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Childhood respiratory illness increases adult mortality risk
Childhood history of bronchitis, pneumonia, or asthma is associated with higher respiratory disease mortality in adulthood, according to a longitudinal study in the UK. Scientists at the University of Bristol followed a cohort of men who attended Glasgow University from 1948 to 1968 whose medical history had been obtained during university health examinations. Among 9,544 students in the original cohort, 1,553 had died by 2001. A childhood history of bronchitis, pneumonia, or asthma was associated with a 57-percent-higher risk of respiratory disease mortality in adulthood.  

Report: New products threaten efforts to reduce US tobacco use
A report recently issued by a US public health organization coalition says an insidious new generation of tobacco products is threatening efforts to reduce tobacco use in the United States. The report describes tobacco manufacturers taking advantage of lax government regulations to design and market products that target children, create and sustain nicotine addiction, and discourage current users from quitting. The coalition is urging Congress to pass pending legislation granting the U.S. Food and Drug Administration authority to regulate tobacco products and their marketing. 

Group to suggest interstate physician licensing
A special committee of the National Governors Association, the State Alliance for E-Health, plans to recommend to US governors that states create a physician licensure system that works uniformly across state lines and permits open physician and patient interaction. The committee recently adopted the recommendation, which it says, "should not be considered a national license." The recommendation is set to go to governors within a few weeks. 

Scottish rugby player cleared after positive drug test from asthma medicine
Scott MacLeod, 28, a Scotland rugby forward, recently was cleared by an independent judicial committee after testing positive for terbutaline in January. Terbutaline is normally prohibited by the World Anti-Doping Code unless a therapeutic use exemption has been obtained in advance. MacLeod had previously obtained an exemption for terbutaline, but had switched to dalbutamol, during the 2006 declaration period. "I actually specified at the time I gave the urine sample that I was taking Bricanyl, so it was quite a shock," MacLeod said. "I've had asthma since I was a toddler and I've never left the house without an inhaler since the age of five. I definitely couldn't play sports without having one on me at all times.” 

A message from ACAAI President Dr. Jay M. Portnoy

All in a day’s work.

The well-trained allergy nurse cautiously inserts a syringe containing a carefully prepared mixture of pollen extracts into a teenage patient who has asthma and allergic rhinitis. After pulling back on the syringe to check for blood backflow, the fluid is slowly injected into the patient’s arm. Almost immediately the young woman describes a sensation of itching at the injection site and on her face and trunk. You are notified and asked what to do. How do you respond?

This common scenario plays itself out across the country every day, yet the answer is anything but simple. The cautious thing to do would be to immediately give the patient an injection of epinephrine. Perhaps some of it could be given at the site of the injection to slow absorption and the rest could be given intramuscularly in another location. On the other hand, this may not be necessary if the itching is mild, easily controlled with antihistamines and the patient otherwise is feeling well. A discussion about issues like this took place recently at a meeting of the Joint Taskforce on Practice Parameters.

Taskforce meetings generally consist of an animated give-and-take among a group of individuals who have been appointed by the ACAAI, the AAAAI and JCAAI to represent their organizations in the development of a series of consensus documents known as allergy practice parameters. To ensure that the resulting documents are fair and unbiased, a large number of reviewers are asked to provide input, and the parameters are placed in draft form on a number of Web sites for comment by the entire allergy community. Support by industry routinely is declined to remove any appearance of conflict. The final documents undergo further vetting by the editors either of the Journal of Allergy and Clinical Immunology or Annals of Allergy, Asthma & Immunology.

Should you call 911 as soon as a systemic reaction is identified or wait until a second dose of epinephrine has been administered? What about IV fluids? When should they be administered? “If you inject patients with epinephrine too quickly, they might not want to continue getting allergy shots” says one member of the taskforce. “On the other hand, deaths from anaphylaxis are more common when epinephrine administration is delayed,” replies another member. “You have to use clinical judgment in these cases,” pipes in an expert advisor and workgroup chair over the telephone. “Should 911 be called right away or should you wait to see if it is necessary?” asks yet another taskforce member. “If we state that 911 should be called too soon, physicians whose judgment leads them to wait will be at increased risk of liability if there is a bad outcome, so we have to leave the recommendations a little vague,” advises one of the taskforce co-chairs.

The boundary between being too prescriptive and too vague with recommendations is a narrow one to be sure. The difficulty is compounded by the fact that there rarely is sufficient evidence in the medical literature to support one opinion over another. Most references simply cite earlier references that cite earlier ones until a purely opinionated recommendation is found to have been made by an “expert” based on no evidence at all. That, after all, is how much of medical mythology gets its start. How would one even design a study to determine the best way to proceed in situations like the one described above?

Admittedly, some of the practice parameters are lengthy and complex, but then that is how medical practice is. Different scenarios need to be considered and suggestions provided for dealing with each one. For example, should adjustments be made to immunotherapy if a patient has a dime-sized local reaction as opposed to a “palm-sized” one? What is the risk of a subsequent reaction and would dose adjustments change those risks? Or consider whether you would inject epinephrine into a patient who develops a single hive near the site of an immunotherapy injection. What if the patient had a hive on a different extremity or if there were 5 or more hives? How big would they need to be? Would the previous history of reactions change those responses? Would you even do the same thing in the same situation on different days?

Medicine is often described as an art. That is true when you consider that we often go with our gut feelings when responding to emergency situations. We have to because the science is simply not there. Fortunately, the Joint Taskforce spends time debating the various nuances of these situations so that their conclusions can be made available to the wider allergy community. This is not cookbook medicine. Think of it instead as a palette of carefully chosen colors that can be combined into a beautiful tapestry of patient care and healing relationships. The results will not always be the same, but a beautiful creation will emerge most of the time. Allergic patients are the main beneficiaries of the care that allergists provide and their palate of decisions is informed by the work of this small group of individuals who participate in the Joint Taskforce on Practice Parameters.

The allergy nurse described above placed ice over the injection site, the itching subsided after a few minutes and the nervous allergist advised the patient to remain in the clinic a little longer under observation. The patient relaxed in her seat and turned the volume of her music player up, oblivious to the complex series of decisions that were just made to ensure her safety. This is as it should be. Another treatment given and another person helped safely. All in a day’s work.

 

ACAAI Annual Meeting: Embracing the Challenges of Change The 2008 ACAAI Annual Meeting, titled Embracing the Challenges of Change, will be held in Seattle, Nov. 6-11.

ACAAI President-Elect and Program Chair Dr. Richard G. Gower outlined four areas to be addressed throughout the program, which include changes in medical, legal, scientific and pharmacologic guidelines.

A one-day program will kick off the meeting on Thursday, Nov. 6, with a morning session on immunotherapy and an afternoon session devoted to clinical dermatological allergy.

The following schedule changes were made in response to membership assessment surveys or time conflicts:

• The meeting will end on Tuesday evening instead of Wednesday afternoon.
• The popular FIT Bowl will be held Saturday rather than Sunday.
• The Convocation was switched from Saturday to Sunday evening.

Vibrant city of Seattle to host College meeting
Seattle is an ideal destination for the College’s November meeting. In addition to having a coffee house on every block and the original Starbucks, here are just a few examples of our host city’s unique attractions:

• Space Needle – a 41-second elevator ride takes you up 520 feet to the observation deck or to SkyCity, the revolving restaurant at the top.
• Seattle's Pike Place Market – 200 businesses operating year-round, 190 craftspeople and 120 farmer booths, plus street performers and musicians
• Seattle waterfront – bustling collection of attractions, restaurants and shopping, as well as starting points for ferries, cruise ships, the Victoria Clipper and Argosy boat tours
• The state ferry system – takes passengers and their vehicles from Seattle and nearby departure points to Vashon Island, the Kitsap Peninsula, the San Juan Islands and Canada.
• Bill Speidel’s Underground Tour – guides visitors through the hidden subterranean passages that once were the main roadways and storefronts of old downtown Seattle and tells stories of the frontier people who lived and worked there.

Join your colleagues in the vibrant city of Seattle for a state-of-the-art, dynamic scientific program built on 65 years of experience.

Destination Jerusalem: Mark your calendar for Dec. 3-6
The College is pleased to jointly sponsor a state-of-the-art CME scientific conference in Jerusalem, Dec. 3-6, in collaboration with the Israel Association of Allergy and Clinical Immunology and Allergists for Israel.

Situated high in the Judean Hills, Jerusalem is one of the most extraordinary cities in the world, with its unique combination of ancient history, beautiful architecture, spiritual sanctity and colorful cultures. Sacred to the world’s three main religions, visitors are captivated by the shining glow of its religious shrines, picturesque scenery and magnificent golden limestone.

Established 3,000 years ago by King David, Jerusalem is the capital of Israel, home to the Israeli parliament (Knesset), the President’s Residence and the government offices.

The ACAAI planning committee includes Drs. Jonathan A. Bernstein (co-chair), James R. Claflin, William K. Dolen, William S. Silvers and Myron J. Zitt.

Don’t miss this unforgettable experience. Mark your calendar to attend the ACAAI – IAACI Conference, Dec. 3-6, in Jerusalem. For more information, contact Beth at afiadm@gmail.com.

View the new Literature Review Course vodcasts
Presentations from the popular Literature Review Course at the 2007 ACAAI Annual Meeting, are vodcast weekly.

The new vodcasts include:
• Update on Infectious Diseases, Antimicrobials and Vaccines – by Dr. Michael S. Blaiss
• Immunotherapy – by Dr. Harold S. Nelson

Each vodcast contains the original audio and presentation slides, and can be viewed from a computer or downloaded to a portable media player (like an iPod). Future vodcasts will feature named lectures and the symposium, “Allergic Rhinitis and the Allergist.” Previous vodcasts are archived for continued viewing.

The ACAAI vodcast program is sponsored by an unrestricted educational grant from GlaxoSmithKline.

EPA’s National Asthma Forum – register today
Attend EPA’s Communities in Action for Asthma-Friendly Environments National Forum from May 1 to 2, in Washington, D.C. The Asthma Forum is an unparalleled opportunity to join asthma leaders from across the nation to share best practices and discuss effective strategies in comprehensive asthma management. Space is limited, so register today!

Welcome to the AMA Corner prepared by Dr. Alnoor A. Malick, ACAAI Delegate to the AMA House of Delegates, to keep you abreast of important AMA news and developments impacting allergy-immunology.

AMA applauds investigation of health insurance industry
The AMA joined New York Attorney General Andrew Cuomo at a Feb. 13 press conference to announce his industry-wide investigation of UnitedHealth Group and a probe of 16 national health insurers regarding an alleged scheme to defraud consumers.

AMA President-elect Dr. Nancy H. Nielsen, said, “UnitedHealth Group and other health insurers have shortchanged tens of millions of patients who agreed to pay higher premiums for access to their choice of physicians from outside a health insurers’ network.”

Urge U.S. senators to take action on Medicare payment
With Congress in recess through Feb. 25 in observance of President’s Day, physicians have a critical opportunity to speak personally with their U.S. senators about the urgency of meeting legislators’ self-imposed deadline of July 1 for preventing steep cuts in Medicare payments to physicians.

Current Medicare physician payment rates are scheduled to be cut 10.6 percent on July 1 and an additional 5 percent on Jan. 1, 2009, making it extremely difficult for physicians to stay involved with the Medicare program. Click links for more AMA information:

Board Review Corner
Welcome to the Board Review Corner prepared by Drs. Bret R. Haymore and Dr. Jennifer W. Mbuthia, Senior and Junior Representatives of ACAAI’s fellows-in-training (FITs) to the Board of Regents. The Board Review Corner is an opportunity to help hone your Board preparedness.

To refer to a previous Board Review Corner, click the “FIT Archive” link in the left column.

Review Questions: Chapter 21 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Review questions were written by Dr. Bret R. Haymore, Walter Reed Army Medical Center.

Copyright © 2008 American College of Allergy, Asthma & Immunology. All rights reserved.
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Do you have news, responses or opinions to share with us? Please e-mail the association office at enews@acaai.org