Michael S. Kaplan

Section on allergy and immunology

Founded in 1948, the Section on Allergy and Immunology is dedicated to ensuring that children receive the highest quality of allergy and immunology care. To accomplish its mission, the Section provides a number of educational, training, and research programs and continually advocates for improved allergy and immunology care and services. The Section sponsors educational programs for both pediatric generalists and subspecialists at the American Academy of Pediatrics (AAP) National Conference and Exhibition (NCE) each fall and at the American Academy of Allergy Asthma & Immunology annual meeting each spring. The Section’s other educational endeavors include this annual “Best Articles Relevant to Pediatric Allergy and Immunology” supplement to Pediatrics, Visiting Professor Program, Pediatric Asthma Speaker’s Kit, online continuing medical education course on “asthma gadgets,” electronic quality improvement in practice program on asthma diagnosis and management (Education in Quality Improvement for Pediatric Practice [eQIPP], which meets the American Board of Pediatrics maintenance-ofcertification criteria), school nurse allergy tool kit, and a number of public education materials. The Section is also active in contributing to educational programs and resources such as AAP News, educational brochures, clinical reports, and many other endeavors. To support training and promote research in pediatric allergy and immunology, the Section awards travel grants to residents and training fellows to participate and present cases at the AAP NCE and provides outstanding abstract awards for training fellows and junior faculty for presentation at the American Academy of Allergy Asthma & Immunology annual meeting. In close collaboration with other subspecialty societies, the Section is actively involved with initiatives to improve subspecialty education such as the American Board of Allergy and Immunology maintenance-of-certification requirements. Section members represent the AAP in national and government conferences and provide input on federal legislation on behalf of the AAP. For more information on all AAP allergy and immunology resources and initiatives, visit www.aap.org/sections/allergy. The reviews contained in the 2011 synopsis were written by Fellows of the AAP Section on Allergy and Immunology and fellows in allergy and immunology training programs who contributed reviews with their mentors. The editor selected the journals to be reviewed on the basis of the likelihood that they would contain articles on allergy and immunology that would be of value and interest to the pediatrician. Each journal was assigned to a voluntary reviewer who was responsible for selecting articles and writing reviews of their articles. Only articles of original research were selected for review. Final selection of the articles to be included was made by the editor. The 2010–2011 journals chosen for review were Allergy, American Journal of Asthma & Allergy for Pediatricians, Archives of Pediatric and Adolescent Medicine, American Journal of Medicine, American Journal of Respiratory and Critical Care Medicine, Annals of Allergy, Asthma, and Immunology, Annals of Internal Medicine, Archives of Disease in Childhood, Archives of Internal Medicine, Blood, British Journal of Dermatology, British Medical Journal, Chest, Clinical and Experimental Allergy, Clinical Pharmacology and Therapeutics, Critical Care Medicine, European Journal of Pediatrics, European Respiratory Journal, Immunology, Journal of Allergy and Clinical Immunology, Journal of the American Academy of Dermatology, Journal of the American Medical Association, Journal of Applied Physiology, Journal of Experimental Medicine, Journal of Immunology, Journal of Infectious Diseases, Journal of Pediatric Gastroenterology and Nutrition, Journal of Pediatrics, Journal of Pharmacology and Experimental Therapeutics, Lancet, Nature, New England Journal of Medicine, Pediatrics, Medicine, Pediatric Allergy and Immunology, Pediatric Asthma, Allergy & Immunology, Pediatric Dermatology, Pediatric Infectious Disease Journal, and Science. The editor and the Section on Allergy and Immunology gratefully acknowledge the work of the reviewers and their trainees who assisted. The reviewers were Stuart L. Abramson, MD, PhD, Sugar Land, TX; James R. Banks, MD, Arnold, MD; Theresa A. Bingemann, MD, Rochester,

Phytohemagglutinin (PHA) skin test in the diagnosis of cellular immunodeficiency

Abstract Phytohemagglutinin (PHA) is a nonspecific activator of lymphocytes and is of value in the in vivo and in vitro assessment of cellular immunity. One hundred and four subjects were skin tested with an intradermal injection of 1 μg of PHA. Ninety-one of 94 subjects with no apparent cellular immunodeficiency gave a positive response at 24 hours, including 5 patients with antibody deficiency but normal cellular immunity. There was a correlation between the in vivo and in vitro response to PHA in 22 of 23 normals tested. Four of 10 patients with cellular immunodeficiencies had no response to a 1 μg PHA skin test; in addition, the mean response for this group was significantly reduced when compared to normals. Five of 10 patients in the cellular immunodeficiency group gave positive skin tests in the presence of an abnormal in vitro response. The PHA skin test is a simple and useful screening test for cellular immune function and is of particular value in infants and young children since it does not require prior sensitization.

Immunologic Reconstitution in Severe Combined Immunodeficiency without Bone-Marrow Chromosomal Chimerism

Abstract An 11-month-old male infant with severe combined immunodeficiency was immunologically reconstituted by bone-marrow transplantation from a female sibling whose cells were HL-A compatible on...

Association of exhaled nitric oxide to asthma burden in asthmatics on inhaled corticosteroids.

Background. Fractional exhaled nitric oxide (FENO) is a marker of airway inflammation. Its role in assessing asthma burden in clinical practice needs more study. Objective. To determine whether higher FENO levels are associated with greater asthma burden. Methods. This was a multicenter cross-sectional retrospective study of atopic 12- to 56-year-old persistent asthmatics on inhaled corticosteroids (ICS). Questionnaire and 1-year retrospective administrative data were used to analyze by unadjusted and adjusted robust Poisson regression (relative risks) and negative binomial regression [incidence rate ratios (IRRs)] the associations of masked FENO levels (NIOX MINO®) to short-acting beta-agonist (SABA) dispensings and oral corticosteroid (OCS) use in the past year independent of spirometry and an asthma control tool [Asthma Control Test (ACT)]. Results. FENO levels ranged from 7–215ppb (median 28ppb) in 325 patients. Higher FENO levels significantly correlated with more SABA dispensings and OCS courses in the past year, lower FEV1% predicted levels, but not ACT score. FENO highest (≥48ppb) versus lowest (≤19ppb) quartile values were associated independently in the past year with ≥7 SABA canisters dispensed (relative risk=2.40, 95% CI=1.25–4.62) and total number of SABA canisters dispensed (IRR=1.46, 95% CI=1.12–1.99) and with ≥1 OCS course (relative risk=1.48, 95% CI=1.06-2.07) and total number of OCS courses (IRR=1.71, 95% CI=1.09–2.66). The significant independent relationship of higher FENO levels to increasing SABA dispensings and OCS courses was confirmed by linear trend analyses. Conclusions. Independent and clinically meaningful associations between higher FENO levels and greater asthma burden during a prior year in persistent asthmatics on ICS suggest that FENO measurement may be a complementary tool to help clinicians assess asthma burden.

EFFECT OF CONJUGATE PNEUMOCOCCAL VACCINE FOLLOWED BY POLYSACCHARIDE PNEUMOCOCCAL VACCINE ON RECURRENT ACUTE OTITIS MEDIA: A RANDOMIZED STUDY

Veenhoven R, Bogaert D, Uiterwaal C, et al. Lancet . 2003;361:2189–2195 To determine whether pneumococcal conjugate vaccine can prevent acute otitis media (AOM) among older children who have experienced previous episodes of AOM. A total of 383 children (1–7 years of age) with ≥2 episodes of AOM in the year before study entry were studied. Children recruited from a Netherlands general hospital and tertiary care hospital were randomized to receive either 7-valent pneumococcal conjugate vaccine followed by 23-valent pneumococcal polysaccharide …

Optimal skin prick wheal size for diagnosis of cat allergy

BACKGROUND The skin prick test is the diagnostic procedure of choice for determination of immediate hypersensitivity. A wheal diameter of 3 mm or larger is generally accepted as the cutoff for a positive test result, although the validity of this assumption has not been rigorously demonstrated. OBJECTIVE To determine the skin prick wheal size that best identifies clinical allergy to cat. METHODS Forty-five patients referred for evaluation of rhinoconjunctivitis underwent determination of atopic status by skin testing using the Greer Dermapik device and a combination of other modalities, including history, in vitro determination of specific IgE level, and nasal challenge with standardized cat pelt extract. Parameters evaluated before and after nasal challenge included symptom score and nasal lavage tryptase and prostaglandin D (PGD2) levels. RESULTS The widely accepted 3-mm wheal for a positive skin test result to cat is highly sensitive but only moderately specific for diagnosis of cat allergy as evaluated by history, specific IgE level, postchallenge symptom score, and tryptase and PGD2 levels. Optimal cutoffs for a positive skin test result to cat based on receiver operating characteristic analysis and 95% positive predictive value were 5.5 mm or greater for each of these parameters. When a true-positive result for cat allergy was defined as a combination of positive history, specific IgE level, postchallenge symptom score, and tryptase and PGD2 levels and a true-negative result as all of these parameters being negative, a 6-mm cutoff was able to distinguish cat allergic from cat nonallergic individuals. CONCLUSION In a potentially allergic population undergoing skin prick testing with the Greer Dermapik using standardized extracts, a 3-mm skin prick wheal will overestimate the presence of cat allergy. A 6-mm wheal appears to distinguish those individuals who are cat allergic from those who are not.

Outcomes from a Medical Weight Loss Program: Primary Care Clinics Versus Weight Loss Clinics

BACKGROUND Few studies have focused on weight loss programs implemented in community-based primary care settings. The objective of this analysis was to evaluate the effectiveness of a weight loss program and determine whether physicians in primary care practices could achieve reductions in body weight and body fat similar to those obtained in weight loss clinics. METHODS Analyses were performed on chart review data from 413 obese participants who underwent weight loss at a primary care (n=234) or weight loss (n=179) clinic. Participants received physician-guided behavioral modification sessions and self-selected a diet plan partially or fully supplemented by meal replacements. A repeated-measures analysis of covariance was conducted with age and sex serving as covariates; significance was set at P≤.05. RESULTS In 178 subjects (43%) completing 12 weeks of the program, primary care clinics were as effective as weight loss clinics at achieving reductions in body weight (12.4 vs 12.1 kg) but better with regard to reduction in body fat percentage (3.8% vs 2.7%; P≤.05). Regardless of location, participants completing 12 weeks lost an average of 11.1% of their body weight. Participants selecting full meal replacement had greater reductions in weight and body fat percentage (12.7 kg, 3.5%) compared with participants selecting a partial meal replacement plan (8.3 kg, 2.3%). CONCLUSION Primary care physicians can successfully manage and treat obese patients using behavioral modification techniques coupled with meal replacement diets.

Non-asthmatic respiratory symptomatology.

Because of the common nature of asthma and the attention this disease has been given in recent years, it is important to consider the possibility of other disorders that may present in a similar manner to asthma. Failure to consider alternative diagnoses often leads to inappropriate treatment with medications such as systemic corticosteroids that result in untoward morbidity. This review will discuss several diseases originating not only in the tracheobronchial tree but also in extrapulmonary sites, such as the gastrointestinal tract, that may be mistakenly diagnosed as asthma. Newly described entities such as irritant vocal cord dysfunction and exercise-induced hyperventilation syndrome are discussed in this article, as is new information pertaining to well-established diseases such as Churg-Strauss syndrome and sarcoidosis.

The importance of appropriate challenges in diagnosing food sensitivity

Two patients with clinically significant immunoglobulin E (IgE) mediated reactions to cows milk which occur only under special circumstances are described. Although double‐blind, placebo‐controlled food challenges or open food challenges are generally very helpful, certain patients who react only under special circumstances might be missed when these office tests are used. The two reported incidences occurred in older children who seemed to outgrow their cow‐milk allergy but still had clinically significant allergic reactions under certain circumstances.

Immunodeficiency and Infections in Ataxia-Telangiectasia

Nowak-Wegrzyn A, Crawford TO, Winkelstein JA, Carson KA, Lederman HM. J Pediatr . 2004;144:505–511 To describe immunodeficiency in ataxia-telangiectasia (A-T) and its clinical manifestations and course. Patients with A-T who underwent multidisciplinary assessment at Johns Hopkins Hospital (Baltimore, MD). Charts from the first 100 consecutive patients with A-T who were assessed at Johns Hopkins Ataxia-Telangiectasia Clinical Center were reviewed. Specific criteria …