October 26, 2010
How Not to Fight a Cold
With cold season on the horizon, you might hear people talking about how to boost their immune systems. But is that really the best thing to do? And do remedies that claim to strengthen immunity help? According to Jennifer Ackerman, a New York Times op-ed columnist, maybe not.
She claims that rather than having a “weak” immune system when we have colds, just the opposite is happening. It’s a very interesting take on immunity and the common cold. Take a look by visiting the following link:
October 26, 2010
Does Tylenol® Cause Asthma?
There have been a number of recent comments about the possible correlation between Tylenol® (acetaminophen) and asthma. An article in the American Journal of Respiratory Critical Care Medicine found the risk to be about 2.5 times greater in teenagers using acetaminophen at least monthly. The findings come from a study of 323,000 13- and 14-year-olds from 50 nations.
The real questions are these: Is acetaminophen dangerous? Does use by pregnant women increase the development of asthma in children? Is intake once a month or once a year dangerous to teenagers?
These questions are more theoretical than real. There is not a great deal of evidence in the literature. And, a correlation does not necessarily indicate a cause. It may very well be that children and pregnant women at risk of asthma might be more likely to take acetaminophen.
The lead author, Dr. Richard W. Beasley, stresses that the study does not show a direct cause, but says that further studies must be done to see if there is such a connection.
The American College of Allergy, Asthma & Immunology (ACAAI) has issued the following statement: “We understand your concerns and are aware of the news that suggests a link between acetaminophen and asthma. It is not definitive, and we will follow this issue carefully. For now, we recommend you use the asthma medications as prescribed and acetaminophen only when needed.”
From an allergist’s standpoint, I agree with this advice.
October 26, 2010
Dr. Permaul Returns to Research
A Message from Dr. Permaul
At certain points in our lives, we all approach crossroads that steer us one way or another, and the best choice is usually to follow your heart. In that respect, I’ve decided to return to one of my first interests: allergy research.
In practicing medicine over the past year at Two River Allergy & Asthma Group, I’ve grown to love the patients and staff here. However, I miss the clinical research activities I was involved in during my training. My passion is to be the person actually conducting cutting-edge allergy and asthma research, rather than the person reading about it in a journal.
After much thought, I’ve decided to return to Boston to pursue clinical research at Massachusetts General Hospital, a Harvard-affiliated teaching hospital. While I will miss everyone here, I’m excited for this new chapter in my life. And of course, you’re in excellent hands with Dr. Picone, who has been practicing for 35 years and is also Harvard trained.
I’m very grateful for my experience here, the friendships I’ve made, and the relationships I’ve built. I wish you all the best!
July 15, 2010
Is Pollen Forecasting Accurate?
If you suffer from environmental allergies, you may find yourself paying more attention to your local news reports in the spring or fall. In fact, the daily pollen count might make a difference in whether you’ll have a good day or a bad one. As allergists, we believe pollen forecasting will become more common. But how accurate is it?
In truth, pollen forecasting is a very complex topic. Take ragweed and other fall weeds, for example. If you were to take a five-year history of ragweed pollen, you could generate a graph of each season that shows the average start date, peak date and end date.
Pollen levels can vary day-by-day due to daily weather events, such as rain and fluctuating temperatures. For example, rain and cooler weather will reduce or stop the release of pollen. So, once the pollen season has started, you can make a general prediction of the next day based on the pollen graph and the weather forecast of the current day.
However, these predictions are only as reliable as the weather forecast. In addition, this model does not take into account such factors as wind speed and relative humidity. Also, a summer with a lot of rain and more sunny days will allow for good growth and will increase pollen levels.
Spring pollen reduction is much more complex because flowering plants release pollen in response to temperatures staying above a certain threshold. Therefore, there is more variation in the springtime pollen counts than in the ragweed counts.
Forecasts may be used to predict which direction the pollen is going. This is particularly applicable in large metropolitan areas surrounded by rural or suburban regions. As an example, pollen may be carried into the city on prevailing winds.
So what’s the practical take on pollen counts? When we hear on the news that the pollen count is very high, it really means that the count the day before was high. Therefore, you really cannot rely on the pollen count for predicting the current day with accuracy.
July 15, 2010
Can Vitamin D Improve Asthma Symptoms?
A few months ago, we commented in our blog about the importance of Vitamin D. Here’s an update: There is growing and convincing evidence of Vitamin D reducing asthma symptoms and having an impact on countless other diseases such as diabetes, heart disease, obesity and bone loss.
In a recent article from the American Journal of Respiratory and Critical Care Medicine, researchers looked at Vitamin D2 and D3 levels in adults with asthma. They also measured obstruction in the lungs in various ways. They reported a significant correlation between Vitamin D levels and lung obstruction. In other words, the lower the Vitamin D level, the more obstruction in the lungs. In addition, decreased or insufficient Vitamin D levels were linked to greater “twitchiness” of the lung, which makes the lungs more sensitive.
It is well known that many people have deficient Vitamin D levels, especially in the northern hemisphere. That’s because one of the sources of Vitamin D is the sun. It may be very surprising to learn, but levels of Vitamin D have also been quite deficient in the southern hemisphere where the sun is abundant.
In another recent study, researchers investigated the Vitamin D levels in children with asthma (newborn to 18 years) in the Denver region. Forty-seven percent of the patients had Vitamin D levels that are considered insufficient, and 17 percent were found to be Vitamin D deficient. The patients with low Vitamin D levels had higher levels of IgE, which signifies allergy. They also had more positive reactions to allergens. These investigators found the correlation between low Vitamin D levels and lung obstruction as in the adult study described above.
It’s promising research, but that doesn’t mean you should start taking large doses of Vitamin D. Instead, if you have allergies or another health issue, we recommend talking to your doctor and having your Vitamin D level checked. Patients who are deficient in Vitamin D3 levels can be given supplements under the advice of a physician.
July 15, 2010
Treating Severe Allergic Reactions
Allergic reactions can sometimes be very scary, and even life threatening. These types of reactions can be caused by foods, insect stings, medications and other allergens. If you or a family member might be at risk for a severe reaction, it’s important to talk to your doctor about it – and carry a life-saving device called an epinephrine auto-injector.
Epinephrine is the primary medication used to treat life-threatening allergic reactions. The symptoms of a severe allergic reaction, or anaphylaxis, include hives, throat swelling, difficulty breathing, stomach cramps, diarrhea, wheezing, chest tightness and low blood pressure. Epinephrine works by relaxing the muscles in the airways and tightening the blood vessels to increase blood pressure.
This medication comes in a single-dose automatic injector, and it is injected into the thigh. It is currently available in only two doses: 0.15 mg and 0.3 mg, and a doctor will prescribe the dose based on weight. It should only be used when someone is experiencing or about to experience a serious allergic reaction.
Multiple Doses
In some cases, it may take more than one epinephrine injection to treat an allergic reaction. In fact, one study reported that 25% of children in schools required two epinephrine doses to control their reaction.
If there is no response to the first dose, an injection may be repeated at 5- to 20-minute intervals. That’s why it’s important to have several epinephrine auto-injectors on hand. As allergists, it is common practice to prescribe more than one auto-injector.
Storage and Expiration
To protect the drug, it’s important to store epinephrine away from very hot or cold temperatures and direct sunlight. Auto-injector expiration dates should be checked, and prescriptions should be renewed promptly. Even if the epinephrine is not expired, it should be refilled if the fluid has turned from clear to a color.
Unique Instructions for Auto-Injectors
Recently, a generic epinephrine auto-injector became available on the market. So, some pharmacies may substitute the generic auto-injector for a brand name auto-injector, or vice versa.
Keep in mind that both brand name auto-injectors like Adrenaclick™, EpiPen® or Twinject™, as well as the generic version, each have their own unique instructions for proper administration. Patients and their families may have been trained by their allergist to use one type of auto-injector, and then receive another type from the pharmacy with different instructions. It’s very important to have a clear understanding of how to administer the epinephrine auto-injector provided by the pharmacy.
If you have been prescribed an epinephrine auto-injector, be sure that you have been carefully instructed on its use, how to recognize the symptoms of a severe reaction, and when to call 9-1-1 for emergency medical assistance.
June 16, 2010
Does Exercise Make You Wheeze?
It’s a beautiful day, so you head out for a long, brisk morning walk. After all, you know it would be beneficial to fit more exercise into your busy schedule. You’re feeling great – that is, until you return home and find yourself having some difficulty breathing. Does this type of scenario sound familiar?
If the answer is yes, you may have exercise-induced asthma, also known as exercise-induced bronchoconstriction (EIB). Other symptoms may include chest tightness, shortness of breath or cough. Bronchoconstriction is tightening of your airway that occurs with exercise, causing symptoms of asthma.
Most people with EIB do not otherwise have asthma. Typically, problems with breathing occur within five to 20 minutes after exercise.
People with EIB are more sensitive to cold and dry air. In the absence of exercise, air is usually warmed and moistened by the nose. However, with vigorous exercise, people tend to breathe through their mouths. As a result, cold, dry air reaches the lungs, triggering asthma symptoms.
Cold weather activities such as cross-country skiing and ice hockey may make symptoms worse. Activities that involve short bursts of energy such as walking, leisure biking, baseball or short-term track and field are less likely to cause symptoms. However, strenuous, ongoing activities such as soccer, basketball or long-distance running make it worse for many people.
Those who suffer from pollen allergies may be more likely to have exercise-induced symptoms. Other triggers may include respiratory infections or air pollutants. Being out of shape, having vocal cord issues and having uncontrolled nasal allergies are some other reasons for experiencing symptoms with exercise, and these also need to be considered.
An allergist can help figure out whether you have EIB and, if you do, develop a treatment plan that can keep you exercising.
June 16, 2010
Should We Ban Peanuts on Airplanes?
Peanut allergy appears to be on the rise. In fact, one study showed that from 1997 to 2002, the incidence of peanut allergy doubled in children. This information is very important, considering that federal regulators are now deciding whether to ban peanuts from being served on commercial airline flights.
Twelve years ago, Congress shot down a proposed peanut food ban on U.S. flights. But last week, the U.S. Transportation Department announced that they are taking a second look at arguments presented by food allergy sufferers, advocates and the food industry.
Published studies to date have shown that severe, or anaphylactic, reactions caused by peanuts on flights generally occur from eating peanut-containing meals or snacks. Allergic reactions due to skin contact or inhalation of peanut particles depend on the sensitivity of each individual. As long as a passenger with a peanut allergy does not eat peanut-containing foods or come into very close contact with them, the risk of reaction from skin contact or inhalation should be minimized.
However, even when proper precautions are taken, a reaction is always a possibility. Knowing that an estimated 1.8 million people have peanut allergies and that allergic symptoms can be quite severe and even life threatening, especially in the confined space of an airplane, why take the risk?
June 16, 2010
Can Probiotics Prevent Allergies?
Did you ever read a yogurt container and wonder exactly what probiotics are? The word probiotic means “for life.” Simply put, probiotics are live, health-promoting microorganisms. When ingested, they can change the natural bacteria in the intestines in a way that may benefit the person taking them.
Some common examples of probiotics are Lactobacillus GG (Culturelle), Lactobacillus acidophilus, Lactobacillus bulgaricus and Bifidobacterium bifidum. These bacteria are often used to culture milk when making yogurt and other fermented dairy products. Over the years, probiotics also have been used to restore balance to the digestive system after a dose of antibiotics, or to help create a stable intestinal environment that is less prone to infectious diseases.
The idea that probiotics may prevent allergies if taken regularly stems from the “hygiene hypothesis.” This is the notion that clean, sterile environments in modern societies – such as ours – have prevented our bodies from acquiring the healthy bacteria we need to develop a healthy immune system. Due to the shortage of bacteria in modern society, our immune systems have malfunctioned, leading to allergies (an abnormal immune response).
It is still debated whether adding bacteria to our guts through probiotics can actually prevent allergies. In fact, there’s a large amount of conflicting data. Some clinical studies have shown improvement in allergic rhinitis (environmental allergies) and eczema (an allergic skin condition). One study showed that infants who were given probiotics were significantly less likely to develop eczema. But, another showed that probiotics may actually make infants more sensitive to allergens.
More rigorous clinical studies, known as randomized controlled trials (studies involving large groups of roughly equal sizes) have shown mixed or unclear results on preventing food allergies, asthma and environmental allergies.
At this time, taking probiotics cannot be recommended for the prevention of allergies. However, there is some promising literature suggesting that adding probiotics to more foods may have an impact. Additional studies are needed to identify the most beneficial probiotic strain, the dose and the types of allergic disease that would benefit the most from this approach.
May 3, 2010
Hypoallergenic Animals or Hype?
Is there such a thing as a hypoallergenic pet? This question is often asked by parents who wonder whether they should get a cat or dog for their pleading child with animal allergies.
Unfortunately, there really is no such thing as a hypoallergenic animal. When a person is allergic to an animal, it is the hair, saliva and dander (tiny scales shed from animal skin, hair or feathers that become airborne) that trigger symptoms. It’s true that if an animal is small or sheds less, there will be less hair and dander allergen. However, the animal still has saliva, a major allergen component.
In fact, most dog allergies are related to a protein called Can f 1, an allergen found in dog saliva. For cats, this allergen is called Fel d 1, a protein secreted by a cat's sebaceous glands in the skin and by the salivary glands. Other warm-blooded animals with hair, such as gerbils, hamsters, horses and rabbits, produce similar allergens.
These allergens are very sticky and cling to shed skin and hair. So, the animal’s hair is usually the carrier and not the source. These proteins can easily adhere to walls, carpet, clothing, furniture and bedding. Studies have shown that even after removing a cat from a household, cat allergen levels can remain elevated for four to six months.
Frequently bathing an animal can cut down on hair and dander shedding, but it’s not very practical. Other measures include adding a HEPA air filtration system to decrease airborne allergens, and aggressively cleaning and vacuuming carpets and upholstered surfaces. Animals should also be kept out of bedrooms.
There are minor differences between various dog and cat breeds. Why then can someone with no symptoms around their own dog have a reaction to another dog? There may be varying degrees of allergic symptoms that depend on the individual. In addition, smaller dogs with less hair or shedding are considered low-allergy breeds. Some examples include basenji, bichon frise, maltese, poodles, schnauzers and Yorkshire terriers.
The best option is to avoid purchasing cats or dogs if you or your child is allergic to them, especially if these animals trigger asthma symptoms.
May 3, 2010
Can Breastfeeding Prevent Asthma?
We know that breast milk provides many benefits for babies. In fact, the American Academy of Pediatrics (AAP) strongly recommends exclusive breastfeeding for the first six months of life. Breast milk, and especially colostrum (the first breast milk to appear), provides the newborn with passive immunity in the form of:
- Antibodies, which protect against viruses and bacteria
- Lactoferrin, which inhibits the growth of iron-dependent bacteria in the gastrointestinal tract
- Lysozyme, an enzyme that protects against e. coli and salmonella bacteria
- Bifidus factor, which supports the growth of lactobacillus, a beneficial bacteria that protects against harmful bacteria by creating an acidic environment where it cannot survive
Breast milk also contains several substances involved in brain development, such as omega-3 fatty acids, cholesterol, lactose and amino acids.
Breastfeeding is often promoted as a way to prevent eczema (an allergic skin condition), allergies and asthma, particularly in families with a high risk for these conditions. Still, whether breast milk actually protects against these allergic diseases has been a topic of controversy in the allergy world. Research studies in this area have given conflicting results.
A new study recently published in the Journal of Allergy and Clinical Immunology (JACI) investigated the relationship between breastfeeding and asthma and allergic sensitivity during the first eight years of life. The authors studied more than 3,000 Swedish children from birth to age 8. They found that breastfeeding for 4 months or more reduced the risk of asthma, especially in those with allergic sensitivities to foods, animals, pollens and molds.
Another study published this month in JACI found that infants breastfed exclusively for more than six months were more likely to develop eczema by age 2. However, the infants were less likely to develop wheezing symptoms as long as they were still being breastfed.The study followed 411 infants who were at increased risk of allergies because their mothers had a history of asthma.
These different results may be related to the complex relationship among breast milk, genetics, the environment and the immune system. Although its role in the prevention of allergic disorders in children is still not conclusive, breast milk is still considered the “best milk” and the most balanced form of nutrition for infants.
May 3, 2010
Battling Springtime Allergies
This spring season is being touted as one of the worst for seasonal allergies in a long time. Although this may seem like the case every pollen season, especially for those who suffer from seasonal allergies, there are several reasons why this spring may be wreaking more havoc than in past years.
This year, we had a cold winter followed by a sudden and sustained warming pattern with no bursts of cold air in between. According to meteorologists, this warming pattern blocked rainstorms from coming in, which usually help to dampen pollen counts. In addition, climate change has led to increasing carbon dioxide levels over the past 100 years, resulting in increased pollen levels. Plants thrive on carbon dioxide.
Whatever the reasons for the elevated pollen counts, you can take certain steps to help alleviate symptoms. Probably the most important thing to know is that allergy medications work best when taken in advance to prevent allergy symptoms rather than to treat symptoms fully underway. Here are some other tips:
How to Reduce Pollen Exposure
- Stay indoors on dry, windy days. If you must go outside, avoid the morning hours when pollen counts are the highest.
- Change your clothes after coming inside and take showers at night to wash pollens from your skin and hair.
- Delegate mowing, gardening and other outdoor activities or wear a mask to cut down on the amount of pollen that you breathe in.
- Keep home and car windows closed. Run air conditioners to filter the air.
- Don’t allow pets to stay in your bed or on upholstered furniture, as pollens can stick to pet fur.
Treatment Options
Your allergist can help you determine what treatment options are right for you. This may include:
- Antihistamines: Allegra, Astepro, Claritin, Patanase, Xyzal, Zyrtec, to name a few
- Intranasal steroid sprays: Flonase, Nasonex, Nasacort AQ, Omnaris, to name a few
- Decongestants, such as Sudafed
- Singulair (blocks leukotrienes which are allergic chemical mediators)
- Nasalcrom (inhibits the release of allergic chemical mediators from mast cells)
- Nasal saline irrigations: NetiPot and NeilMed are some common brands
- Allergy shots
For current pollen counts and forecasts, check your local radio or television station or visit www.pollen.com. A pollen count is expressed in terms of a concentration of pollen in the air in a specific area at a certain point in time. The exact measure is grains of pollen per cubic meter over a 24-hour period. Therefore, pollen reports on radio and television may represent yesterday's count and not today's.
February 9, 2010
Penicillin Skin Testing Returns
At long last, penicillin skin testing is back! PRE-PEN® was a widely used penicillin skin test product for over 30 years. In 2004, it was withdrawn from the market due to the lack of a dedicated penicillin manufacturing facility. Its safety was never in question, and it remains the most sensitive antibiotic skin test we have. When this product was unavailable, our ability to test for penicillin allergy was severely limited.
Many people are mislabeled “penicillin allergic” when they don’t have a true allergy. In fact, less than 20% of all patients who believe they have a penicillin allergy are truly allergic to penicillin. They may have had a reaction to penicillin, such as a rash, but this does not necessarily mean they have an allergy. Instead, they may have experienced a side effect of penicillin.
The resurgence of PRE-PEN® is extremely important both to patients and to public health in general. The alternative effective antibiotics prescribed for those thought to be penicillin allergic are usually more costly and broader spectrum, which can contribute to overall antibiotic resistance.
We are now pleased to offer PRE-PEN® skin testing in our office. If you have been labeled penicillin allergic and would like further evaluation to confirm whether it is a true allergy, please call us at 732-747-8188 for an appointment.
February 9, 2010
H1N1 Vaccine Still Encouraged
Available at Two River Allergy and Asthma Group
As spring is finally on the horizon, fewer people are coming down with the flu. In fact, most of the cases we’re seeing now are caused by H1N1, rather than the traditional seasonal flu viruses.
Compared to this past fall when H1N1 vaccine supplies were limited, there are now plenty of vaccine supplies throughout the country, and many people would still benefit from vaccination, according to a spokeswoman from the Centers for Disease Control and Prevention (CDC). The declining second wave of H1N1 may eventually lead to a series of new, unknown strains of seasonal flu – and the existing H1N1 vaccines may be effective against these strains. So, H1N1 vaccination is still important to decrease the spread of the virus.
People with asthma who develop either seasonal or H1N1 flu illnesses are at increased risk for serious complications and are more likely to be hospitalized. The flu can also worsen chronic health problems like asthma. Everyone with asthma, ages 6 months and older, should be vaccinated with the H1N1 flu shot. Antiviral drugs (such as Tamiflu® or Relenza®) should be started early to treat flu in those with asthma or other conditions that put them at high risk for complications.
The CDC recommends vaccination as the first and most important step in protecting against the flu. With an adequate vaccine supply now available, the CDC is encouraging everyone to get vaccinated against 2009 H1N1, including people 65 years and older.
We are pleased to offer the H1N1 vaccine in our office. However, we have limited supplies and are offering vaccines on a first come, first served basis. Please contact us if you would like to receive the H1N1 vaccine. You can also check with your local health department for vaccine administration locations.
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