponsiveness compared to patients treated with traditional medicine.

Study was done to analyzed the effect of recreational swimming on lung function and bronchial hyperresponsiveness (BHR) in patients with mild persistent asthma. They included 65 patients with mild persistent asthma, who were divided into two groups: experimental group A (n = 45) and control group B (n = 20). Patients from both groups were treated with low doses of inhaled corticosteroids (ICS) and short-acting beta2 agonists salbutamol as needed. The program for patients in group A was combined asthma education with swimming (twice a week on a 1-h basis for the following 6 months).  At the end of the study, in Group A, They found out a statistically significant increase of lung function parameters FEV1 (forced expiratory volume in 1 sec) (3.55 vs. 3.65) (p < 0.01), FVC (forced vital capacity) (4.27 vs. 4.37) (p < 0.05), PEF (peak expiratory flow) (7.08 vs. 7.46) (p < 0.01), and statistically significant decrease of BHR (PD20 0.58 vs. 2.01) (p < 0.001). In Group B, there was a statistically significant improvement of FEV1 3.29 vs. 3.33 (p < 0.05) and although FVC, FEV1/FVC, and PEF were improved, it was not significant. When Groups A and B were compared at the end of the study, there was a statistically significant difference of FVC (4.01 vs. 4.37), FEV1 (3.33 vs. 3.55), PEF (6.79 vs.7.46), and variability (p < 0.001), and statistically significantly decreased BHR in Group A (2.01 vs. 1.75) (p < 0.001).

ScientificWorldJournal. 2007 Aug 17;7:1182-8.

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Question: Is acupuncture effective and safe in patient with persistent allergic rhinitis?

October 21st, 2007

Answer:

Findings suggest that acupuncture is effective in the symptomatic treatment of persistent allergic rhinitis.Expert investigated the effectiveness and safety of acupuncture in persistent allergic rhinitis (PAR). They did a randomised, single-blind, sham-controlled trial conducted from May 2004 to February 2005. 80 patients with PAR (age, 16-70 years) were randomly assigned to receive real or sham acupuncture. After a 1-week baseline period, participants were treated twice weekly for 8 weeks and followed up for another 12 weeks. Nasal obstruction, sneezing, rhinorrhoea and nasal itch were each self-assessed daily on a 5-point scale, and scores were aggregated weekly. The sum of the symptom scores (total nasal symptom score, TNSS) was also determined. A secondary outcome was use of PAR relief medication. After 8 weeks’ treatment, the weekly mean difference in TNSS from baseline was greater with real (-17.2; 95% CI, -24.6 to -9.8) than with sham acupuncture (-4.2; 95% CI, -11.0 to 2.7) (P = 0.01). The decrease in individual symptom score was also greater with real acupuncture for rhinorrhoea (P < 0.01) but not the other symptoms. At the end of follow-up, the greater difference in TNSS from baseline in the real acupuncture group was still apparent: real, -21.0 (95% CI, -29.1 to -12.9) versus sham, – 2.3 (95% CI, -10.2 to 5.6) (P = 0.001). Moreover, the differences from baseline in all four individual symptom scores were greater for the real than for the sham group (P < 0.05). Real and sham acupuncture were both well tolerated.

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Question: A 20 year-old patient presents with hypotension, wheezing, and urticaria 30 minutes after a bee sting. What is the appropriate treatment?

October 12th, 2007

Answer:

This patient’s presentation is that of systemic anaphylaxis. Anaphylaxis is an immediate hypersensitivity reaction caused by mast cell/basophil release of multiple potent mediators, including histamine, prostaglandins, and leukotrienes, into tissues and the circulation. Prompt treatment is critical, and therapy should be directed toward maintaining cardiovascular and pulmonary function. Initial treatment should be administration of epinephrine either by subcutaneous or intramuscular (IM) routes (0.3-0.5cc of a 1:1000 dilution). In the face of cardiovascular collapse, intravenous (IV) epinephrine may be indicated. Other immediate steps include applying a tourniquet proximal to the site of allergen inoculation (for example, a bee sting or allergen injection in the forearm). If the anaphylaxis is due to oral intake of an allergen (such as food ingestion), a nasogastric (NG) tube may be inserted and residual gastric contents removed to prevent further antigen absorption. The patient’s legs should be elevated, oxygen and airway support provided as needed, and IV fluids (such as normal saline) given for blood pressure support. Parenteral H1 (diphenhydramine) and H2 (Ranitidine) antihistamines may also be administered. Inhaled beta-1 agonists can be given prophylactically or if bronchospasm is present. Repeat doses of medication such as epinephrine should be given as needed and vasopressor agents given when indicated. Although steroids will not alter the acute course of anaphylaxis, they may be given to attenuate a subsequent late phase response. The aggressiveness of the above outlined therapy depends on the severity of the anaphylaxis and the response to treatment.

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Which class of medication should be used with particular caution in patients prone to develop anaphylaxis?

September 20th, 2007

Beta blockers should be avoided whenever possible, because they may accentuate the severity of anaphylaxis and prolong its cardiovascular and pulmonary manifestations. They may also markedly decrease the effectiveness of epinephrine in reversing the life-threatening manifestation of anaphylaxis

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What is the Chinese restaurant syndrome?

September 20th, 2007

It is a reaction to glutamate ingested as MSG (monosodium glutamate), a flavoring agent commonly used in Chinese cooking. It occurs within 15-30 minutes of ingestion and consists of a sensation of warmth and tightness on the face and anterior chest. It is  occasionally confused with angina pectoris, but is benign and requires no therapy except avoidance of foods cooked with MSG.

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What is the “innocent bystander” mechanism of drug-induced hemolysis?

September 5th, 2007

Some drugs (such as sulfonamides, phenothiazines, quinidine, and quinine) can cause an immune hemolytic anemia even though they do not bind to RBCs. These drugs, bound to plasma proteins, stimulate the formation of complement-fixing antibodies that activate the classical complement pathway. Generated C3b binds to the RBC, which leads to intravascular hemolysis of these”innocent bystanders“.

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