Bret R. Haymore

Correlation between eosinophilic oesophagitis and aeroallergens.

Aliment Pharmacol Ther 31, 509–515

Risk of angioedema with angiotensin receptor blockers in patients with prior angioedema associated with angiotensin-converting enzyme inhibitors: a meta-analysis.

BACKGROUND Patients who have angioedema after taking angiotensin-converting enzyme inhibitors (ACE-Is) have been reported to develop angioedema when taking an angiotensin receptor blocker (ARB), but few studies quantify the risk. OBJECTIVE To perform a systematic review of the literature. METHODS A literature search was performed in MEDLINE, EMBASE, BIOSIS, and Current Contents, with no limitations from January 1990 to May 2007. Any article that described a cohort of patients who had angioedema after taking an ACE-I, were subsequently exposed to an ARB, and were followed for a least 1 month were included. The percentage of patients who had angioedema was abstracted from each article, and confidence intervals were calculated using the exact binomial method. The pooled percentage was calculated with the inverse variance method. RESULTS Two-hundred fifty-four unique articles were identified, and 3 articles met inclusion criteria, which described 71 patients with the outcome of interest. One was a randomized controlled trial and 2 were retrospective cohorts. These articles described both confirmed and possible cases of angioedema. The risk of angioedema was 9.4% (95% confidence interval, 1.6%-17%) for possible cases and 3.5% (95% confidence interval, 0.0%-9.2%) for confirmed cases. No fatal events were reported. No statistical heterogeneity was reported between trials (P > .3). CONCLUSIONS Limited evidence suggests that for patients who develop angioedema when taking an ACE-I, the risk of development of any subsequent angioedema when taking an ARB is between 2% and 17%; for confirmed angioedema, the risk is 0% to 9.2%. This information will aid clinicians in counseling patients regarding therapy options after development of angioedema due to ACE-Is.

Common variable immune deficiency (CVID) presenting as an autoimmune disease: role of memory B cells

Common variable immunodeficiency (CVID) is a clinically heterogeneous disorder. Most often patients present with recurrent sinopulmonary infections, although it may present with autoimmune manifestations. Immune cytopenias, particularly thrombocytopenia and hemolytic anemia, are the most commonly observed. While the pathophysiology of CVID remains elusive, in many patients it may be due to an intrinsic B cell defect. Memory B cells (CD27+) in particular, have been noted to correlate with certain aspects of the disease. High numbers of IgM+ memory B cells appear to correlate with the presence of infections, whereas decreased numbers of switched memory B cells correlate with lower serum IgG levels and increased rates of autoimmune features. Because of these defects in the memory B cell compartment, there is a greater potential risk for infection and related complications. Review of the literature suggests that splenectomy should be avoided in patients with immune cytopenia and CVID and that serum immunoglobulins should be obtained in patients presenting with immune cytopenias to screen for CVID.

Effect of allergen immunotherapy practice parameters on cat extract prescribing patterns, 1993-2009.

BACKGROUND Cat extract allergen immunotherapy (AIT) is an effective treatment for cat allergy. The prescribed dose for cat AIT varies among prescribers, despite published data supporting an effective dose range. The original practice parameter published in December 1996 did not recommend a dose of cat allergen, but updates in January 2003 and September 2007 recommend cat extract dose ranges of 2,000 to 3,000 BAU and 1,000 to 4,000 BAU, respectively. OBJECTIVE To describe the prescribing patterns for cat AIT among practicing allergists in a large health care system and the effect of practice parameters on these patterns. METHODS A total of 27,788 prescriptions were analyzed to determine the date and amount of maintenance dose cat allergen prescribed. The data were subdivided into periods before and after the 3 published AIT practice parameters. RESULTS From January 2003 to September 2007, 1,810 prescriptions (18.0%) were written in the recommended range. From September 2007 to May 2009, 3,143 prescriptions (82.6%) were written in the recommended range. Cat AIT maintenance doses were 1,000 to 4,000 BAU 22.1% of the time before January 2003, 61.8% from January 2003 to September 2007, and 82.6% from September 2007 to May 2009. CONCLUSIONS In this large systemic evaluation of cat AIT prescribing patterns, maintenance dose recommendations in the AIT practice parameters were associated with changes in the prescribing patterns for cat AIT. Most prescriptions for cat AIT were inconsistent with recommended doses in the AIT practice parameters between 2003 and 2007. Dosing within recommended ranges improved after 2007, in part due to a widening of the recommended dose range.

Imported fire ant immunotherapy prescribing patterns in a large health care system during a 17-year period.

BACKGROUND No large evaluation has been performed of the maintenance vial concentration commonly used by physicians when prescribing imported fire ant (IFA) immunotherapy since the publication of the first Stinging Insect Hypersensitivity Practice Parameter 10 years ago. OBJECTIVE To describe the prescribing patterns for IFA immunotherapy among practicing allergists in a large health care setting and the impact of published Practice Parameter recommendations. METHODS Data from the US Army Centralized Allergen Extract Laboratory were analyzed to determine IFA immunotherapy prescribing patterns from 1990 to May 2007. This extract laboratory provides prescriptions for more than 320 US Department of Defense, US Department of Veterans Affairs, and US Public Health Service clinics. RESULTS A total of 1,091 patients were given 1,437 new or revised prescriptions for IFA immunotherapy. Monotherapy for Solenopsis invicta and Solenopsis richteri was prescribed in 169 (11.8%) and 3 (0.1%) instances, respectively, with the remainder of patients given both IFA antigens. The most commonly prescribed maintenance vial dose was 0.5 mL of a 1:200 (wt/vol) dilution, accounting for 36.3% of prescriptions. A total of 17.3% of prescriptions had a maintenance vial dose of 0.5 mL of a 1:100 (wt/vol) dilution, 4.6% had a dilution of 1:10 (wt/vol), and 50.6% had a dilution between 1:10 and 1:100 (wt/vol). The mean starting dose was 4.4 10-fold dilutions below the maintenance dose (5.4 vials per treatment set). CONCLUSIONS The most commonly prescribed maintenance dose was 0.5 mL of a 1:200 (wt/vol) dilution, although most prescriptions used a maintenance dose consistent with recommended dosing in the Stinging Insect Practice Parameters. Both IFA antigens were used by most physicians. Further study evaluating the effective dose range for IFA immunotherapy is needed.

S1857 The Correlation Between Eosinophilic Esophagitis and Aeroallergens

for each feature). EE patients also had significantly higher epithelial scores (mean of 7.33 as compared to 0.52 in GERD, p<0.001) and higher LP maximum scores (mean 4.5 versus 1 in GERD, p<0.001). Epithelial histologic features correlated well with endoscopic features of furrows/thickening, plaques, and pallor (r=0.62-0.82, p<0.001 for each) while LP scores correlated best with the endoscopic feature of thickening/furrows (r=0.64, p=0.002). Symptom complaints of dysphagia + anorexia/early satiety correlated best with epithelial scores (r=0.32, p=0.01); dysphagia correlated best with LP scores (r=0.45, p=0.04). None of the other symptoms assessed correlated with histologic or endoscopic findings. Conclusion: EE patients have significantly more severe endoscopic and histologic changes as compared with GERD patients. The objective endoscopic and epithelial/LP histologic features correlate well with one another. However, of subjective complaints, only dysphagia and anorexia/early satiety correlate with histologic and endoscopic findings.

Loss-of-Function Variations Within the Filaggrin Gene Predispose for Atopic Dermatitis With Allergic Sensitizations

Weidinger S, Illig T, Baurecht H, et al. J Allergy Clin Immunol. 2006;118:214–219 PURPOSE OF THE STUDY. Evaluation for genetic basis for impaired epidermal skin barrier in atopic dermatitis (AD). STUDY POPULATION. White German families with AD (N = 476). METHODS. Evaluation of the association of the loss-of-function mutations Arg501Xaa and 2282del4 within the filaggrin (FLG) gene by using the transmission-disequilibrium test. RESULTS. This study revealed prominent associations between the 2 loss-of-function FLG mutations and AD, as previously observed in a traditional Mendelian linkage analysis and case-control cohort analysis approach. In addition, an association of the FLG mutations was made in particular with the extrinsic subtype of AD, which is characterized by high total serum immunoglobulin E levels and concomitant allergic sensitization. Furthermore, FLG mutations were significantly associated with palmar hyperlinearity in patients with AD, which represents a shared feature of AD and ichthyosis vulgaris. CONCLUSIONS. These data implicate FLG as the first strong genetic factor identified in a common complex disease. REVIEWER COMMENTS. These findings confirm the importance of FLG as a genetic factor in AD as found by other investigators. This is the strongest genetic evidence to date to identify a cause of the breakdown of the epidermal barrier in AD. Filaggrin may be the “mortar” that is essential within the “bricks” of keratinocytes to maintain the integrity of the epithelial barrier. These findings further support the crucial role of the skin barrier in preventing allergic sensitization.