Extrapolating Evidence-Based Medicine of AIT Into Clinical Practice in the United States.

Allergy/immunology specialists in the United States prescribing allergy immunotherapy (AIT) have placed a heavy value on practical experience and anecdotal evidence rather than research-based evidence. With the extensive research on AIT conducted in the last few decades, the time has come to better implement evidence-based medicine (EBM) for AIT. The goal of this review was to critically assess EBM for debated concepts in US AIT practice for respiratory allergies in the context and quality of today's regulatory standards. Debated topics reviewed were the efficacy and safety of AIT in various subgroups (eg, polyallergic patients, older patients, patients with asthma, and pregnant women), diagnosis topics (eg, skin prick test vs allergen-specific serum IgE, factors affecting skin prick tests, use of nasal or conjunctival allergen challenges, and telemedicine for diagnosis), and dosing topics (eg, optimal dosing for subcutaneous immunotherapy and sublingual immunotherapy tablets, US liquid allergen extract history, duration of treatment, and biomarkers of efficacy). In addition, EBM for patient-centered AIT issues (eg, adherence, use of practice guidelines, and pharmacoeconomics) and the approach to implementation of AIT EBM in future clinical practice were addressed. The EBM for each concept was briefly summarized, and when possible, a practical, concise recommendation was given.

A 48-year-old female with perioperative anaphylaxis.

Identifying the culprit medication in cases of perioperative anaphylaxis can be extremely challenging. A detailed and accurate history, coupled with the appropriate testing, plays a key role in discovering the etiology of perioperative anaphylaxis. We present the case of a 48-year-old woman with a cranial meningioma who was scheduled for surgery. Chlorhexidine, midazolam, lidocaine, propofol, fentanyl, rocuronium, and furosemide were administered during the perioperative period. She developed hypotension, urticaria, bronchospasm, and other symptoms of anaphylaxis soon after general anesthesia. The serum tryptase level obtained during anaphylaxis was 119 ng/mL (normal, <11.4 ng/mL). Epinephrine was administered, and the surgery was canceled, with no cause identified. For the next surgical attempt, she was pretreated with diphenhydramine and ranitidine, and the neuromuscular blocker was withheld. Again, she developed hypotension consistent with anaphylaxis, and epinephrine was administered. She was referred for consultation. A detailed and accurate history was obtained. The baseline serum tryptase level was 6.4 ng/mL. Skin-prick puncture tests were completed, and a diagnosis was made. The surgical team was instructed to avoid the culprit medication, and the cranial surgery was successful. Although difficult, cases of perioperative anaphylaxis can be solved with a detailed history, keen detective work, and appropriate testing.

A Practical Approach to Assist Asthmatics to Lose Weight.

Treating patients with obesity, particularly asthmatics, is a complex challenge that requires a unique and individually tailored approach. Obesity, defined by the Centers for Disease Control and Prevention, is a body mass index of 30.0 kg/m2 or greater. It affects approximately 43% of adults and 19% of youth in America. It is a multifactorial disease and should be managed with the same intensity as any other medical problem, for it represents a risk factor for the onset and severity of asthma. Furthermore, it is a comorbid condition that exacerbates rhinosinusitis, gastroesophageal reflux disease, obstructive sleep apnea, hypertension, anxiety, and depression. Being obese also increases morbidity for cardio/cerebrovascular diseases, metabolic syndrome, type 2 diabetes, breast and bladder cancer, and migraines. Osteoarthritis, in particular, of the knees and hips, is also associated with obesity, and that too will complicate asthma by hindering a subject's mobility and ability to exercise. This paper reviews the epidemiology and pathophysiology of obesity, its effect on asthma, and practical strategies to achieve weight loss.