Evolution of Guidelines on Peanut Allergy and Peanut Introduction in Infants: A Review.

Importance: The reported prevalence of peanut allergy among children in the United States has increased more than 3-fold in the last 20 years. Medical guidelines on the introduction of peanut as well as other allergenic foods have evolved with the emerging evidence that an early introduction to these foods is more beneficial than a delayed introduction. This review highlights the studies that have led to the evolving guidelines on peanut introduction in infants. Observations: The prevalence of peanut allergy has increased despite the publication of guidelines from the American Academy of Pediatrics in 2000, which recommended a delayed introduction of peanut. Since the 2000 guidelines, studies have provided evidence to support an earlier rather than delayed introduction. As a result, the American Academy of Pediatrics updated their guidelines in 2008 to promote peanut introduction during infancy. Current evidence continues to support the benefits of an earlier rather than delayed introduction. Conclusions and Relevance: Over the years, guidelines on the introduction of peanut have evolved, and recent literature suggests that an earlier rather than delayed introduction is beneficial to prevent peanut allergies in infants.

Possible association of lower rate of postherpetic neuralgia in patients on anti-tumor necrosis factor-α.

Recently, a study of patients with rheumatoid arthritis who developed herpes zoster while taking a tumor necrosis factor (TNF)-α inhibitor reported a decreased incidence of postherpetic neuralgia. The objective of this study was to investigate whether patients on TNF-α inhibitors who developed herpes zoster have a lower incidence of subsequent development of postherpetic neuralgia. A retrospective review of herpes zoster patients on TNF-α inhibitors (infliximab, etanercept, or adalimumab) was conducted in 12 dermatology clinics. Medical records of such patients were reviewed thoroughly to confirm herpes zoster and TNF-α inhibitors and any subsequent development of postherpetic neuralgia (pain score ≥ 3 out of 10 after 90 days of shingles onset) was noted. A total of 206 cases were reviewed, of which only 2 cases (<1%) developed postherpetic neuralgia, a considerably lower incidence rate than noted in the literature. Increasing age is a known risk factor in the development of postherpetic neuralgia. However, of the 58 (28.1%) cases ≥ 70 years of age, only 1 patient (1.7%) developed neuralgia compared to approximately 50% of patients who develop postherpetic neuralgia in this age group as reported in the literature. Treatment with TNF-α inhibitors may be associated with a lower incidence of postherpetic neuralgia but further prospective large-scale studies are needed to confirm this data.

Infliximab treatment for psoriasis in 120 patients on therapy for a minimum of one year: a review.

Infliximab is a chimeric monoclonal antibody, which acts by binding to both the soluble and membrane-bound tumor necrosis factor-?. In clinical practice, it is used as either monotherapy or in combination with other systemic therapies, particularly methotrexate. This study reviews clinical response and adverse events in 120 psoriasis patients with moderate-to-severe psoriasis who have received infliximab for a minimum of one year. The medical records of 120 infliximab-treated psoriasis patients at our referral psoriasis clinic in Dallas between 2002-2008 were reviewed for response rates, side effects and concomitant therapies. Of 120 charts reviewed, 112 (93%) patients had plaque type psoriasis, six (5%) had recalcitrant palmoplantar disease and two (1.6%) had severe acropustulosis of Hallopeau. Eighty-four (70%) patients had symptomatic psoriatic arthritis. The mean follow-up time was 2.2±1.1 years. One hundred and nine (91%) of the 120 patients had clearance of their psoriasis (response of more than 90% of initial BSA) at a median time of 12 weeks. Concomitant systemic treatments, primarily methotrexate, were given to 62 (52%) patients. Nineteen patients (16%) discontinued infliximab in the post-one-year treatment period for a variety of reasons, primarily failure to maintain adequate response. One hundred and four (87%) of patients required more than the standard dose of 5 mg/kg every eight weeks to maintain clearance. Infliximab either as monotherapy or in combination with traditional antipsoriatic agents is an effective and well-tolerated treatment option for patients with moderate to severe psoriasis and psoriatic arthritis on therapy for over one year and continuing for the long term.

Lymphoma and immunosuppression: a report of a case associated with efalizumab therapy.

Lymphomas have been associated with immunodeficiency disorders, including those acquired secondary to the use of immunosuppressants for autoimmune disorders and for the prevention of graft rejection. Biologic agents have also been associated with the development of lymphoproliferative disorders. We report the case of Epstein-Barr Virus- negative diffuse large B-cell lymphoma associated with efalizumab, a monoclonal antibody that inhibits T-cell activity. Discontinuation of efalizumab resulted in a partial remission of lymphoma, although administration of chemotherapy was ultimately required. The use of immunomodulators must be tempered with the knowledge of their effect on the immune system and their association with lymphoproliferative disorders.

Atypical presentation of histoplasmosis in a patient with psoriasis and psoriatic arthritis on infliximab therapy.

Infliximab is a chimeric monoclonal antibody to TNF-alpha which acts on both the soluble and transmembrane forms of TNF-alpha. It has been used successfully for the treatment of psoriasis and psoriatic arthritis, rheumatoid arthritis, Crohn's disease and ankylosing spondylitis either as monotherapy or in combination with drugs such as methotrexate. To date, over 20,440 patients with moderate-to-severe psoriasis have been treated with infliximab worldwide. Opportunistic infections and reactivation of underlying latent infections are an area of concern with the use of infliximab particularly when used in conjunction with other immunosuppresants. The authors report a case of histoplasmosis presenting with signs of severe hypercalcemia and renal failure in a patient on infliximab for approximately three years in combination with low dosages of methotrexate and prednisone. This report stresses the importance of maintaining a high index of suspicion for unusual pathogens while managing patients receiving TNF-alpha inhibitors, particularly when used in combination with other immunosuppressants. In addition, the authors emphasize the role of a multi-disciplinary approach and appropriate coordination among caregivers.

Topical treatment of psoriasis.

Topical therapy forms the cornerstone in the management of psoriasis. Of significant value as monotherapy in mild to moderate psoriasis, it is used predominantly as adjunctive therapy in moderate and severe forms of the disease. Over the past decade, topical treatment of psoriasis has evolved from the age-old applications of tar and dithranol to the more acceptable and efficacious options of topical corticosteroids, retinoids and vitamin D analogues, with the advent of a wide range of appropriately tailored vehicles and sophisticated delivery modes. To ensure therapeutic success, proper patient education about the disease, the treatment options, their specific application modality and adverse effects is essential. This will help alleviate the common problem of poor patient adherence, and inevitably result in more optimal clinical outcomes.

Hirsutism in Kashmir: an etiological study.

BACKGROUND: Hirsutism refers to the presence of terminal hairs at the body sites under androgenic control. Various factors, including genetic makeup and hormonal status, influence the rate and pattern of hair growth at these sites. PURPOSE: To study the pattern of hirsutism in Kashmir. MATERIALS AND METHODS: Thirty five consecutive patients of hirsutism were included in the study. After detailed history taking, physical examination and relevant investigations, scoring of hirsutism was done using the Ferriman Gallwey (FG) scoring system. FINDINGS: The FG score ranged from 10-34. Twenty patients had associated menstrual abnormalities. Polycystic ovarian syndrome (PCOS) was diagnosed in four patients, hypothyroidism in two and congenital adrenal hyperplasia (CAH) in one. The rest of the patients had idiopathic hirsutism. CONCLUSION: Idiopathic hirsutism was the most common category, whilst PCOS, hypothyroidism and CAH were also seen.