Andrew S. Nickels

Electronic cigarettes: navigating the vapor

Electronic cigarettes (e-Cigarettes) are novel nicotine delivery systems that have the potential to drastically change the landscape of nicotine addiction and tobacco use. Their increasing popularity has raised concerns that e-Cigarettes might undercut the gains associated with tobacco cessation efforts and limits on public use and advertising.1,2 Particularly worrisome is the increasing use of e-Cigarettes in youth. The goal of this piece is to (1) introduce the reader to e-Cigarettes, (2) describe safety concerns and the limited evidence supporting potential benefits, and (3) discuss pertinent regulatory issues. The authors conclude by suggesting proactive responses that medical professionals can take regarding this developing issue.

Absence of the thymic shadow in a neonate suspected of primary immunodeficiency: Not a straightforward clinical sign of immunodeficiency

A 33-week-old male presented with respiratory distress and fever after birth to a mother experiencing an acute diarrheal illness. Evaluation of the infant revealed Campylobacter jejunibacteremia. Thenewborn screen, collected at 30 hours of life, was positive for severe combined immunodeficiency (SCID). A chest radiograph on day 9 demonstrated an absence of the thymic shadow (Figure 1). Investigation of the immune system revealed normal TBNK cell subsets, CD4 recent thymic emigrants, and T-cell receptor excision circles, suggesting the newborn screen was a false positive. On reviewing a chest radiograph obtained at birth, the thymic shadow was clearly present (Figure 2; available at www.jpeds. com). The disappearance of the thymus was concluded to be attributable to acute stress from the infection. An essential secondary lymphoid organ, the thymus is the primary location of T-cell maturation. On neonatal chest radiography, the thymus appears as a widened mediastinum anterior to the cardiac silhouette and normal width is greater than the 2 times the width of the third thoracic vertebra. In most forms of SCID, the thymus is very small or absent, resulting in absence of a thymic shadow. Rare forms of

Uncertainty and the ethics of allergy care

At its inception, the field of allergy professed a commitment to the highest standards of professionalism as reflected in the original charter of the American College of Allergy, Asthma and Immunology (then the College of Allergy): “To maintain and advance the highest possible standards among those engaged in the practice of allergy” and “to perpetuate the best traditions of medicine and medical ethics.”1 Currently, medical ethics tends to focus on intense acute care at the extremes of life and less so on daily ambulatory care issues allergists face today.2 In this way, ethics seems distant to the national allergy dialogue or training. The allergy literature seems to support this assertion.3 In contrast, we argue that uncertainty is a rich primary focal point of medical ethics encountered by allergists and offers a relevant and timely contribution for our profession. Uncertainty is inherent in medicine, and the practice of allergy is no exception. When faced with uncertainty, the practitioner’s ability to mitigate its destabilizing effects is critical for optimal patient care. We use examples from allergy practice to demonstrate that understanding the ethics of uncertainty is a crucial dimension of the exemplary practice of medicine in allergy care.

Putting allergy/immunology into context: analysis of the 2012 US Medicare reimbursement data

[1] Wenzel SE. Asthma phenotypes: the evolution from clinical to molecular approaches. Nat Med. 2012;18:716e725. [2] Juel CT, Ulrik CS. Obesity and asthma: impact on severity, asthma control, and response to therapy. Respir Care. 2013;58:867e873. [3] Bennett WD, Hazucha MJ, Folinsbee LJ, et al. Acute pulmonary function response to ozone in young adults as a function of body mass index. Inhal Toxicol. 2007;19:1147e1154. [4] Shore SA, Rivera-Sanchez YM, Schwartzman IN, et al. Responses to ozone are increased in obese mice. J Appl Physiol. 2003;95:938e945. [5] Johnston RA, Theman TA, Lu FL, et al. Diet-induced obesity causes innate airway hyperresponsiveness to methacholine and enhances ozone-induced pulmonary inflammation. J Appl Physiol. 2008;104: 1727e1735. [6] Kim HY, Lee HJ, Chang YJ, et al. Interleukin-17eproducing innate lymphoid cells and the NLRP3 inflammasome facilitate obesity-associated airway hyperreactivity. Nat Med. 2014;20:54e61. [7] Wen H, Gris D, Lei Y, et al. Fatty acideinduced NLRP3-ASC inflammasome activation interferes with insulin signaling. Nat Immunol. 2011;12:408e415. [8] Hernandez M, Brickey WJ, Alexis N, et al. Airway cells from atopic asthmatic patients exposed to ozone display an enhanced innate immune gene profile. J Allergy Clin Immunol. 2012;129:259e261. [9] Celedon JC, Palmer LJ, Litonjua AA, et al. Body mass index and asthma in adults in families of subjects with asthma in Anqing, China. Am J Respir Crit Care Med. 2001;164:1835e1840.

Percutaneous and intradermal allergy skin test utilization in the United States 2012 Medicare population.

In April 2014, as part of efforts to make the health care system more transparent, affordable, and accountable, the Center for Medicare and Medicaid Services released individual physician reimbursement data for 2012. The Provider Utilization and Payment Data Physician and Other Supplier Public Use File (Physician and Other Supplier PUF) includes reimbursement data on 6000 different types of procedures and services paid to more than 880,000 health care providers. This data set includes statistics on Common Procedural Terminology Codes (CPT) (American Medical Association, Chicago, Ill) for percutaneous skin testing (CPT 95004) and intradermal skin testing (CPT 95024). We analyzed these data with the hopes of better understanding the landscape of allergy care in the United States, as well as to allow practicing allergists to compare their allergen testing practices with national and regional norms. The methodology and sources for the Physician and Other Supplier PUF data are published fully by the Center for Medicare and Medicaid Services. All providers with a valid National Provider Number who submitted claims for a service and/or procedure reimbursed 11 or more times to Medicare Part B during 2012 were included in the reports, which list provider specialty type, the number of procedures reimbursed, total number of Medicare beneficiaries per service per day, and average amount paid by Medicare per procedure for each provider. We used Microsoft Excel 2010 Version 10.2 (Microsoft Corp, Redmond, Wash) and JMP Version 10.0 (SAS Institute Inc, Cary, NC) for analysis. The average number of procedures per patient per visit was calculated by dividing the total number for reimbursements (“line_srvc_cnt”) by the total number of Medicare beneficiaries per day of service (“bene_day_srvc_cnt”) for that procedure. Cost information was calculated by multiplying each provider’s average amount paid by Medicare per procedure by the number of procedures reimbursed. Regional variation of allergy/immunology providers was investigated by categorizing providers into 5 different regions by using the regions set forth by the National Allergy Bureau (American Academy of Allergy, Asthma & Immunology). Hawaii, Puerto Rico, and Alaska were excluded due to the limited number of providers. In 2012, 7,072,942 percutaneous skin tests were reimbursed by Medicare at an average of

The Role of a Positive Exhaled Nitric Oxide in Evaluating the Pulmonary Patient: Exhaled Nitric Oxide Versus Methacholine Challenge?

5.00 per test to 3513 unique providers, which cost Medicare a projected

Exhaled Nitric Oxide Performance Compared To Methacholine Challenge In Asthma

35,591,070. Thirtyfour different provider types were reimbursed, with allergy/ immunology providers accounting for 63.2% (n1⁄4 2220). Otolaryngologists represented 16.0% (n 1⁄4 563); internal medicine, 7.3% (n 1⁄4 258); and family practice, 5.5% (n 1⁄4 194). Providers identified as nurse practitioners/physician assistants accounted for 2.2% (n 1⁄4 79). The remaining 5.7% (n 1⁄4 199) was ordered by a variety of other provider types. A total of 2127 providers, which represent 21 different provider types, were reimbursed an average of

Social Media and the Allergist: Evidence Supports Increasing Our Engagement

5.98 for 1,688,105 intradermal tests with allergen extracts (CPT Code 95024) to give a projected cost of

Newborn Screening for Severe Combined Immunodeficiency: Changing the Landscape of Pediatric Primary Immunodeficiencies.

10,664,532. Allergy/immunology providers accounted for 61.9% (n 1⁄4 1317), whereas otolaryngologists accounted for 27.2% (n 1⁄4 580), internal medicine for 3.4% (n 1⁄4 72), family practice for 1.6% (n 1⁄4 34), and nurse practitioners/physician assistants for 2.2% (n 1⁄4 47). A variety of other provider types account for the remaining 3.6% (n 1⁄4 77) (Figure 1). Overall, the average SD number of percutaneous skin tests per patient per service day performed was 46.6 16.7, and average SD intradermal skin tests per patient per service day was 18.1 10.8. Utilization of percutaneous and intradermal skin tests shows variation among provider types. For percutaneous skin testing, the average SD number of percutaneous skin tests reimbursed per patient per day of service by provider type is as follows: allergy/immunology 46.3 16.3, otolaryngology 39.6 15.4, internal medicine 54.1 16.0, family practice 54.5 12.9, nurse practitioners/physician assistant 50.9 19.8, and all others provider types 50.2 18.9. Intradermal testing utilization (average SD) by provider types reveals the following: allergy/immunology 16.7 8.5, otolaryngology 20.0 13.6, internal medicine 20.8 13.9, family practice 22.7 13.3, nurse practitioners/physician assistant 19.4 13.7, and all others provider types 19.5 10.9. With the focus solely on allergy/immunology providers, the regional variation of number of providers, averages, and percentiles of percutaneous and intradermal skin test utilization are given in Table I. Based on the information in the Physician and Other Supplier PUF, it appears that allergy/immunology providers administered the majority of percutaneous and intradermal skin testing reimbursed by Medicare in 2012. Otolaryngologists represent the second largest speciality that uses allergen skin testing. Generalists (internal medicine and family practice) were reimbursed for a small minority of allergen skin tests in 2012. Minor variation in utilization exists between provider types as well as regionally among allergists. The Physician and Other Supplier PUF provides novel insights into utilization of allergy skin testing in the Medicare population. A previous attempt to study skin test utilization among allergists by means of a survey-based study was limited by a low response rate (18%). The Physician and Other Supplier PUF represents a national cross-sectional view of health care utilization that is being actively analyzed by patient advocacy groups, insurance companies, and physician organizations.