Ultrarush venom desensitization after systemic reactions during conventional venom immunotherapy.

BACKGROUND: Rush and ultrarush venom immunotherapy (VIT) protocols are safe and effective in patients with Hymenoptera hypersensitivity. However, these protocols have typically been used instead of conventional VIT and not in patients who have experienced adverse reactions during conventional VIT. To date, there are no reports of using an ultrarush VIT protocol to desensitize patients with a history of severe systemic reactions during conventional VIT. OBJECTIVE: To determine whether ultrarush VIT can be safely administered to a high-risk patient with a history of severe systemic reactions to conventional VIT. METHODS: Premedication with 40 mg of prednisone, 180 mg of fexofenadine, and 150 mg of ranitidine orally twice daily was initiated. The patient received VIT to mixed vespid and wasp in a medical intensive care unit via a 13-step buildup on day 1 followed by a 2-step buildup on day 2. Immunotherapy was begun with a dose of 0.005 microg of mixed vespid and 0.002 microg of wasp venom and achieved a total dose of 300 microg of mixed vespid and 100 microg of wasp venom. RESULTS: The patient tolerated the procedure with minimal adverse effects. She subsequently received maintenance dosing in the outpatient clinic weekly for 4 weeks and bimonthly for 8 weeks, and she continues monthly maintenance VIT. CONCLUSIONS: We report the first successful use of ultrarush VIT in a high-risk patient with a history of severe systemic reactions during conventional VIT. This protocol should be considered in patients with a history of allergy to vespids or wasps who require VIT but cannot reach a maintenance dose with conventional VIT owing to systemic reactions.

A practical approach to allergic rhinitis and sleep disturbance management.

Sleep quality can be significantly impacted by nasal congestion, a common symptom related to allergic rhinitis (AR). This may lead to decreased learning ability, productivity at work or school, and a reduced quality of life. A number of inflammatory cells and the release of inflammatory mediators lead to increased nasal congestion, causing disrupted sleep and subsequent daytime somnolence. Therefore, it is important to treat AR with medications that improve congestive symptoms without worsening sedation. Second-generation antihistamines and anticholinergic drugs are well tolerated but have little effect on congestion and therefore are limited in their ability to reduce AR-associated daytime somnolence. However, intranasal corticosteroids reduce congestion, improve sleep and sleep problems, and reduce daytime sleepiness, fatigue, and inflammation. Montelukast, a leukotriene receptor antagonist, has joined the approved therapies for AR. Montelukast significantly improves both daytime and nighttime symptoms. AR treatment should endeavor to improve daytime and nighttime symptoms, sleep, and productivity thereby improving quality of life.

The effect of intranasal steroid budesonide on the congestion-related sleep disturbance and daytime somnolence in patients with perennial allergic rhinitis.

Patients with perennial allergic rhinitis (PAR) often present with nasal congestion, poor sleep, daytime fatigue, and daytime somnolence. Pharmacologic therapy that reduces nasal congestion should improve the PAR patients' sleep quality and reduce daytime somnolence and fatigue. Our hypothesis is that intranasal steroid budesonide (BUD), an effective topical anti-inflammatory agent, will reduce nasal congestion and improve the patients' quality of life. The objective of this study was to determine whether topical steroid BUD improves sleep, daytime somnolence, and fatigue in patients with PAR. Twenty-six subjects were enrolled in a double-blind, placebo-controlled, crossover study using Balaam's design. Patients were treated with intranasal steroid spray BUD or placebo. The Epworth Sleepiness Scale, daily diary, and questionnaires were used as tools for subjective data analysis, which focused on nasal symptoms, sleep quality, daytime somnolence, and fatigue. The results were summarized and compared by PROC MIXED in SAS. The daily diary data showed significant improvement in self-reported nasal congestion (p = 0.04) and daytime sleepiness (p = 0.01) and a trend in reduction of daytime fatigue (p = 0.08) in the BUD group compared with the placebo group. The sleep measures showed statistically significant improvement in total sleep measures score (p = 0.04), "sleep compared with absolute" (p = 0.01), and "refreshing and restorative" sleep (p = 0.04) in the active group. Nasal corticosteroid BUD is effective in reducing nasal congestion, daytime somnolence, and daytime fatigue, and improving sleep quality in PAR.

Asthma and the diver.

Self-contained underwater breathing apparatus (scuba) diving has grown in popularity, with nearly 9 million sport divers in the United States alone. Approximately 7% of the population has been diagnosed with asthma, which is similar to the percentage of divers admitting they have asthma. Numerous concerns exist regarding subjects with asthma who choose to participate in recreational diving. Among these concerns are pulmonary barotrauma, pneumomediastinum, pneumothorax, arterial gas embolism, ear barotrauma, sinus barotrauma, and dental barotrauma. Despite these concerns, a paucity of information exists linking asthma to increased risk of diving complications. However, it has long been the norm to discourage individuals with asthma from participating in recreational scuba diving. This article examines the currently available literature to allow for a more informed decision regarding the possible risks associated with diving and asthma. It examines the underlying physiological principles associated with diving, including Henry's law and Boyle's law, to provide a more intimate understanding on physiological changes occurring in the respiratory system under compressive stress. Finally, this article offers a framework for guiding the patient with asthma who is interested in scuba diving. Under the right circumstances, the patient with asthma can safely participate in recreational diving without apparent increased risk of an asthma-related event.

Contemporary issues in food allergy: seafood toxin-induced disease in the differential diagnosis of allergic reactions.

Seafood, including fish, shrimp, lobster, crab, crayfish, mussel, and clam are among the most frequent causes of food allergy. Seafood poisoning, including reactions to natural toxins, frequently masquerades as an allergic reaction on presentation. Ingestion of contaminated shellfish results in a wide variety of symptoms, depending on the toxins present, their concentrations in the shellfish, and the amount of contaminated shellfish consumed. Five types of shellfish poisoning have been identified clearly including paralytic, neurotoxic, diarrhetic, amnestic, and azaspiracid shellfish poisonings. Based on the presence or absence of the toxin at the time of capture, fish poisoning can be considered conceptually in two categories. In ciguatera and puffer fish poisoning, the toxin is present in live fish, whereas in scombroid, it is produced only after capture, in the fish flesh, by contaminating bacteria because of improper refrigeration. Most shellfish-associated illness is infectious in nature (bacterial or viral), with the Norwalk virus accounting for most cases of gastroenteritis.