Joint Task Force Algorithm and Annotations for Diagnosis and Management of Rhinitis.

The algorithm and text annotations in this document are intended to assist clinical decision making about patients who present with symptoms of rhinitis. This document complements the Executive Summary of Joint Task Force Practice Parameters for Diagnosis and Management of Rhinitis (Ann Allergy, Asthma, Immunol 1998; 81:463-468) and Diagnosis and Management of Rhinitis: Complete Guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology (Ann Allergy, Asthma, Immunol 1998;81:478-578). The Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology is co-sponsored by the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council of Allergy, Asthma and Immunology.

Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology.

This document contains complete guidelines for diagnosis and management of rhinitis developed by the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology and the Joint Council on Allergy, Asthma and Immunology. The guidelines are comprehensive and begin with statements on clinical characteristics and diagnosis of different forms of rhinitis (allergic, non-allergic, occupational rhinitis, hormonal rhinitis [pregnancy and hypothyroidism], drug-induced rhinitis, rhinitis from food ingestion), and other conditions that may be confused with rhinitis. Recommendations on patient evaluation discuss appropriate use of history, physical examination, and diagnostic testing, as well as unproven or inappropriate techniques that should not be used. Parameters on management include use of environmental control measures, pharmacologic therapy including recently introduced therapies and allergen immunotherapy. Because of the risks to patients and society from sedation and performance impairment caused by first generation antihistamines, second generation antihistamines that reduce or eliminate these side effects should usually be considered before first generation antihistamines for the treatment of allergic rhinitis. The document emphasizes the importance of rhinitis management for comorbid conditions (asthma, sinusitis, otitis media). Guidelines are also presented on special considerations in patients subsets (children, the elderly, pregnancy, athletes and patients with rhinitis medicamentosa); and when consultation with an allergist-immunologist should be considered.

Cystic fibrosis and neuroblastoma.

Two cases of coexistent cystic fibrosis and infantile thoracic neuroblastoma are presented. In one patient, neuroblastoma was congenital, and diagnosis of cystic fibrosis was made at 3 months of age; in the other, the diagnosis of cystic fibrosis was made at 7 months of age, preceding that of neuroblastoma by 4 months. In both infants, surgical resection of the tumors have been successful. Recent advances in the genetic aspects of neuroblastoma, including translocation and activation of the oncogene N-myc, are discussed. Current recombinant DNA technology, which can identify translocation of N-myc and allow localization of the cystic fibrosis gene if the translocation occurs near the cystic fibrosis allele, is being applied to these cases.

Allergy to semisynthetic penicillins in cystic fibrosis.

Allergic reactions to anti-Pseudomonal penicillin derivatives are an increasing problem in therapy of cystic fibrosis lung disease. We evaluated 15 patients, ages 12 to 37 years, with documented allergic reactions to carbenicillin, ticarcillin, or piperacillin. Intradermal skin test reactions were positive for benzylpenicillin in seven patients, penicilloyl-polylysine in one, and ticarcillin or piperacillin in eight, for a total of 11 of 11 tested. Results of radioallergosorbent testing to penicilloyl conjugates were positive in eight of 14 patients and equivocal in four others. Overall, skin tests or RAST results were positive in 13 of 15 patients. All patients were desensitized with a semisynthetic penicillin by continuous serial intravenous infusion of 10-fold dose increments, beginning with 10(-6) of the therapeutic dose. Desensitization was successful in 25 of 26 instances. After intravenously administered therapy, maintenance of desensitization with dicloxacillin orally was unsuccessful in four of six patients. We conclude that (1) allergy to semisynthetic penicillins in cystic fibrosis usually is IgE mediated; (2) such allergy can be evaluated by skin testing; (3) it can be safely and in most cases successfully treated by intravenous desensitization; and (4) allergic patients should be desensitized on each subsequent admission for intravenously administered therapy.

Reduction of interference by specific IgG with a modified microtiter solid-phase radioimmunoassay to measure honeybee venom IgE.

By means of monoclonal mouse anti-human IgE antibody, the microtiter solid-phase radioimmunoassay (MSPRIA) was modified to measure honeybee venom (HBV) IgE. HBV IgG was measured by MSPRIA(G) using affinity column purified goat anti-human IgG antibody and correlated with results obtained with staphylococcal protein A-SPRIA. Nonlinear specific IgE dilution curves were associated with high HBV IgG content. By serial transfer and assay of the supernatant, the interference of IgE by specific IgG could be reduced. The degree of interference was correlated with the specific IgG content. The principle of serial supernatant transfer and assay was applied to the standardization of reference HBV IgE serum, and the quantitation of HBV IgE contents in patients and controls. HBV IgE levels in patients allergic to honeybee stings correlated with the skin-test endpoint titrations. While 75% of the allergic patients were skin-test positive, 83% of them were IgE positive by the MSPRIA and 67% were IgE positive by the RAST.

Honey bee venom specific immunoglobulin G4 in honey bee sting allergic patients and bee keepers.

Honey bee venom (HBV) IgG4 antibody was studied in bee keepers and honey bee sting allergic patients on immunotherapy using mouse monoclonal anti-human IgG4 antibody in a modified microtiter solid phase radioimmunoassay (MSPIRA). The mean HBV IgG4 in bee keepers was 31 units/ml. In patients the mean HBV IgG4 pre- and post-immunotherapy were 2.9 and 11.6 units/ml, respectively, representing a mean rise of 7.3-fold as compared to a rise of 1.6-fold for total HBV IgG. The mean HBV IgG level in bee keepers was 14 micrograms/ml which was not significantly different from the mean level of 17 micrograms/ml in allergic patients at diagnosis. The percentage interference of HBV IgE detection in vitro correlated with HBV IgG but not with HBV IgG4. On the other hand, there was an inverse relationship between serum HBV IgE and HBV IgG4 levels while none was found for HBV IgE and IgG.

Does hyperimmunoglobulinemia-E protect tropical populations from allergic disease?

The Waorani Indians of eastern Ecuador have the highest blood concentration of IgE reported in a human population. Evidence obtained by medical history, physical examination, and immediate hypersensitivity skin tests suggests that pollen allergy and other atopic diseases are rare among the Waorani. A similar association between parasite-induced hyperimmunoglobulinemia-E and a low prevalence of conventional atopic disease has been reported in numerous other tropical populations. Saturation of mast cell IgE receptors with antibodies directed to the parasite and/or other antigens and competitive inhibition of passive binding of pollen allergen-specific IgE is one hypothetical cause of this association. We have tested this interesting conjecture by passively sensitizing the skin of Waorani Indians with serum containing pollen allergen-specific IgE antibodies. Waorani Indians with hyperimmunoglobulinemia-E can be adoptively sensitized with human ragweed or rye grass hyperimmune IgE antisera. This suggests that the cutaneous mast cells of healthy Waorani have active IgE receptors. The high circulating plasma concentrations of IgE in the Waorani do not prevent adoptive cutaneous sensitization with pollen-specific IgE antibodies.

Measurement of hypothetical burnout in cystic fibrosis caregivers.

Three hypothetical phases of staff burnout were measured in a population of cystic fibrosis caregivers and a control population from other areas of specialty pediatrics. The cystic fibrosis caregivers displayed a higher level of emotional exhaustion, lower level of patient depersonalization, and an equal sense of personal accomplishment from the job compared to the controls. We conclude that hypothetical staff burnout can be measured and postulate that these values can be used to quantitate the outcome of anti-burnout programs.

Binding of 125I-labeled proteinases to plasma proteins in cystic fibrosis.

Samples of plasma or serum from 53 cystic fibrosis (CF) patients, 90 relatives of CF patients , and 159 controls have been incubated with porcine or bovine 125I-trypsin, electrophoresed on polyacrylamide gel, and autoradiographed. In these individuals, the main binding protein for 125I-trypsin has been shown to be alpha 2-macroglobulin (alpha 2M). Using this method of analysis, no difference in electrophoretic migration of 125I-trypsin-alpha 2M complexes has been observed between CF and control individuals. However, trypsin binding to IgG has been observed in 80% of CF patients, 30% of their mothers, 3% of controls, and in two patients affected with pancreatitis. These trypsin binding immunoglobulins are called TbIg, and specifically, Tb1gG when referring to the G class. Experimental evidence indicates that binding of trypsin to IgG occurs through the Fab portion of the molecule. Tb1gG must be antibodies most probably induced by the exogenous trypsin ingested daily by most CF patients (and by patients affected with chronic pancreatitis). Antibodies against porcine pancreatic elastase have been observed using the same analysis, but not as frequently as Tb1g.

Antimicrobial susceptibilities of rough, smooth, and mucoid colony types of Pseudomonas isolated from cystic fibrosis patients.

Minimal inhibitory concentrations of carbenicillin, chloramphenicol, tetracycline, gentamicin, tobramycin, and trimethoprim-sulfamethoxazole were determined for rough, smooth, and mucoid Pseudomonas sp. isolates from sputa collected from 40 cystic fibrosis patients. Ninety-four percent of the minimal inhibitory concentrations obtained by using mixed inocula of colonies of different morphological types fell within one serial dilution of the most resistant minimal inhibitory concentration obtained when each colony type was tested separately.