Can immunotherapy in children prevent progression to asthma?

ABSTRACT:

“Purpose of Review: The purpose of this review is to describe the scientific evidence that specific immunotherapy can prevent the development of asthma in patients suffering from rhinoconjunctivitis as well as reduce the number of new allergies developing.

Recent Findings: Proposed strategies for the prevention of the development of allergic rhinoconjunctivitis and asthma include allergen avoidance, pharmacological treatment (antihistamines and steroids) and specific immunotherapy. Long-term follow-up on immunotherapy studies demonstrates that specific immunotherapy for 3 years shows persistent long-term effects on clinical symptoms after termination of treatment and long-term, preventive effects on later development of asthma in children with seasonal rhinoconjunctivitis. It is so far the only treatment for allergic diseases that has been shown to be able to prevent worsening of disease and development of asthma. Also, specific immunotherapy seems to reduce the development of new allergic sensitivities as measured by the skin prick test as well as specific IgE measurements.

Summary: Specific immunotherapy is the only treatment that interferes with the basic pathophysiological mechanisms of the allergic disease and thereby carries the potential for changes in the long-term prognosis of respiratory allergy. Specific immunotherapy should be recognized not only as first-line therapeutic treatment for allergic rhinoconjunctivitis, but also as secondary preventive treatment for respiratory allergic diseases.”

THE WITCH DOCTOR’S NOTES

The link between, rhinitis and asthma

80% of asthmatic patients have nasal symptoms.
40% of rhinitis patients reported coexisting asthma.
20% of rhinitis patients develop asthma in later life.
Many rhinitis patients have twitchy bronchi (BHR) out-with the pollen season and being sensitised to one allergen also increases the risk of being sensitised with more allergens over time.

The management of a patient with inhalant allergy should include:

1. Education of the patient
2. Avoidance of allergens
3. Elimination treatment
4. Treatment of symptoms
5. Allergen specific immunotherapy

Allergen Specific Immunotherapy

Suppresses the seasonal increase in eosinophilia.
Reduces late phase reactions.
Shift from Th2 to Th1 responses.

One study shows that 72% children treated with specific immunotherapy were asthma free compared with only 22% of SIT treated children. The follow-up was for 14 years. SIT was given for a period of 4 years with mixtures of allergens individualised. the best effects were seen in those children receiving the highest doses of allergen.

The tendency to non- specific twitchy airways was also reduced.

The Preventative Allergy Treatment (PAT) Study

First prospective study. Involved 208 children aged 6-14 with allergic conjuctivitis to birch or grass pollen.
SIT given for three years and then assessed for development of asthma.
Patients with known perennial or seasonal asthma were excluded but investigation demonstrated mild asthma during baseline pollen season, and more than a third had BHR measured by metacholine challenge.
The SIT treated group without baseline asthma had less asthma and BHR than controls.

Similar trend in study using sublingual immunotherapy (SLIT)

Evidence for The Prevention Of New Allergies

In 1961, it was shown that subcutaneous immunotherapy could decrease the risk of new sensitivities developing.
There have been subsequent studies since demonstrating highly signiican benefit.

Conclusion

“Long-term follow-up on immunotherapy studies demonstrates that SIT for 3 years with high doses of standardized allergen extracts shows persistent long-term effects on clinical symptoms after termination of treatment and long-term, preventive effects on later development of asthma in children with seasonal rhinoconjunctivitis. It is so far the only treatment for allergic diseases that has been shown to be able to prevent worsening of disease and development of asthma. In this light, SIT should be recognized not only as first-line therapeutic treatment for allergic rhinoconjunctivitis, but also as secondary preventive treatment for respiratory allergic diseases.”

TO OBTAIN THIS INFORMATION THE WITCH DOCTOR READ THE FOLLOWING

“How Strong is the Evidence That Immunotherapy in Children Prevents the Progression of Allergy and Asthma?”
Lars Jacobsen; Erkka Valovirta
Curr Opin Allergy Clin Immunol. 2007;7(6):556-560. ©2007 Lippincott Williams & Wilkins

PLEASE READ DISCLAIMER

Anaphylaxis during anaesthesia – how common?

INCIDENCE:

Two studies on the overall incidence of anaphylaxis during general anaesthetics was 1 in 4500 in the first study and 1 in 13,000 in the second.

The incidence of anaphylaxis to neuromuscular blocking agents was 1 in 6500.

The incidence appears to be increasing but it is unclear whether this is genuine or relates to increased awareness.

CONFIRMATION BY ALLERGY TESTING:

42% of 1648 patients with typical symptoms of anaphylaxis had positive allergy tests.
37% of 1648 patients with typical symptoms of anaphylaxis had negative allergy tests.
The remaining 21% of these patients were thought not to have anaphylaxis based on review of clinical features and negative allergy testing.

“A study in France that included 200,000 general anesthetic administrations found an incidence of anaphylaxis of 1 in 4500, with a mortality rate of 6% (Hatton, 1983; Levy, 1992). Another French epidemiological study conducted between 1994 and 1996 evaluated suspected anaphylactic reactions occurring during anesthesia. The overall incidence of reaction was 1 in 13,000 anesthetic administrations, while the incidence of anaphylaxis to neuromuscular blocking agents was 1 in 6500 anesthetic administrations. Of the 1648 patients studied, 692 demonstrated characteristic symptoms and positive allergy tests. In 611 patients, there were characteristic symptoms and negative allergy tests. In 345 patients, the anaphylactic reactions were thought to be due to other causes because of negative allergy tests and different clinical features (Laxenaire, 1999; Association of Anesthetists, 2003).

It has been suggested that the incidence of perioperative anaphylactic reactions has been increasing; however, this may be due to increased awareness and reporting of the condition (Levy, 1992, 1999). Reactions to drug additives/preservatives and muscle relaxants may be more frequently reported because these drugs are most often administered (Levy, 1992).

Estimation of the frequency of anaphylactic reactions during surgery is difficult for several reasons (Levy, 1999; Association of Anesthetists, 2003). First, multiple drugs with relatively high potential to cause adverse allergic and other reactions are administered in the perioperative setting. Most of the information regarding the incidence of anaphylaxis in the United States is from case reports and, to a lesser extent, retrospective studies, which introduces the issues of an unknown denominator and the methodological issues related to retrospective analyses. The relative propensity of a drug to produce an allergic reaction is therefore not reflected in these reports. Protamine is the only drug that has been studied in a relatively large series for the incidence of anaphylaxis (Levy, 1999).

Most patients do not know if they have a specific drug allergy due to occult exposure from prior hospitalizations or therapies; this is especially true in patients who have undergone surgery in the past, because they usually do not know what drugs were administered during the procedure. Patients and physicians may mistakenly refer to other predictable adverse drug effects (eg, gastrointestinal events) as being allergic reactions. It is difficult to establish a precise diagnosis of an allergic reaction or anaphylaxis in critically ill patients and in the perioperative setting because the major signs and symptoms of anaphylaxis are related to cardiopulmonary dysfunction, which can occur due to multiple factors.

PLEASE READ DISCLAIMER

Drug allergy – how common?

“Approximately 6% to 10% of all adverse drug reactions are due to allergic reactions, and the risk of an allergic reaction is approximately 1% to 3% for most drugs (Levy, 1999).

The risk of a perioperative anaphylactic reaction is approximately 1 in 2500 to 5000 patients (0.02% to 0.04%) (Levy, 1992, 1999).

It is estimated that 5% of adults in the United States are allergic to 1 or more drugs, and as many as 15% believe they may be or have been labeled as being allergic to 1 or more drugs. Allergic reactions are an important cause of adverse drug reactions, which are a major cause of morbidity and mortality worldwide. Adverse drug reactions are the most common iatrogenic illness, complicating 5% to 15% of therapeutic drug courses (Riedl, 2003). They are common in hospitalized patients, occurring in 6% to 15% of this population, and they are responsible for 3% to 6% of all hospital admissions and for more than 100,000 deaths each year in the United States.”

(Riedl, 2003; Lazarou, 1998; Einarson, 1993).

TO OBTAIN THS INFORMATION, The Witch Doctor read:

“Evaluation and Treatment of Hypersensitivity in Cardiac Surgery
Registration”

http://www.medscape.com/viewprogram/7684_pnt (23 of 24) [29/12/2007 18:37:50]

Menopause linked to increased risk of asthma

Previous research has suggested that the current or past use of estrogen hormone therapy can increase the risk for
incident adult-onset asthma.

The current study demonstrates that menopause is associated with reduced pulmonary function and an increased
frequency of respiratory tract symptoms. However, menopause did not affect the rates of COPD or chronic cough.

TO OBTAIN THS INFORMATION, The Witch Doctor read:

Adipokines

White adipose tissue does not just sit there doing nothing. It is biologically very active.

The key year for interest in fat was 1994 when the protein leptin was discovered. It was the product of a gene that was given the name “obese” better known by its nickname “ob”.

Since then, more than 50 molecules, many acting as cytokines have been identified as products of this hitherto “boring” tissue associated with obesity. Adiponectin, resistin, visfatin are the names of some of these other molecules.

TO OBTAIN THS INFORMATION, The Witch Doctor read:

“Adipokines As Emerging Mediators of Immune Response and Inflammation”
Francisca Lago, MD Carlos Dieguez, MD Juan Gómez-Reino, MD Oreste Gualillo, MD
Nat Clin Pract Rheumatol 3(12):716-724, 2007.
© 2007 Nature Publishing Group

Mid-Staffordshire : Response of Royal College of Physicians Edinburgh

Time to refocus the NHS on quality and dignity of patient care: RCPE response to Mid
Staffordshire

SENIOR CARE AND REVIEW

Many of the detailed recommendations also offer potential for improving standards, including the recommendation that ‘hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient’s case’. However, we believe this should not be a matter for local hospitals to consider and discount; instead this should be enshrined in national standards. The benefits of early senior review in reducing mortality, and of consultant-delivered care are clear and the requirement to have a named senior clinical lead responsible for individual patients could greatly assist efforts to improve continuity of care in increasingly fragmented clinical environments. Clearly, this will require moving towards a consultant presence seven days per week, over an extended working day, and this will have to be taken into account by workforce planners. The recent report from the Academy of Medical Royal Colleges and Faculties provides related standards which require to be implemented in the NHS.

Historically, the NHS has relied heavily on the goodwill and commitment of consultants to work well beyond their contracted hours. However, there is evidence that this ‘goodwill model’ is not sustainable.4 Doctors cannot be expected to absorb additional commitments ad infinitum while continuing to provide high quality patient care. This reality and the changing mood within the workforce, in which young doctors are increasingly choosing alternative career paths away from the medical specialties, must also be taken into account when planning what level of workforce will be required to provide high quality, safe patient care. In parallel, we must work to ensure that future generations of doctors are supported, do not become disengaged and less committed to delivering care and are prepared to work beyond hours as patients’ needs require.

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Lost in Care : The Waterhouse Report

LOST IN CARE

The general background to the Inquiry
“When announcing the Government’s decision to appoint this Tribunal, the Secretary of State for Wales referred to the fact that it had been known for several years that serious sexual and physical abuse of children had taken place in homes managed by the former Clwyd County Council in the 1970s and 1980s. The Secretary of State mentioned, in particular, an intensive investigation by North Wales Police begun in 1991, in which about 2,600 statements had been obtained from individuals and which had resulted in eight prosecutions and seven convictions of former care workers, but he said that, nevertheless, speculation had continued in North Wales that the actual abuse was on a much greater scale than the convictions themselves suggested.”

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House of Lords : HSCB – Hansard

HEALTH AND SOCIAL CARE BILL : TUESDAY 11 OCTOBER 2011

“Moved By Earl Howe

That the Bill be read a second time.

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe): My Lords, this is a Bill of profound importance for the quality and delivery of health and care in England, for patients and for all those who care for them. As such it has been, quite rightly, the subject of intense scrutiny, not only in another place, but also more widely. Indeed, the intensity of the spotlight directed at its content over the last few months is borne out by the number of your Lordships who wish to speak today and tomorrow. I look forward to the debate ahead of us.

In approaching this Bill, I believe it is instructive to look backwards to its roots as well as forward to what it seeks to achieve. In opposition, the two coalition parties asked themselves the same simple question: “How can we make the NHS better?”. In asking that question we were clear about several things. We were clear that the founding principles of the NHS-that it should be a comprehensive service, free at the point of use, regardless of ability to pay, and funded from general taxation-should remain sacrosanct. We were also clear that we should reject any system that discriminated between rich and poor. The NHS should aspire to the highest standards of service for all our citizens, but in seeking ways to make the health service better, it was necessary to identify the challenges that it faces. What are they?

The first, and most obvious, is rising demand for healthcare from a growing and ageing population and the increase in long-term conditions. The second is the rising expectations of patients about what should be on offer to them from a health service in the 21st century, including new drugs and technologies. The third is the financial challenge-the inexorably rising costs of providing services against an increasingly constrained budget.

Two key principles emerge from this analysis: the need for maximum efficiency in the way the health budget is spent; and the need to make the service patient-centred. For many years, politicians have spoken of the NHS as a patient-centred service, but how can a service be truly patient-centred if decisions about the treatments and pathways of care that are available to patients are taken at several removes from those who know best what the needs of patients are-namely, the patients themselves and the healthcare professionals who look after them?….”

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Future Forum : Response of RCOG to David Cameron

RCOG STATEMENT ON THE PM’s SPEECH ON THE LISTENING EXERCISE

“However, several key issues still remain.

These are:

In order for GP Commissioning Consortia to work, there needs to be a process involving service providers in the decision-making process since they have the front-line experience and knowledge of what services are needed in their respective specialties

There needs to be clearer explanation of the way in which competition in the NHS will work. While competition can be a spur to drive up quality and drive out inefficiencies, the extent of the private and charity sectors’ roles in the NHS need to be far better defined and delimited

There is real anxiety over workforce planning and the training and education of doctors in training, a critical factor in the future development of high-quality specialists. To be involved, ‘any qualified providers’ must provide training, subject to the same standards and conditions as NHS providers. These developments will have serious consequences on our medical workforce in the future.”

GOVERNMENT RESPONSE TO NHS FUTURE

My Black Cat is SCREECHING! Wonder why?

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Government Response to NHS Future Forum

GOVERNMENT RESPONSE TO NHS FUTURE FORUM

“The Government has announced that it accepts the core recommendations of the NHS Future Forum report and will make changes to its plans for modernisation of health and social care.

The key changes include:

Reaffirming that Ministers are accountable overall.

The original duty to promote a comprehensive health service will remain.”

My Black Cat is SCREECHING! Wonder why?

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LINK TO MY BLACK CAT’S INTERTWINGLEMENT BLOG (Updated 13 March 2011)

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