Comparison of systemic reactions in rush, cluster, and standard-build aeroallergen immunotherapy.

BACKGROUND: Given the choice of standard, cluster, and rush build-up for aeroallergen immunotherapy, standard-build immunotherapy has generally been preferred because of a perceived high rate of systemic reactions (SRs) associated with cluster and rush immunotherapy. OBJECTIVE: To characterize the incidence of SRs during standard, cluster, and rush build-up immunotherapy in an allergy practice during a 5-year period. METHODS: A retrospective review was conducted among patients receiving standard-build, 8- to 10-step cluster, or 2-day rush immunotherapy from January 1, 2010, through December 31, 2014, at Family Allergy & Asthma clinics in Louisville, Kentucky. Investigators excluded reactions that occurred during skin prick testing, venom immunotherapy, and not-true SRs, and identified the build-up method, age, sex, date of reaction, vial concentration, and presence of asthma. Per-shot and per-patient incidence of SRs was computed from these data. RESULTS: During our review period, 2,549,643 injections were administered to 11,982 patients. Per-shot incidence of SR was 0.01%, 0.06%, and 0.33% for standard, cluster, and rush immunotherapy, respectively; per-patient incidence of SR was 2.84%, 2.52%, and 11.86% for standard, cluster, and rush immunotherapy, respectively. A total of 42% of SRs were grade 1, 43% were grade 2, 12% were grade 3, and 3% were grade 4. No fatalities were reported. A total of 70% of total SRs, 75% of cluster SR, and 55% of rush SR occurred in females, with an emergent peak in SR from May to October. CONCLUSION: Compared with previously published rates, we observed a decrease in the incidence of SR for standard, cluster, and rush immunotherapy, with peak seasonality from May to October and a female predominance.

Portable spirometry in the deployed setting.

Recent studies suggest an increased risk of respiratory complaints associated with deployment. The objective measurement of lung function provided by portable spirometry is likely to improve the ability of military providers to diagnose and treat lung disease. A portable spirometer was taken to southern Afghanistan on a recent deployment and used at both a level I aid station and a level II medical facility, which were colocated on a forward operating base in the Kandahar Province. In addition to being helpful managing asthma, the spirometer also facilitated identification of nonobstructive causes of dyspnea. The following cases provide proof of concept that portable spirometry can add to the limited armamentarium of military providers practicing in the austere deployment environment.

Hymenoptera of Afghanistan and the central command area of operations: assessing the threat to deployed U.S. service members with insect venom hypersensitivity.

Insect venom hypersensitivity can pose a threat to personnel deployed to a combat zone but the exposure risk in Afghanistan is currently unknown. This study was designed to assess the threat of Hymenoptera stings and associated allergic reactions in Afghanistan. Hymenoptera species were collected during a deployment to southern Afghanistan from June 2010 through January 2011. The literature was also reviewed to determine species of medically important Hymenoptera recorded in the region. The U.S. Army theater electronic medical data system was mined for ICD-9 codes associated with insect stings to determine the number of theater medical clinic encounters addressing insect sting reactions. Three species of flying hymenoptera were commonly encountered during the study period: Vespa orientalis L., Polistes wattii Cameron, and Vespula germanica (F.). A literature review also confirms the presence of honeybees (Apidae), numerous velvet ant (Mutillidae) species, and various ant (Formicidae) species all capable of stinging. No evidence was identified to suggest that fire ants (Solenopsis ssp.) are a threat in the region. Based on electronic medical records from the U.S. Central Command area of operations over a 2-year period, roughly 1 in 500 clinic visits involved a patient with a diagnosis of insect bite or sting. Cross-reactive members of all five flying Hymenoptera species commonly assessed for in Hymenoptera allergy evaluations are present in Afghanistan. The review of in-theater medical records confirms that insect stings pose an environmental threat to deployed service members.

The autoimmune lymphoproliferative syndrome: A rare disorder providing clues about normal tolerance.

The autoimmune lymphoproliferative syndrome (ALPS) is characterized by chronic, non-malignant lymphoproliferation, autoimmunity often manifesting as multilineage cytopenias, and an increased risk of lymphoma. While considered a rare disease, there are currently over 250 patients with ALPS being followed at the National Institutes of Health in Bethesda, Maryland. Most of these patients have a mutation in the gene for the TNF receptor-family member Fas (CD 95, Apo-1), and about one-third have an unknown defect or mutations affecting function of other signaling proteins involved in the apoptotic pathway. While ALPS is one of the few autoimmune diseases with a known genetic defect, there remain unanswered questions regarding how a defect in apoptosis results in the observed phenotype. In addition to shedding light on the pathophysiology of this rare and fascinating condition, studying ALPS may improve our understanding of normal tolerance and more common, sporadic autoimmune disorders.

Applying principles of physics to the airway to help explain the relationship between asthma and gastroesophageal reflux.

Gastroesophageal reflux (GER) and asthma have been linked, but the true nature of this relationship is incompletely understood. Most of the literature examining this association has implicated GER as the factor contributing to asthma. GER has also been linked to conditions of the upper airway like sinusitis and obstructive sleep apnea (OSA), and once again, usually presumed to be the causative factor. While GER seems to be capable of exacerbating airway disease, mounting evidence suggests that airway obstruction is a risk factor for developing GER. This article examines the principles of physics that predict what should occur given the anatomy of the airway and the esophagus, and provides multiple examples of disease associations that appear to support the hypothesis that airway obstruction is a significant risk factor for development of gastroesophageal reflux.