Jonathan S. Tam

Systematic Review of Nutrient Intake and Growth in Children with Multiple IgE-Mediated Food Allergies

BACKGROUND Food allergies affect up to 8% of American children. The current recommended treatment for food allergies is strict elimination of the allergens from the diet. Dietary elimination of nutrient-dense foods may result in inadequate nutrient intake and impaired growth. The purpose of this review was to critically analyze available research on the effect of an elimination diet on nutrient intake and growth in children with multiple food allergies. METHODS A systematic review of the literature was conducted and a workgroup was established to critically analyze each relevant article. The findings were summarized and a conclusion was generated. RESULTS Six studies were analyzed. One study found that children with food allergies are more likely to be malnourished than children without food allergies. Three studies found that children with multiple food allergies were shorter than children with 1 food allergy. Four studies assessed nutrient intake of children with multiple food allergies, but the inclusion and comparison criteria were different in each of the studies and the findings were conflicting. One study found that children with food allergies who did not receive nutrition counseling were more likely to have inadequate intake of calcium and vitamin D. CONCLUSION Children with multiple food allergies have a higher risk of impaired growth and may have a higher risk of inadequate nutrient intake than children without food allergies. Until more research is available, we recommend monitoring of nutrition and growth of children with multiple food allergies to prevent possible nutrient deficiencies and to optimize growth.

Screening for severe combined immunodeficiency in neonates

Severe combined immunodeficiency (SCID) is a rare disease that severely affects the cellular and humoral immune systems. Patients with SCID present with recurrent or severe infections and often with chronic diarrhea and failure to thrive. The disease is uniformly fatal, making early diagnosis essential. Definitive treatment is hematopoietic stem cell transplantation, with best outcomes prior to 3.5 months of age. Newborn screening for SCID using the T-cell receptor excision circle assay has revolutionized early identification of infants with SCID or severe T-cell lymphopenia.

Common variable immunodeficiency.

Common variable immunodeficiency (CVID) is a common primary immunodeficiency characterized by a failure in B-cell differentiation with defective immunoglobulin production. Affected patients are uniquely susceptible to recurrent infection with encapsulated organisms and have an increased propensity for the development of inflammatory and autoimmune manifestations. The diagnosis of CVID is commonly delayed and the underlying cause of the disorder is not understood. Replacement antibody therapy reduces the risk of serious infections. However, optimal treatment regimens for the uncommon manifestations associated with this disease, such as granulomatous lymphocytic interstitial lung disease, require further research.

Cutaneous Manifestation of Food Allergy

Hypersensitivity reactions to foods can have diverse and highly variable manifestations. Cutaneous reactions, such as acute urticaria and angioedema, are among the most common manifestations of food allergy. However, cutaneous manifestations of food allergy encompass more than just IgE-mediated processes and include atopic dermatitis, contact dermatitis, and even dermatitis herpetiformis. These cutaneous manifestations provide an opportunity to better understand the diversity of adverse immunologic responses to food and the interconnected pathways that produce them.

The Role of Skin Barrier in the Pathogenesis of Food Allergy

Food allergy is a serious public health problem with an increasing prevalence. Current management is limited to food avoidance and emergency treatment. Research into the pathogenesis of food allergy has helped to shape our understanding of how patients become sensitized to an allergen. Classically, food sensitization was thought to occur through the gastrointestinal tract, but alternative routes of sensitization are being explored, specifically through the skin. Damaged skin barrier may play a crucial role in the development of food sensitization. Better understanding of how patients initially become sensitized may help lead to the development of a safe and effective treatment for food allergies or better prevention strategies.

Benefits of subspecialty adherence after asthma hospitalization and patient perceived barriers to care

BACKGROUND Comparative studies have demonstrated that asthma education to pediatric patients decreases average hospital usage and that allergy specialists provide stronger asthma education and more improved outcomes. OBJECTIVE To evaluate the real-world benefits of allergy subspecialty involvement outside inpatient consultation and the impediments for patients in establishing allergy subspecialty care. METHODS The study population was composed mostly of minority children 0 to 18 years old seen at a large university-affiliated stand-alone childrens hospital who had a hospital discharge diagnosis of asthma from 2009 to 2013. The retrospective portion of the study compared all variables pertaining to asthma, teaching, and discharge reconciliation for the following subgroups: patients recommended to allergy and immunology (AI) follow-up who adhered to the appointment (adherent), patients recommended to AI follow-up who did not adhere (nonadherent), and patients not recommended to AI follow-up (non-referred). In the phone interview portion of the study, the nonadherent patients were contacted to identify barriers to AI follow-up. RESULTS Of the referred sample, the adherent group had significantly fewer visits to the pediatric intensive care unit, days in the pediatric intensive care unit, and days in the hospital. Providing more specific hospital discharge instructions increased AI follow-up and hospital teaching given on the baseline admission decreased hospital visits. Phone interviews showed that nonadherent patients most commonly missed follow-up because the parents believed it unnecessary because their child showed acute improvement or from advice from their primary care physician. CONCLUSION These results showed improvement in outcomes for patients who attended AI follow-up and specifically identified key barriers that could be addressed in a standardized form to prevent nonadherence in the future.

Disseminated Mycobacterium kansasii Disease in Complete DiGeorge Syndrome

PurposeComplete DiGeorge syndrome (cDGS) describes a subset of patients with DiGeorge syndrome that have thymic aplasia, and thus are at risk for severe opportunistic infections. Patients with cDGS and mycobacterial infection have not previously been described. We present this case to illustrate that patients with cDGS are at risk for nontuberculous mycobacterial infections and to discuss further antimicrobial prophylaxis prior to thymic transplantation.MethodsA 13-month old male was identified as T cell deficient by the T cell receptor excision circle (TREC) assay on newborn screening, and was subsequently confirmed to have cDGS. He presented with fever and cough, and was treated for chronic aspiration pneumonia as well as Pneumocystis jirovecii infection without significant improvement. It was only after biopsy of mediastinal lymph nodes seen on CT that the diagnosis of disseminated Mycobacterium kansasii was made. We reviewed the literature regarding atypical mycobacterial infections and prophylaxis used in other immunocompromised patients, as well as the current data regarding cDGS detection through TREC newborn screening.ResultsMultiple cases of cDGS have been diagnosed via TREC newborn screening, however this is the first patient with cDGS and disseminated mycobacterial infection to be reported in literature. Thymic transplantation is the definitive treatment of choice for cDGS. Prophylaxis with either clarithromycin or azithromycin has been shown to reduce mycobacterial infections in children with advanced human immunodeficiency virus infection.ConclusionsChildren with cDGS should receive thymic transplantion as soon as possible, but prior to this are at risk for nontuberculous mycobacterial infections. Severe, opportunistic infections may require invasive testing for diagnosis in patients with cDGS. Antimicrobial prophylaxis should be considered to prevent disseminated mycobacterial infection in these patients.

Dendritic Cells, Viruses, and the Development of Atopic Disease

Dendritic cells are important residents of the lung environment. They have been associated with asthma and other inflammatory diseases of the airways. In addition to their antigen-presenting functions, dendritic cells have the ability to modulate the lung environment to promote atopic disease. While it has long been known that respiratory viral infections associate with the development and exacerbation of atopic diseases, the exact mechanisms have been unclear. Recent studies have begun to show the critical importance of the dendritic cell in this process. This paper focuses on these data demonstrating how different populations of dendritic cells are capable of bridging the adaptive and innate immune systems, ultimately leading to the translation of viral illness into atopic disease.

Increased Survival Time With SS-31 After Prolonged Cardiac Arrest in Rats

BACKGROUND Cardiac arrest is one of the leading causes of death with a very high mortality rate. No therapeutic drug that can be administered during resuscitation has been reported. Mitochondrial dysfunction is believed to play an important role for the pathogenesis of cardiac arrest. SS-31, a tetra-peptide, has been shown to protect mitochondria from ischaemia/reperfusion injury. Therefore, we tested whether SS-31 improves rat survival after prolonged cardiac arrest. METHODS Rats were randomised into two groups. After 25minutes of asphyxia-induced cardiac arrest, rats were resuscitated with or without SS-31 using cardiopulmonary bypass resuscitation. Rat survival was followed for additional 4.5hours using haemodynamic monitoring. The blood gas was analysed for surviving rats at multiple time points. RESULTS AND CONCLUSIONS After 5hours, 5 of 10 rats survived in the SS-31 group whereas only 1 of 10 rats survived in the control group (p=0.026). At 90minutes after resuscitation, the blood lactate level in the SS-31 treated rats (4.29±2.5mmol/L) was significantly lower than in control rats (7.36±3.1mmol/L, p=0.026), suggesting mitochondrial aerobic respiration was improved with SS-31 treatment. Overall, our data show the potential of SS-31 as a novel therapeutic in cardiac arrest.

Evaluation of vomiting and regurgitation in the infant.

INSTRUCTIONS Credit can now be obtained, free for a limited time, by reading the review article in this issue and completing all activity components. Please note the instructions listed below: ● Review the target audience, learning objectives, and all disclosures. ● Complete the pre-test online at http://www.annallergy.org (click on the CME heading). ● Follow the online instructions to read the full version of the article, including the clinical vignette; reflect on all content as to how it may be applicable to your practice. ● Complete the post-test/evaluation and claim credit earned; at this time, youwill have earned up to 1.0 AMA PRA Category 1 Credit. Please note that the minimum passing score on the post-test is 70%. ● Approximately 4-6 weeks later you will receive an online assessment regarding your application of this article to your practice. Once you have completed this assessment, you will be eligible to receive MOC Part II credit from the American Board of Allergy and Immunology. Release Date: January 1, 2012 Expiration Date: December 31, 2013 Estimated Time to Complete: 60 minutes Target Audience: Physicians involved in providing patient care in the field of allergy/asthma/immunology Learning Objectives: At the conclusion of this activity, participants should be able to: ● Demonstrate knowledge of the diseases that are the major causes of food intolerance in infants ● Discuss the diagnostic tests that are best used to evaluate an infant with food intolerance Accreditation: The American College of Allergy, Asthma & Immunology (ACAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Designation: The American College of Allergy, Asthma & Immunology (ACAAI) designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Planning Committee Members: Jonathan S. Tam, MD (Sr. Author) Mitchell H. Grayson, MD (Author/Associate Editor) Gailen D. Marshall, Jr, MD, PhD (Editor-in-Chief) Disclosure of Relevant Financial Relationships: M.H. Grayson has received research support from the National Institutes of Health (NIH). J.S. Tam and G.D. Marshall have nothing to disclose. No unapproved/investigative use of a product/device is discussed. Recognition of Commercial Support: This activity has not received external commercial support. Copyright Statement: Copyright 2011-2013 ACAAI. All rights reserved. CME Inquiries: Contact the American College of Allergy, Asthma & Immunology at education@acaai.org or 847-427-1200.