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1.  328 Epidemiology of Asthma Cases in the Allergy Service of a Third Level Medical Center. Six Year Expirience 
The World Allergy Organization Journal  2012;5(Suppl 2):S122-S123.
The creation of an Allergy service was required because of the high frequency of allergic diseases among paediatric population in the general consultation of a third level medical centre.
The purpose of this study is to report the cases of asthma diagnosed in the Allergy service from a Third level medical centre since its creation in July 2005.
This is a descriptive, retrospective, transversal study from July 2005 to February 2011. Selected medical records of patients apply for diagnostic criteria for an allergy disease. GINA guide 2009 was used to make diagnosis of asthma. Patients were classified by age and sex and find out how many of them skin prick test were made and also how many patients began treatment with immunotherapy.
Thirteen thousand seven hundred thirty seven consultations were attended in the Allergy service between the time period mentioned above. Two thousand three hundred thirty seven medical records of patients were selected, 1608 patients applied for a specific diagnosis for an allergy disease as follows: Asthma 411, Atopic Conjunctivitis 58, Atopic Dermatitis 180, Allergic Rhinitis 869, Urticaria 90. Four hundred eleven patients completed criteria for Asthma. Two hundred thirteen (51.8%) patients were female, 198 (48.2%) patients were male. Two hundred twenty seven (55.2%) patients were found to be in the range of 0 to 9 years, 141 (62.1%) of them were between 5 to 9 years. The majority of asthma patients were males in the range of 5 to 9 years. Some increase in asthma cases were found in females between 30 and 40 years of age, 75 (35.2%) of total female cases, about 18% of total cases of asthma. Skin prick test were made in 164 (40%) asthma patients. In 134 were positive to a specific allergen and began immunotherapy.
Asthma represents the second highest incidence in allergy diseases among children. However, it is the main cause of hospitalization among allergy diseases because of the presence of crises that increases the cost of medical attention. It is very important therefore to make a good diagnosis of asthma early on in order to bring adequate treatment, including immunotherapy. Education to these patients is also an important task, mainly in children.
PMCID: PMC3512707
2.  Food Allergy and Increased Asthma Morbidity in a School-Based Inner-City Asthma Study 
Children with asthma have increased prevalence of food allergies. The relationship between food allergy and asthma morbidity is unclear.
We aimed to investigate the presence of food allergy as an independent risk factor for increased asthma morbidity using the School Inner-City Asthma (SICAS), a prospective study evaluating risk factors and asthma morbidity among urban children.
We prospectively surveyed 300 children from inner-city schools with physician-diagnosed asthma, followed by clinical evaluation. Food allergies were reported including symptoms experienced within one hour of food ingestion. Asthma morbidity, pulmonary function, and resource utilization were compared between children with food allergies and without.
Seventy-three (24%) of 300 asthmatic children surveyed had physician- diagnosed food allergy, and 36 (12%) had multiple food allergies. Those with any food allergy independently had increased risk of hospitalization (OR: 2.35, 95% CI: 1.30–4.24, p=0.005), and use of controller medication (OR: 1.99, 95% CI: 1.06–3.74, p=0.03). Those with multiple food allergies also had an independently higher risk of hospitalization in the past year (OR: 4.10 95% CI: 1.47–11.45, p=0.007), asthma-related hospitalization (OR: 3.52, 95% CI: 1.12–11.03, p=0.03), controller medication use (OR: 2.38 95% CI: 1.00–5.66, p=0.05), and more provider visits (median 4.5 versus 3.0, p=0.008). Furthermore, lung function was significantly lower (% predicted FEV1 and FEV1/FVC ratios) in both food allergy category groups.
Food allergy is highly prevalent in inner-city school-aged children with asthma. Children with food allergies have increased asthma morbidity and health resource utilization with decreased lung function, and this association is stronger in those with multiple food allergies.
PMCID: PMC3777668  PMID: 24058900
asthma; food allergy; hospitalization; morbidity; prevalence; resource utilization; risk
3.  e-Health, m-Health and healthier social media reform: the big scale view 
In the upcoming decade, digital platforms will be the backbone of a strategic revolution in the way medical services are provided, affecting both healthcare providers and patients. Digital-based patient-centered healthcare services allow patients to actively participate in managing their own care, in times of health as well as illness, using personally tailored interactive tools. Such empowerment is expected to increase patients’ willingness to adopt actions and lifestyles that promote health as well as improve follow-up and compliance with treatment in cases of chronic illness. Clalit Health Services (CHS) is the largest HMO in Israel and second largest world-wide. Through its 14 hospitals, 1300 primary and specialized clinics, and 650 pharmacies, CHS provides comprehensive medical care to the majority of Israel’s population (above 4 million members). CHS e-Health wing focuses on deepening patient involvement in managing health, through personalized digital interactive tools. Currently, CHS e-Health wing provides e-health services for 1.56 million unique patients monthly with 2.4 million interactions every month (August 2011). Successful implementation of e-Health solutions is not a sum of technology, innovation and health; rather it’s the expertise of tailoring knowledge and leadership capabilities in multidisciplinary areas: clinical, ethical, psychological, legal, comprehension of patient and medical team engagement etc. The Google Health case excellently demonstrates this point. On the other hand, our success with CHS is a demonstration that e-Health can be enrolled effectively and fast with huge benefits for both patients and medical teams, and with a robust business model.
CHS e-Health core components
They include:
1. The personal health record layer (what the patient can see) presents patients with their own medical history as well as the medical history of their preadult children, including diagnoses, allergies, vaccinations, laboratory results with interpretations in layman’s terms, medications with clear, straightforward explanations regarding dosing instructions, important side effects, contraindications, such as lactation etc., and other important medical information. All personal e-Health services require identification and authorization.
2. The personal knowledge layer (what the patient should know) presents patients with personally tailored recommendations for preventative medicine and health promotion. For example, diabetic patients are push notified regarding their yearly eye exam. The various health recommendations include: occult blood testing, mammography, lipid profile etc. Each recommendation contains textual, visual and interactive content components in order to promote engagement and motivate the patient to actually change his health behaviour.
3. The personal health services layer (what the patient can do) enables patients to schedule clinic visits, order chronic prescriptions, e-consult their physician via secured e-mail, set SMS medication reminders, e-consult a pharmacist regarding personal medications. Consultants’ answers are sent securely to the patients’ personal mobile device.
On December 2009 CHS launched secured, web based, synchronous medical consultation via video conference. Currently 11,780 e-visits are performed monthly (May 2011). The medical encounter includes e-prescription and referral capabilities which are biometrically signed by the physician. On December 2010 CHS launched a unique mobile health platform, which is one of the most comprehensive personal m-Health applications world-wide. An essential advantage of mobile devices is their potential to bridge the digital divide. Currently, CHS m-Health platform is used by more than 45,000 unique users, with 75,000 laboratory results views/month, 1100 m-consultations/month and 9000 physician visit scheduling/month.
4. The Bio-Sensing layer (what physiological data the patient can populate) includes diagnostic means that allow remote physical examination, bio-sensors that broadcast various physiological measurements, and smart homecare devices, such as e-Pill boxes that gives seniors, patients and their caregivers the ability to stay at home and live life to its fullest. Monitored data is automatically transmitted to the patient’s Personal Health Record and to relevant medical personnel.
The monitoring layer is embedded in the chronic disease management platform, and in the interactive health promotion and wellness platform. It includes tailoring of consumer-oriented medical devices and service provided by various professional personnel—physicians, nurses, pharmacists, dieticians and more.
5. The Social layer (what the patient can share). Social media networks triggered an essential change at the humanity ‘genome’ level, yet to be further defined in the upcoming years. Social media has huge potential in promoting health as it combines fun, simple yet extraordinary user experience, and bio-social-feedback. There are two major challenges in leveraging health care through social networks:
a. Our personal health information is the cornerstone for personalizing healthier lifestyle, disease management and preventative medicine. We naturally see our personal health data as a super-private territory. So, how do we bring the power of our private health information, currently locked within our Personal Health Record, into social media networks without offending basic privacy issues?
b. Disease management and preventive medicine are currently neither considered ‘cool’ nor ‘fun’ or ‘potentially highly viral’ activities; yet, health is a major issue of everybody’s life. It seems like we are missing a crucial element with a huge potential in health behavioural change—the Fun Theory. Social media platforms comprehends user experience tools that potentially could break current misconception, and engage people in the daily task of taking better care of themselves.
CHS e-Health innovation team characterized several break-through applications in this unexplored territory within social media networks, fusing personal health and social media platforms without offending privacy. One of the most crucial issues regarding adoption of e-health and m-health platforms is change management. Being a ‘hot’ innovative ‘gadget’ is far from sufficient for changing health behaviours at the individual and population levels.
CHS health behaviour change management methodology includes 4 core elements:
1. Engaging two completely different populations: patients, and medical teams. e-Health applications must present true added value for both medical teams and patients, engaging them through understanding and assimilating “what’s really in it for me”. Medical teams are further subdivided into physicians, nurses, pharmacists and administrative personnel—each with their own driving incentive. Resistance to change is an obstacle in many fields but it is particularly true in the conservative health industry. To successfully manage a large scale persuasive process, we treat intra-organizational human resources as “Change Agents”. Harnessing the persuasive power of ~40,000 employees requires engaging them as the primary target group. Successful recruitment has the potential of converting each patient-medical team interaction into an exposure opportunity to the new era of participatory medicine via e-health and m-health channels.
2. Implementation waves: every group of digital health products that are released at the same time are seen as one project. Each implementation wave leverages the focus of the organization and target populations to a defined time span. There are three major and three minor implementation waves a year.
3. Change-Support Arrow: a structured infrastructure for every implementation wave. The sub-stages in this strategy include:
Cross organizational mapping and identification of early adopters and stakeholders relevant to the implementation wave
Mapping positive or negative perceptions and designing specific marketing approaches for the distinct target groups
Intra and extra organizational marketing
Conducting intensive training and presentation sessions for groups of implementers
Running conflict-prevention activities, such as advanced tackling of potential union resistance
Training change-agents with resistance-management behavioural techniques, focused intervention for specific incidents and for key opinion leaders
Extensive presence in the clinics during the launch period, etc.
The entire process is monitored and managed continuously by a review team.
4. Closing Phase: each wave is analyzed and a “lessons-learned” session concludes the changes required in the modus operandi of the e-health project team.
PMCID: PMC3571141
e-Health; mobile health; personal health record; online visit; patient empowerment; knowledge prescription
4.  What do school personnel know, think and feel about food allergies? 
The incidence of food allergy is such that most schools will be attended by at least one food allergic child, obliging school personnel to cope with cases at risk of severe allergic reactions. Schools need to know about food allergy and anaphylaxis management to ensure the personal safety of an increasing number of students. The aim of this study was to investigate Italian school teachers and principals’ knowledge, perceptions and feelings concerning food allergy and anaphylaxis, to deeply understand how to effectively support schools to manage a severely allergic child. In addition a further assessment of the impact of multidisciplinary courses on participants was undertaken.
1184 school teachers and principals attended courses on food allergy and anaphylaxis management at school were questioned before and after their course. Descriptive and inferential statistics were used to analyze the resulting data.
Participants tended to overestimate the prevalence of food allergy; 79.3% were able to identify the foods most likely involved and 90.8% knew the most frequent symptoms. 81.9% were familiar with the typical symptoms of anaphylaxis but, while the majority (65.4%) knew that “adrenaline” is the best medication for anaphylaxis, only 34.5% knew indications of using adrenaline in children. 48.5% thoroughly understood dietary exclusion. School personnel considered that food allergic students could have social difficulties (10.2%) and/or emotional consequences (37.2%) because of their condition. “Concern” was the emotion that most respondents (66.9%) associated with food allergy. At the end of the course, the number of correct answers to the test increased significantly.
Having adequately trained and cooperative school personnel is crucial to significantly reduce emergencies and fatal reactions. The results emphasize the need for specific educational interventions and improvements in school health policies to support schools to deal with allergic students ensuring their safety and psychological well-being.
PMCID: PMC4176479  PMID: 24274206
School; Food allergy; Anaphylaxis
5.  Knowledge of drug prescription in dentistry students 
Students in schools of dentistry attend to patients with illnesses, and often prescribe medication. Because students are still learning, they are influenced by a variety of factors: the different teaching approaches of the professors at the clinics and in the pharmacology course, fellow students, and even the information provided by the pharmaceutical industry.
The aim of this pilot study was to assess the prescription knowledge and common mistakes in fourth-year students at the School of Dentistry at the Universidad Nacional Autónoma de México.
In March 2010, a survey was conducted among 66 fourth-year students at the School of Dentistry, applying a previously validated questionnaire consisting of six open-ended questions The following factors were assessed: the most frequent illness requiring dental prescription; the most prescribed nonsteroidal anti-inflammatory drugs and antibiotics; the most frequent errors; sources of information used for prescribing drugs; and whether the students knew and followed the World Health Organization Guide to Good Prescribing.
The most frequent response for each question was considered the most significant. The most common reason for prescribing medication was infection (n = 37, 56%), followed by pain (n = 24, 38%); the most used painkillers were ibuprofen and acetaminophen at equal levels (n = 25, 37.8%), followed by ketorolac (n = 7, 10.6%), naproxen (n = 6, 9.1%), diclofenac (n = 2, 3%), and aspirin (n = 1, 1.5%); the most widely prescribed antibiotics were amoxicillin (n = 52, 78.9%), ampicillin (n = 7, 10.6%), and penicillin V and clindamycin (n = 3, 4.5%). The most frequent errors reported by students were: lack of knowledge about drug posology (n = 49, 74.2%), improperly filled prescriptions (n = 7, 10.7%), not knowing the brand names and uncertainty about the correct drug indicated for each case (n = 3, 4.54%), not knowing the duration of treatment (n = 2, 3%), not asking the patient about possible allergies, and not giving prescriptions (n = 1, 1.5%). The sources of information used by students for prescribing drugs included the professors at the clinics (n = 49, 74.2%), the pharmacology course (n = 7, 10.7%), medical dictionary consultation (n = 15, 22.72%), classmate support (n = 3, 4.54%), and information provided by medical representatives from pharmaceutical companies (n = 1, 1.5%). Finally, only 20 students (30.3%) followed the WHO Guide to Good Prescribing, 40 students acknowledged not following it (60.6%), and six students (9.1%) had no knowledge of it.
The knowledge of pharmacology among fourth-year students in the School of Dentistry has gaps that could affect patient safety. More studies are needed to determine whether this issue affects the quality of patient care and the effectiveness and safety of treatments. Since prescribing accurately is extremely important, it is necessary to develop therapeutic guidelines, and to provide pharmacological therapy courses. The implementation of educational programs, including the WHO Guide to Good Prescribing and Patient Safety Curriculum Guide, would be beneficial in helping students develop prescribing skills.
PMCID: PMC3396048  PMID: 22807647
prescription; dentistry prescription; most used NSAIDs by dentists; most used antibiotics; dentist prescribing errors; sources of information for prescribing; WHO Guide to Good Prescribing
6.  Hip fracture 
Clinical Evidence  2010;2010:1110.
Between 12% and 37% of people will die in the year after a hip fracture, and 10% to 20% of survivors will move into a more dependent residence.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of surgical interventions in people with hip fracture? What are the effects of perisurgical medical interventions on surgical outcome and prevention of complications in people with hip fracture? What are the effects of rehabilitation interventions and programmes after hip fracture? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 55 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: anaesthesia (general, regional); antibiotic regimens; arthroplasty; choice of implant for internal fixation; conservative treatment; co-ordinated multidisciplinary approaches for inpatient rehabilitation of older people; cyclical compression of the foot or calf; early supported discharge followed by home-based rehabilitation; extramedullary devices; fixation (external, internal); graduated elastic compression; intramedullary devices; mobilisation strategies; nerve blocks for pain control; nutritional supplementation (oral multinutrient feeds, nasogastric feeds); perioperative prophylaxis with antibiotics, with antiplatelet agents, or with heparin (low molecular weight or unfractionated); preoperative traction to the injured limb; and systematic multicomponent home-based rehabilitation.
Key Points
Between 12% and 37% of people will die in the year after a hip fracture, and 10% to 20% of survivors will move into a more dependent residence.
Surgery is routinely used in the treatment of hip fracture. Surgical fixation leads to earlier mobilisation and less leg deformity compared with conservative treatment.In people with intracapsular hip fracture, internal fixation is associated with less operative trauma and deep wound sepsis, but is more likely to require subsequent revision surgery, compared with arthroplasty. We don't know the best method for internal fixation, or the best method of arthroplasty, for these fractures. Older fixed nail plates for extramedullary fixation of extracapsular fracture increase the risk of fixation failure compared with sliding hip screws. Short intramedullary cephalocondylic nails, Ender nails, and older fixed nail plates increase the risk of re-operation compared with extramedullary fixation with a sliding hip screw device, but we don't know whether other kinds of extramedullary devices are better than the sliding hip screw. We also don't know how different intramedullary devices compare with each other.
Various perisurgical interventions may be used with the aim of improving surgical outcome and preventing complications. Routine preoperative traction to the injured limb has not been shown to relieve pain or to aid subsequent surgery. Antibiotic prophylaxis reduces wound infections, but we don't know which is the most effective regimen (regimens assessed are antibiotics given on the day of surgery and single-dose antibiotics versus multiple-dose regimens). Antiplatelet agents and heparin reduce the risk of deep vein thrombosis (DVT) when used prophylactically, but both treatments increase the risk of bleeding. We don't know how low molecular weight heparin and unfractionated heparin compare at reducing risk of DVT. Cyclical compression devices also reduce the risk of DVT, but we don't know whether graduated elastic compression stockings are effective. Oral protein and energy multinutrient feeds may reduce unfavourable outcomes after surgery.We don't know whether nerve blocks are effective in reducing pain post-surgery or the pain or requirement for analgesia after surgery. We don't how different anaesthetic regimens compare with each other.We don't know whether nasogastric feeds for nutritional supplementation are effective at improving outcomes after hip fracture.
Various rehabilitation interventions and programmes aim to improve recovery after a hip fracture. Co-ordinated multidisciplinary care may improve outcomes compared with usual care, but we don't know which method is best.We don't know how effective mobilisation strategies, early supported discharge, or multidisciplinary home-based rehabilitation are at improving outcomes after hip surgery.
PMCID: PMC2907602  PMID: 21726483
7.  Predictive value of specific IgE for clinical peanut allergy in children: relationship with eczema, asthma, and setting (primary or secondary care) 
The usefulness of peanut specific IgE levels for diagnosing peanut allergy has not been studied in primary and secondary care where most cases of suspected peanut allergy are being evaluated. We aimed to determine the relationship between peanut-specific IgE levels and clinical peanut allergy in peanut-sensitized children and how this was influenced by eczema, asthma and clinical setting (primary or secondary care). We enrolled 280 children (0–18 years) who tested positive for peanut-specific IgE (> 0.35 kU/L) requested by primary and secondary physicians. We used predefined criteria to classify participants into three groups: peanut allergy, no peanut allergy, or possible peanut allergy, based on responses to a validated questionnaire, a detailed food history, and results of oral food challenges.
Fifty-two participants (18.6%) were classified as peanut allergy, 190 (67.9%) as no peanut allergy, and 38 (13.6%) as possible peanut allergy. The association between peanut-specific IgE levels and peanut allergy was significant but weak (OR 1.46 for a 10.0 kU/L increase in peanut-specific IgE, 95% CI 1.28-1.67). Eczema was the strongest risk factor for peanut allergy (aOR 3.33, 95% CI 1.07-10.35), adjusted for demographic and clinical characteristics. Asthma was not significantly related to peanut allergy (aOR 1.93, 95% CI 0.90-4.13). Peanut allergy was less likely in primary than in secondary care participants (OR 0.46, 95% CI 0.25-0.86), at all levels of peanut-specific IgE.
The relationship between peanut-specific IgE and peanut allergy in children is weak, is strongly dependent on eczema, and is weaker in primary compared to secondary care. This limits the usefulness of peanut-specific IgE levels in the diagnosis of peanut allergy in children.
PMCID: PMC3852137  PMID: 24112405
Peanut allergy; Peanut-specific IgE; Peanut sensitization; Eczema; Asthma; Children; Teenagers
8.  Asthma and allergies in Jamaican children aged 2–17 years: a cross-sectional prevalence survey 
BMJ Open  2012;2(4):e001132.
To determine the prevalence and severity of asthma and allergies as well as risk factors for asthma among Jamaican children aged 2–17 years.
A cross-sectional, community-based prevalence survey using the International Study of Asthma and Allergies in Childhood questionnaire. The authors selected a representative sample of 2017 children using stratified, multistage cluster sampling design using enumeration districts as primary sampling units.
Jamaica, a Caribbean island with a total population of approximately 2.6 million, geographically divided into 14 parishes.
Children aged 2–17 years, who were resident in private households. Institutionalised children such as those in boarding schools and hospitals were excluded from the survey.
Primary and secondary outcome measures
The prevalence and severity of asthma and allergy symptoms, doctor-diagnosed asthma and risk factors for asthma.
Almost a fifth (19.6%) of Jamaican children aged 2–17 years had current wheeze, while 16.7% had self-reported doctor-diagnosed asthma. Both were more common among males than among females. The prevalence of rhinitis, hay fever and eczema among children was 24.5%, 25% and 17.3%, respectively. Current wheeze was more common among children with rhinitis in the last 12 months (44.3% vs 12.6%, p<0.001), hay fever (36.8% vs 13.8%, p<0.001) and eczema (34.1% vs 16.4%, p<0.001). Independent risk factors for current wheeze (ORs, 95% CI) were chest infections in the first year of life 4.83 (3.00 to 7.77), parental asthma 4.19 (2.8 to 6.08), rhinitis in the last 12 months 6.92 (5.16 to 9.29), hay fever 4.82 (3.62 to 6.41), moulds in the home 2.25 (1.16 to 4.45), cat in the home 2.44 (1.66 to 3.58) and dog in the home 1.81 (1.18 to 2.78).
The prevalence of asthma and allergies in Jamaican children is high. Significant risk factors for asthma include chest infections in the first year of life, a history of asthma in the family, allergies, moulds and pets in the home.
Article summary
Article focus
The prevalence of asthma and allergies in both developed and developing countries is continuing to rise.
In some Caribbean countries, asthma is a public health problem associated with high economic costs.
This study determined the prevalence of asthma, allergy symptoms and associated risk factors.
Key messages
We demonstrated that the prevalence of asthma and allergy symptoms among Jamaican children aged 2–17 years is high.
Both the prevalence and severity of asthma symptoms are comparable to that reported among children in high-income countries.
Current wheeze and doctor-diagnosed asthma were more common in males and in children with allergies.
A history of asthma in the family, chest infections in the first year of life, allergies, exposure to moulds and pets in the home were associated with significant risk for asthma.
Identifying children at high risk for asthma and controlling modifiable risk factors is important in reducing the prevalence and morbidity related to asthma.
Strengths and limitations of this study
This is the first national study on asthma and allergies in Jamaica using a nationally representative sample of children with a response rate of 80%.
We used a modified ISAAC protocol in which sampling was done by household rather than by school. Using a population-based sampling strategy; we sampled one child and one adult per household. This approach enabled us to obtain national prevalence estimates for both adults and children in one survey at a reduced cost.
Limitations of this study include the fact that the prevalence of asthma and allergies was based solely on self-reports, no objective measures were done. Also in younger children, caregivers responded to questionnaires.
PMCID: PMC3400072  PMID: 22798254
9.  232 Epidemiology of Allergic Rhinitis Cases in the Allergy Service of a Third Level Medical Center. Six Year Experience 
The purpose of this study is to report the cases of Allergic Rhinitis (AR) in the Allergy service from a Third level medical centre since its creation in July 2005.
This is a descriptive, retrospective, transversal study from July 2005 to February 2011. Selected medical records of patients apply for diagnostic criteria for an allergy disease were made. ARIA guide 2009 was used to make diagnosis of allergic rhinitis. Patients were classified by age and sex and find out how many skin prick test were made in such patients, and how many patients began immunotherapy.
13737 consultations were attended in the Allergy service between the period mentioned above. 2337 medical records of patients were selected, 1608 patients applied for a specific diagnosis for an allergy diseases as follows: Asthma 411, Atopic conjuctivitis 58, Atopic Dermatitis 180, Allergic Rhinitis 869, Urticaria 90. 869 patients completed criteria for Allergic Rhinitis. 433 (49.9%) patients were female, 436 (50.1%) patients were male. 490 (56.3%) patients were found to be in the range of 0 to 14 years. The mayority of allergic rhinitis patients were males in the range of 5 to 14 years, with 270 (42.5%) patients. There were an increase of AR cases in females in the range of 20 to 40 years, with 171 (39.4%) of total female cases. In 408 (47%) patients skin prick test were made, in 305 (35%) patients were positive and began treatment with immunotherapy.
In this study, AR represents the most frequent allergy disease among children, a good diagnosis of AR is mandatory because of the confusion of symptoms mainly related with upper respiratory tract infections, that implies a different management, increasing the risk of complications, such as asthma and therefore the cost of treatment, including immunotherapy. The results of this study are helpful to improve specialized medical attention not only in paediatric patients but also in adults.
PMCID: PMC3512972
10.  342 Epidemiology of Atopic Dermatitis in the Allergy Service of a Third Level Medical Center 
The creation of an Allergy service was required because of the high frequency of allergic diseases among paediatric population in the general consultation of a third level medical centre.
The purpose of this study is to report the cases of Atopic Dermatitis (AD) in the Allergy service from a Third level medical centre since its creation in July 2005.
This is a descriptive, retrospective, transversal study from July 2005 to February 2011. Selected medical records of patients, some records supplied by the Dermatology service, applied for diagnostic criteria for an allergy disease. The EAACI/AAAI/PRACTALL/ 2006 guide was used to make diagnosis of AD. Patients were classified by age and sex and find out how many skin prick test were made in such patients, and how many patients began immunotherapy.
Thirteen thousand seven hundred thirty seven consultations were attended in the Allergy service between the time period mentioned above. Two thousand three hundred thirty seven medical records of patients were selected, 1608 patients applied for a specific diagnosis for an allergy diseases as follows:
Asthma 411; atopic conjuctivitis 58; atopic dermatitis 180; allergic rhinitis 869; and urticaria 90.869 patients completed criteria for allergic rhinitis.
From 180 patients with diagnosis of AD, 111 (61.6%) patients were female, 69 (38.4%) patients were male. Ninety six (53.3%) patients were found to be in the range of 0 to 9 years. The mayority of atopic dermatitis patients were females in the range of 0 to 14 years, with 82 (45.5%) patients.
There was an increase of atopic dermatitis cases in females in the range of 30 years compared with males (F 10/ M 3). In 111 patients with DA skin prick test were made, only in 76 (42%) patients were positive and began treatment with immunotherapy.
In this study, AD represents the third cause of allergy disease in frequency among children. AD requires interdisciplinary management because of dermatological and allergological aspects for treatment, including immunotherapy. Education of parents and patients is also an important task in the treatment of AD. The results of this study are helpful to improve specialized medical attention in paediatric patients and adults with AD.
PMCID: PMC3513176
11.  Association of Medical Students' Reports of Interactions with the Pharmaceutical and Medical Device Industries and Medical School Policies and Characteristics: A Cross-Sectional Study 
PLoS Medicine  2014;11(10):e1001743.
Aaron Kesselheim and colleagues compared US medical students' survey responses regarding pharmaceutical company interactions with the schools' AMSA PharmFree scorecard and Institute on Medicine as a Profession's (IMAP) scores.
Please see later in the article for the Editors' Summary
Professional societies use metrics to evaluate medical schools' policies regarding interactions of students and faculty with the pharmaceutical and medical device industries. We compared these metrics and determined which US medical schools' industry interaction policies were associated with student behaviors.
Methods and Findings
Using survey responses from a national sample of 1,610 US medical students, we compared their reported industry interactions with their schools' American Medical Student Association (AMSA) PharmFree Scorecard and average Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database score. We used hierarchical logistic regression models to determine the association between policies and students' gift acceptance, interactions with marketing representatives, and perceived adequacy of faculty–industry separation. We adjusted for year in training, medical school size, and level of US National Institutes of Health (NIH) funding. We used LASSO regression models to identify specific policies associated with the outcomes. We found that IMAP and AMSA scores had similar median values (1.75 [interquartile range 1.50–2.00] versus 1.77 [1.50–2.18], adjusted to compare scores on the same scale). Scores on AMSA and IMAP shared policy dimensions were not closely correlated (gift policies, r = 0.28, 95% CI 0.11–0.44; marketing representative access policies, r = 0.51, 95% CI 0.36–0.63). Students from schools with the most stringent industry interaction policies were less likely to report receiving gifts (AMSA score, odds ratio [OR]: 0.37, 95% CI 0.19–0.72; IMAP score, OR 0.45, 95% CI 0.19–1.04) and less likely to interact with marketing representatives (AMSA score, OR 0.33, 95% CI 0.15–0.69; IMAP score, OR 0.37, 95% CI 0.14–0.95) than students from schools with the lowest ranked policy scores. The association became nonsignificant when fully adjusted for NIH funding level, whereas adjusting for year of education, size of school, and publicly versus privately funded school did not alter the association. Policies limiting gifts, meals, and speaking bureaus were associated with students reporting having not received gifts and having not interacted with marketing representatives. Policy dimensions reflecting the regulation of industry involvement in educational activities (e.g., continuing medical education, travel compensation, and scholarships) were associated with perceived separation between faculty and industry. The study is limited by potential for recall bias and the cross-sectional nature of the survey, as school curricula and industry interaction policies may have changed since the time of the survey administration and study analysis.
As medical schools review policies regulating medical students' industry interactions, limitations on receipt of gifts and meals and participation of faculty in speaking bureaus should be emphasized, and policy makers should pay greater attention to less research-intensive institutions.
Please see later in the article for the Editors' Summary
Editors' Summary
Making and selling prescription drugs and medical devices is big business. To promote their products, pharmaceutical and medical device companies build relationships with physicians by providing information on new drugs, by organizing educational meetings and sponsored events, and by giving gifts. Financial relationships begin early in physicians' careers, with companies providing textbooks and other gifts to first-year medical students. In medical school settings, manufacturers may help to inform trainees and physicians about developments in health care, but they also create the potential for harm to patients and health care systems. These interactions may, for example, reduce trainees' and trained physicians' skepticism about potentially misleading promotional claims and may encourage physicians to prescribe new medications, which are often more expensive than similar unbranded (generic) drugs and more likely to be recalled for safety reasons than older drugs. To address these and other concerns about the potential career-long effects of interactions between medical trainees and industry, many teaching hospitals and medical schools have introduced policies to limit such interactions. The development of these policies has been supported by expert professional groups and medical societies, some of which have created scales to evaluate the strength of the implemented industry interaction policies.
Why Was This Study Done?
The impact of policies designed to limit interactions between students and industry on student behavior is unclear, and it is not known which aspects of the policies are most predictive of student behavior. This information is needed to ensure that the policies are working and to identify ways to improve them. Here, the researchers investigate which medical school characteristics and which aspects of industry interaction policies are most predictive of students' reported behaviors and beliefs by comparing information collected in a national survey of US medical students with the strength of their schools' industry interaction policies measured on two scales—the American Medical Student Association (AMSA) PharmFree Scorecard and the Institute on Medicine as a Profession (IMAP) Conflicts of Interest Policy Database.
What Did the Researchers Do and Find?
The researchers compared information about reported gift acceptance, interactions with marketing representatives, and the perceived adequacy of faculty–industry separation collected from 1,610 medical students at 121 US medical schools with AMSA and IMAP scores for the schools evaluated a year earlier. Students at schools with the highest ranked interaction policies based on the AMSA score were 63% less likely to accept gifts as students at the lowest ranked schools. Students at the highest ranked schools based on the IMAP score were about half as likely to accept gifts as students at the lowest ranked schools, although this finding was not statistically significant (it could be a chance finding). Similarly, students at the highest ranked schools were 70% less likely to interact with sales representatives as students at the lowest ranked schools. These associations became statistically nonsignificant after controlling for the amount of research funding each school received from the US National Institutes of Health (NIH). Policies limiting gifts, meals, and being a part of speaking bureaus (where companies pay speakers to present information about the drugs for dinners and other events) were associated with students' reports of receiving no gifts and of non-interaction with sales representatives. Finally, policies regulating industry involvement in educational activities were associated with the perceived separation between faculty and industry, which was regarded as adequate by most of the students at schools with such policies.
What Do These Findings Mean?
These findings suggest that policies designed to limit industry interactions with medical students need to address multiple aspects of these interactions to achieve changes in the behavior and attitudes of trainees, but that policies limiting gifts, meals, and speaking bureaus may be particularly important. These findings also suggest that the level of NIH funding plays an important role in students' self-reported behaviors and their perceptions of industry, possibly because institutions with greater NIH funding have the resources needed to implement effective policies. The accuracy of these findings may be limited by recall bias (students may have reported their experiences inaccurately), and by the possibility that industry interaction policies may have changed in the year that elapsed between policy grading and the student survey. Nevertheless, these findings suggest that limitations on gifts should be emphasized when academic medical centers refine their policies on interactions between medical students and industry and that particular attention should be paid to the design and implementation of policies that regulate industry interactions in institutions with lower levels of NIH funding.
Additional Information
Please access these websites via the online version of this summary at
The UK General Medical Council provides guidance on financial and commercial arrangements and conflicts of interest as part of its good medical practice document, which describes what is required of all registered doctors in the UK
Information about the American Medical Student Association (AMSA) Just Medicine campaign (formerly the PharmFree campaign) and about the AMSA Scorecard is available
Information about the Institute on Medicine as a Profession (IMAP) and about its Conflicts of Interest Policy Database is also available
“Understanding and Responding to Pharmaceutical Promotion: A Practical Guide” is a manual prepared by Health Action International and the World Health Organization that medical schools can use to train students how to recognize and respond to pharmaceutical promotion
The US Institute of Medicine's report “Conflict of Interest in Medical Research, Education, and Practice” recommends steps to identify, limit, and manage conflicts of interest
The ALOSA Foundation provides evidence-based, non-industry-funded education about treating common conditions and using prescription drugs
PMCID: PMC4196737  PMID: 25314155
12.  444 Associations between Self-reported Adherence to Asthma Anti-inflammatory Therapy and Risk Factors for Non-adherence (NA) in Pediatric Patients 
The World Allergy Organization Journal  2012;5(Suppl 2):S158-S159.
Identifying patient adherence status and reasons for non-adherence are important components of asthma management. GINA 2008 Guidelines have identified risk-factors associated with poor adherence
Three hundred sixty one parents of children with intermittent and persistent asthma (59.6% male; 64.1% Caucasian; mean age 8.07 years) completed the AsthmaPACT, a 96-item asthma survey hosted by the Asthma and Allergy Foundation of America website. The AsthmaPACT identifies risk-factors for not following treatment recommendations as well as medication use. Asthma surveys were completed from August 2009 thru June 2011.
Descriptive statistics indicated that 259 of the sample reported giving their child one or more of the anti-inflammatory medication prescribed. Of these, 69 (27%) were diagnosed as NA, operationalized as whether a parent reported giving the child anti-inflammatory medication "less than prescribed by their physician." During the 4 weeks prior to completing the survey, 43.0% were having symptoms daily and 39.4% were using albuterol MDI daily. In this cross-sectional data set, items intended to relate risk factors to NA were examined using chi square (χ2). Parents who claimed that their child receive less anti-inflammatory medication than prescribed, were more likely to report: 1) symptoms from emotional states: crying χ2(df = 2) = 8.643 P = 0.013; frustration χ2(df = 2) 6.202 P = 0.045; anger χ2(df = 2) = 11.029 P = 0.0042); Parent more likely to see child as anxious or a worrier χ2(df = 2) = 6.527 P = 0.038; 2) Child's Quality of Life (QoL): is more likely to be effected at school χ2(df = 2) = 12.963 P = 0.002; and interfere with family activities χ2 (df = 2) = 8.856 P = 0.012; 3) Parent's QoL is more likely to interfere with work χ2 (df = 2) = 16.517 P < 0.001; recreational activities χ2 (df = 2) 17.759 P < 0.001 and family activities χ2 (df = 2) = 16.517 P < 0.001; 4) Parents are more likely not to agree regarding asthma management χ2 (df = 2) = 7.677 P = 0.022; not to agree with relatives/caregivers on how to manage asthma χ2 (df = 2) = 9.853 P = 0.007; lack confidence in teachers/school personnel to manage asthma at school χ2(df = 2) = 20.216 P < 0.001.
The AsthmaPACT provides an assessment of 1) risk-factors for non-adherence and 2) patient self-report of adherence, and is readily available as a tool to individuals with asthma who have access to the Internet. Findings in this study are consistent with GINA 2008 Guidelines regarding common risk-factors for non-adherence and specifically to the child's emotional state and QoL for both the child and parent. The AsthmaPACT might be considered for symptomatic patients to identify barriers to treatment and diagnose adherence status.
PMCID: PMC3512985
13.  Are Sudanese community pharmacists capable to prescribe and demonstrate asthma inhaler devices to patrons? A mystery patient study 
Pharmacy Practice  2012;10(2):110-115.
Although community pharmacists have become more involved in the care of asthma patients, several studies have assessed pharmacists’'ability to illustrate appropriately inhalation technique of different asthma devices. Many studies addressed inappropriate use of asthma devices by patients and pharmacists, in addition to its clinical, humanistic and economic burden.
To evaluate community pharmacists' practical knowledge and skills of demonstrating proper inhalation technique of asthma inhaler devices available in Sudan.
Three hundred community pharmacies located around the three major hospitals in the capital city (Khartoum) and four other provinces were approached, and four asthma devices were assessed: Metered-dose inhaler (MDI) (n=105), MDI with Spacer (n=83), Turbuhaler (n=61), and Diskus (n=51). Investigator (a pharmacist) acted as a mystery patient. He selected one device and asked the serving pharmacist to demonstrate how to use the device. Investigator completed a checklist of 9 steps of inhaler device use immediately after leaving the pharmacy. Essential steps derived from published literature were pre-specified for each device. Five evaluation categories were accordingly formulated as follows: optimal technique, adequate technique, poor technique, totally unfamiliar with the device, and does not know.
More than half of the pharmacists approached with metered dose inhaler did not know how to use optimal technique (ie all steps correct) all through. A third poorly demonstrated the technique, and only one pharmacist was categorized as being able to demonstrate an "optimal technique". The majority of pharmacists approached with spacing chamber and dry powder inhalers (Turbuhaler and Diskus) either did not know proper technique or were totally unfamiliar with the devices.
The majority of community pharmacists, who were expected to educate asthma patients on their dispensed inhalers, lack the basic knowledge of proper use of commonly dispensed asthma inhaler devices.
PMCID: PMC3780485  PMID: 24155826
Nebulizers and Vaporizers; Asthma; Community Pharmacy Services; Pharmacists; Patient Simulation; Sudan
14.  Developmental Profiles of Eczema, Wheeze, and Rhinitis: Two Population-Based Birth Cohort Studies 
PLoS Medicine  2014;11(10):e1001748.
Using data from two population-based birth cohorts, Danielle Belgrave and colleagues examine the evidence for atopic march in developmental profiles for allergic disorders.
Please see later in the article for the Editors' Summary
The term “atopic march” has been used to imply a natural progression of a cascade of symptoms from eczema to asthma and rhinitis through childhood. We hypothesize that this expression does not adequately describe the natural history of eczema, wheeze, and rhinitis during childhood. We propose that this paradigm arose from cross-sectional analyses of longitudinal studies, and may reflect a population pattern that may not predominate at the individual level.
Methods and Findings
Data from 9,801 children in two population-based birth cohorts were used to determine individual profiles of eczema, wheeze, and rhinitis and whether the manifestations of these symptoms followed an atopic march pattern. Children were assessed at ages 1, 3, 5, 8, and 11 y. We used Bayesian machine learning methods to identify distinct latent classes based on individual profiles of eczema, wheeze, and rhinitis. This approach allowed us to identify groups of children with similar patterns of eczema, wheeze, and rhinitis over time.
Using a latent disease profile model, the data were best described by eight latent classes: no disease (51.3%), atopic march (3.1%), persistent eczema and wheeze (2.7%), persistent eczema with later-onset rhinitis (4.7%), persistent wheeze with later-onset rhinitis (5.7%), transient wheeze (7.7%), eczema only (15.3%), and rhinitis only (9.6%). When latent variable modelling was carried out separately for the two cohorts, similar results were obtained. Highly concordant patterns of sensitisation were associated with different profiles of eczema, rhinitis, and wheeze. The main limitation of this study was the difference in wording of the questions used to ascertain the presence of eczema, wheeze, and rhinitis in the two cohorts.
The developmental profiles of eczema, wheeze, and rhinitis are heterogeneous; only a small proportion of children (∼7% of those with symptoms) follow trajectory profiles resembling the atopic march.
Please see later in the article for the Editors' Summary
Editors' Summary
Our immune system protects us from viruses, bacteria, and other pathogens by recognizing specific molecules on the invader's surface and initiating a sequence of events that culminates in the death of the pathogen. Sometimes, however, our immune system responds to harmless materials (allergens such as pollen) and triggers allergic, or atopic, symptoms. Common atopic symptoms include eczema (transient dry itchy patches on the skin), wheeze (high pitched whistling in the chest, a symptom of asthma), and rhinitis (sneezing or a runny nose in the absence of a cold or influenza). All these symptoms are very common during childhood, but recent epidemiological studies (examinations of the patterns and causes of diseases in a population) have revealed age-related changes in the proportions of children affected by each symptom. So, for example, eczema is more common in infants than in school-age children. These findings have led to the idea of “atopic march,” a natural progression of symptoms within individual children that starts with eczema, then progresses to wheeze and finally rhinitis.
Why Was This Study Done?
The concept of atopic march has led to the initiation of studies that aim to prevent the development of asthma in children who are thought to be at risk of asthma because they have eczema. Moreover, some guidelines recommend that clinicians tell parents that children with eczema may later develop asthma or rhinitis. However, because of the design of the epidemiological studies that support the concept of atopic march, children with eczema who later develop wheeze and rhinitis may actually belong to a distinct subgroup of children, rather than representing the typical progression of atopic diseases. It is important to know whether atopic march adequately describes the natural history of atopic diseases during childhood to avoid the imposition of unnecessary strategies on children with eczema to prevent asthma. Here, the researchers use machine learning techniques to model the developmental profiles of eczema, wheeze, and rhinitis during childhood in two large population-based birth cohorts by taking into account time-related (longitudinal) changes in symptoms within individuals. Machine learning is a data-driven approach that identifies structure within the data (for example, a typical progression of symptoms) using unsupervised learning of latent variables (variables that are not directly measured but are inferred from other observable characteristics).
What Did the Researchers Do and Find?
The researchers used data from two UK birth cohorts—the Avon Longitudinal Study of Parents and Children (ALSPAC) and the Manchester Asthma and Allergy Study (MAAS)—for their study (9,801 children in total). Both studies enrolled children at birth and monitored their subsequent health at regular review clinics. At each review clinic, information about eczema, wheeze, and rhinitis was collected from the parents using validated questionnaires. The researchers then used these data and machine learning methods to identify groups of children with similar patterns of onset of eczema, wheeze, and rhinitis over the first 11 years of life. Using a type of statistical model called a latent disease profile model, the researchers found that the data were best described by eight latent classes—no disease (51.3% of the children), atopic march (3.1%), persistent eczema and wheeze (2.7%), persistent eczema with later-onset rhinitis (4.7%), persistent wheeze with later-onset rhinitis (5.7%), transient wheeze (7.7%), eczema only (15.3%), and rhinitis only (9.6%).
What Do These Findings Mean?
These findings show that, in two large UK birth cohorts, the developmental profiles of eczema, wheeze, and rhinitis were heterogeneous. Most notably, the progression of symptoms fitted the profile of atopic march in fewer than 7% of children with symptoms. The researchers acknowledge that their study has some limitations. For example, small differences in the wording of the questions used to gather information from parents about their children's symptoms in the two cohorts may have slightly affected the findings. However, based on their findings, the researchers propose that, because eczema, wheeze, and rhinitis are common, these symptoms often coexist in individuals, but as independent entities rather than as a linked progression of symptoms. Thus, using eczema as an indicator of subsequent asthma risk and assigning “preventative” measures to children with eczema is flawed. Importantly, clinicians need to understand the heterogeneity of patterns of atopic diseases in children and to communicate this variability to parents when advising them about the development and resolution of atopic symptoms in their children.
Additional Information
Please access these websites via the online version of this summary at
The UK National Health Service Choices website provides information about eczema (including personal stories), asthma (including personal stories), and rhinitis
The US National Institute of Allergy and Infectious Diseases provides information about atopic diseases
The UK not-for-profit organization Allergy UK provides information about atopic diseases and a description of the atopic march
MedlinePlus encyclopedia has pages on eczema, wheezing, and rhinitis (in English and Spanish)
MedlinePlus provides links to further resources about allergies, eczema, and asthma (in English and Spanish)
Information about ALSPAC and MAAS is available
Wikipedia has pages on machine learning and latent disease profile models (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
PMCID: PMC4204810  PMID: 25335105
15.  Risk Assessment and Community Participation Model for Environmental Asthma Management in an Elementary Public School: A Case Study in Puerto Rico 
Asthma is a rapidly growing chronic disease in the general population of the world, mostly in children. Puerto Ricans have the highest prevalence of children with asthma among the Hispanic community in the US and its territories. Asthma and air quality are becoming a significant and potentially costly public health issue in Puerto Rico. The CDC has reported that in Puerto Rico, 320,350 adults have asthma and this number represents 11.5% of the island adult population. The north east municipality of Carolina, Puerto Rico, has the highest asthma prevalence in the 0 to 17 year old range (2001 data). In this study, we address the potential relationship between anthropogenic and naturally occurring environmental factors, and asthma prevalence in an urban elementary public school in Carolina in an effort to empower and engage communities to work on their environmental health issues. We integrated geographic information systems (GIS) data of anthropogenic activities near the school as well as the natural resources and geomorphology of the region. We found that as Carolina is close by to Caribbean National Forest (El Yunque), this together with the temperature and precipitation cycles in the zone creates the ideal environmental conditions for increased humidity and pollen, mold and fungi development through out the year. We also collected health and socio economic data to generate an asthma profile of the students, employees and parents from the school community, and through a survey we identified perceptions on environmental asthma triggers, and indoor air quality in the school and homes of the students and employees. Finally, we implemented a workshop on indoor air quality designed to engage the school community in managing asthma triggers and the school environment. Our results showed that nearly 30 % of its student’s population has asthma, and from this group 58% are males and 42% are female students. Of all asthmatic children, only 43% receive treatment for the disease. The study also showed that most asthmatic children are between 7 and 9 year old, and live in households with an annual income below $10,000. It also showed that 25 % of the student’s parents have the condition, and that 25% of the employees are also affected by this chronic condition. All these numbers are significantly higher than those reported by the CDC for Puerto Rico. The perception component had a response of 83% of school employees, and a 39% response from parents. It showed that people know asthma as a disease but many can’t identify most environmental asthma triggers. Pre and post tests of the workshop protocol showed that before the activity only 21% of participants can identify asthma triggers. At the end of the workshop nearly 80% were able to identify and manage environmental asthma triggers. This work validates the fact that Puerto Rico continues to have a significant number of people with asthma, particularly children asthma, and that schools are an important settings to create community based action plans to manage environmental asthma triggers through outreach and training.
PMCID: PMC3785682  PMID: 16823079
Asthma; Environment; Prevalence; Schools; Community; Puerto Rico
16.  Advances in Pediatric Asthma in 2010: Addressing the Major Issues 
Last year’s Advances in Pediatric Asthma concluded with the following statement “If we can close these [remaining] gaps through better communication, improvements in the health care system and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children”. This year’s summary will focus on recent advances in pediatric asthma that take steps moving forward as reported in Journal of Allergy and Clinical Immunology publications in 2010.
Some of those recent reports show us how to improve asthma management through steps to better understand the natural history of asthma, individualize asthma care, reduce asthma exacerbations, manage inner city asthma, and some potential new ways to use available medications to improve asthma control. It is clear that we have made many significant gains in managing asthma in children but we have a ways to go to prevent asthma exacerbations, alter the natural history of the disease, and to reduce health disparities in asthma care.
Perhaps new directions in personalized medicine and improved health care access and communication will help maintain steady progress in alleviating the burden of this disease in children, especially young children.
PMCID: PMC3032272  PMID: 21211645
asthma; asthma control; asthma impairment; asthma risk; asthma severity; early intervention in asthma; biomarkers; genetics; inhaled corticosteroids; leukotriene receptor antagonists; long-acting β-adrenergic agonists; omalizumab; personalized medicine; therapeutics
17.  Role of Skin Prick Test in Allergic Disorders: A Prospective Study in Kashmiri Population in Light of Review 
Indian Journal of Dermatology  2013;58(1):12-17.
Skin prick test (SPT) is the most effective diagnostic test to detect IgE mediated type I allergic reactions like allergic rhinitis, atopic asthma, acute urticaria, food allergy etc. SPTs are done to know allergic sensitivity and applied for devising immunotherapy as the therapeutic modality.
Materials and Methods:
This prospective study was conducted in the department of Immunology and Molecular medicine at SKIMS. A total of 400 patients suffering from allergic rhinitis, asthma and urticaria were recruited in this study. SPT was performed with panel of allergens including house dust mite, pollens, fungi, dusts, cockroach, sheep wool and dog epithelia. Allergen immunotherapy was given to allergic rhinitis and asthmatic patients as therapeutic modality.
In our study, age of patients ranged from 6 to 65 years. Majority of patients were in the age group of 20-30 years (72%) with Male to female ratio of 1:1.5. Of the 400 patients, 248 (62%) had urticaria, 108 (27%) patients had allergic rhinitis and 44 (11%) patients had asthma. SPT reaction was positive in 38 (86.4%) with allergic asthma, 74 (68.5%) patients with allergic rhinitis and 4 (1.6%) patient with urticaria, respectively. Allergen immunotherapy was effective in 58% patients with allergic rhinitis and 42% allergic asthma.
Identifiable aeroallergen could be detected in 86.4% allergic asthma and 68.5% allergic rhinitis patients by SPT alone. Pollens were the most prevalent causative allergen. There was significant relief in the severity of symptoms, medication intake with the help of allergen immunotherapy.
PMCID: PMC3555364  PMID: 23372205
Allergic rhinitis; asthma; Kashmir; skin prick test
18.  Advanced medical students’ experiences and views on professionalism at Kuwait University 
BMC Medical Education  2014;14:150.
Professionalism is a core competency in the medical profession worldwide. Numerous studies investigate how this competency is taught and learned. However, there are few reports on the students’ views and experiences with professionalism especially in the Arab world. Our aim was to explore the experiences and views of Kuwait final-year medical students on professionalism.
This was a questionnaire study of final-year medical students at Kuwait University (n = 95). Open- and close-ended questions were used to determine the students’ experiences and views on: definition, teaching, learning, and assessment of professionalism.
Eighty-five of the students completed the questionnaire (89.5%). A total of 252 attributes defining professionalism were listed by our respondents. The majority (98.0%) of these attributes were categorized under the CanMEDS theme describing professionalism as commitment to patients, profession, and society through ethical practice. The most helpful methods in learning about professionalism for the students were contact with positive role models, patients and families, and with their own families, relatives and peers. The students’ rating of the quality and quantity of teaching professionalism in the institution was quite variable. Despite this, 68.2% of the students felt very or somewhat comfortable explaining the meaning of medical professionalism to junior medical students. Almost half of the students felt that their education had always or sometimes helped them deal with professionally-challenging situations. Majority (77.6%) of the students thought that their academic assessments should include assessment of professionalism and should be used as a selection criterion in their future academic careers (62.3%). Most of the students discussed and sought advice regarding professionally-challenging situations from their fellow medical students and colleagues. Seventy-five (88.2%) students did not know which organizational body in the institution deals with matters pertaining to medical professionalism.
This study highlights the influence of the curriculum, the hidden curriculum, and culture on medical students’ perception of professionalism. Medical educators should take in account such influences when teaching and assessing professionalism. Future research should aim at creating a framework of competencies that addresses professionalism in a context suitable for the Arabian culture.
PMCID: PMC4118198  PMID: 25056201
Professionalism; Undergraduate; Curriculum
19.  583 Epidemiology of Urticaria Cases in the Allergy Service from a Third Level Medical Center. Six Year Experience 
The World Allergy Organization Journal  2012;5(Suppl 2):S201-S202.
The purpose of this study is to report the cases of Urticaria diagnosed in the Allergy service from a Third level medical centre since its creation in July 2005.
This is a descriptive, retrospective, transversal study from July 2005 to February 2011. Selected medical records of patients apply for diagnostic criteria for an allergy disease. EAACI/GA2LEN/EDF/WAO guideline 2009 was used to make diagnosis of urticaria. Patients were classified by age and sex, and how many of them had skin prick test, also how many patients began treatment with immunotherapy.
Thirteen thousand seven hundred and thirty seven consultations were attended in the Allergy service between the period mentioned; 2,337 medical records of patients were selected; 1,608 patients applied for a specific diagnosis for an allergy disease; 90 completed criteria for urticaria, after allergic rhinitis, asthma an atopic conjuntivitis. 49 (54.4%) patients were found to be in the range of 30 to 40 years; 36 (73.4%) of them were female. The majority of urticaria patients were in the range of 40's with 28 (18 F/10 M) corresponding to 31.1% of total of patients. 43 patients were classified with acute urticaria, 26 as chronic urticaria. 19 patients presented angioedema at the time of diagnosis. Skin prick test were made in 27 patients only in 10 were positive and began immunotherapy. Patients with positive skin prick test results with 9 at dust mites, 4 cockroach, 3 mosquito, 3 fungus and 8 grass and tree pollen.
Urticaria represents the fourth cause of incidence in allergy diseases in this study. Female sex is more frequently affected in the range of 30 to 40 years of age. We found statistical data comparable with international information, that forms part of our data base en Mexican patients in our center, also we standaridzed procedures for testing physical urticaria.
PMCID: PMC3512948
20.  Variably severe systemic allergic reactions after consuming foods with unlabelled lupin flour: a case series 
Lupin allergy remains a significant cause of food-induced allergic reactivity and anaphylaxis. Previous work suggests a strong association with legume allergy and peanut allergy in particular. Both doctors and the public have little awareness of lupin as an allergen.
Case presentation
Case 1 was a 41-year-old Caucasian woman without previous atopy who developed facial swelling, widespread urticaria with asthma and hypotension within minutes of eating a quiche. Her lupin allergy was confirmed by both blood and skin tests. Her lupin sensitivity was so severe that even the miniscule amount of lupin allergen in the skin testing reagent produced a mild reaction.
Case 2 was a 42-year-old mildly atopic Caucasian woman with three episodes of worsening urticaria and asthma symptoms over 6 years occurring after the consumption of foods containing lupin flour. Blood and skin tests were positive for lupin allergy.
Case 3 was a 38-year-old Caucasian woman with known oral allergy syndrome who had two reactions associated with urticaria and vomiting after consuming foods containing lupin flour. Skin testing confirmed significant responses to a lupin flour extract and to one of the foods inducing her reaction.
Case 4 was a 54-year-old mildly atopic Caucasian woman with a 7 year history of three to four episodes each year of unpredictable oral tingling followed by urticaria after consuming a variety of foods. The most recent episode had been associated with vomiting. She had developed oral tingling with lentil and chickpeas over the previous year. Skin and blood tests confirmed lupin allergy with associated sensitivity to several legumes.
Lupin allergy can occur for the first time in adults without previous atopy or legume sensitivity. Although asymptomatic sensitisation is frequent, clinical reactivity can vary in severity from severe anaphylaxis to urticaria and vomiting. Lupin allergy may be confirmed by skin and specific immunoglobulin E estimation. Even skin testing can cause symptoms in some highly sensitive individuals. The diagnosis of lupin allergy in adults may be difficult because it is frequently included as an undeclared ingredient. Better food labelling and medical awareness of lupin as a cause of serious allergic reactions is suggested.
PMCID: PMC3943371  PMID: 24529316
Anaphylaxis; Food labelling; Gluten-free spaghetti; Lupin allergy; Oral allergy
21.  Asthma, allergy, and atopy in three south-east Asian populations. 
Thorax  1994;49(12):1205-1210.
BACKGROUND--Whilst many recent reports have suggested a rise in the prevalence of asthma and allergic disease in Western countries, little is known about the epidemiology of these common conditions in south-east Asia. This study compared the prevalence of asthma and allergic disease amongst secondary school students in three south-east Asian populations--Hong Kong, Kota Kinabalu in Malaysia, and San Bu in China--and investigated the associations with atopy and family history. METHODS--Secondary school students were given standard questionnaires on respiratory and allergic symptoms for completion by parents with response rates of 89.2% in Hong Kong (611 male, 451 female; mean (SD) age = 13.9 (1.8 years), 87.6% in Kota Kinabalu (134 male, 275 female; 15.5 (2.1) years), and 98.6% in San Bu (492 male, 245 female; 16.4 (1.8) years). Skin tests were performed in a subsample of students to determine atopic status. RESULTS--The respective prevalence (and 95% CI) for hayfever, eczema, and wheeze or asthma were 15.7% (13.5, 17.9), 20.1% (17.7, 22.5), 11.6% (9.3, 13.9) in Hong Kong, 11.2% (8.2, 14.3), 7.6% (5.0, 10.1), 8.2% (5.5, 10.9) in Kota Kinabalu, and 2.1% (1.2, 3.1), 7.2% (5.4, 9.1), 1.9% (0.7, 3.1) in San Bu. Atopy was common and was present in 49.0-63.9% of subjects in the three populations. Dust mite and cockroach were the commonest allergens that gave positive reactions in 42.8-60.5% and 25.7-35.9% of students respectively. A higher proportion of students in Hong Kong had severe degree of reactivity on skin test than the other two populations. Family history was associated with asthma and allergic symptoms in the three populations conferring a 3-80-fold increase in risk to family members and was a stronger predictor for asthma and allergy than atopy. CONCLUSIONS--Prevalence of asthma and allergic disease is low compared with Western countries, but considerable differences exist between the three south-east Asian populations despite similar rates of atopy. Asthma and allergic disease are more strongly associated with family history than atopy, which suggests that genetic and environmental factors common to the family, other than aeroallergen sensitisation, are important in the pathogenesis of asthma and allergy in the region.
PMCID: PMC475324  PMID: 7878553
22.  Health-related quality of life among adolescents with allergy-like conditions – with emphasis on food hypersensitivity 
It is known that there is an increase in the prevalence of allergy and that allergic diseases have a negative impact on individuals' health-related quality of life (HRQL). However, research in this field is mainly focused on individuals with verified allergy, i.e. leaving out those with self-reported allergy-like conditions but with no doctor-diagnosis. Furthermore, studies on food hypersensitivity and quality of life are scarce. In order to receive information about the extent to which adolescent females and males experience allergy-like conditions and the impact of these conditions on their everyday life, the present study aimed to investigate the magnitude of self-reported allergy-like conditions in adolescence and to evaluate their HRQL. Special focus was put on food hypersensitivity as a specific allergy-like condition and on gender differences.
In connection with lessons completed at the children's school, a study-specific questionnaire and the generic instrument SF-36 were distributed to 1488 adolescents, 13–21 years old (response rate 97%).
Sixty-four per cent of the respondents reported some kind of allergy-like condition: 46% reported hypersensitivity to defined substances and 51% reported allergic diseases (i.e. asthma/wheezing, eczema/rash, rhino-conjunctivitis). A total of 19% reported food hypersensitivity. Females more often reported allergy-like conditions compared with males (p < 0.001). The adolescents with allergy-like conditions reported significantly lower HRQL (p < 0.001) in seven of the eight SF-36 health scales compared with adolescents without such conditions, regardless of whether the condition had been doctor-diagnosed or not. Most adolescents suffered from complex allergy-like conditions.
The results indicate a need to consider the psychosocial impact of allergy-like conditions during school age. Further research is needed to elucidate the gender differences in this area. A team approach addressing better understanding of how allergy-like conditions impair the HRQL may improve the management of the adolescent's health problems, both in health-care services and in schools.
PMCID: PMC534793  PMID: 15555064
Health-related quality of life; hypersensitivity; allergic disease; food hypersensitivity; adolescence; gender
23.  445 Inability of Medical Students to Use of Three Types of Inhaler 
Several studies have demonstrated that a significant percentage of health care professionals are deficient in both knowledge and skill regarding the inhalers. But no data is available about the assessment of inhaler technique and knowledge among medical students in Korea. The aim of this study was to evaluate the proficiency and knowledge of medical students in proper use of 3 kinds of inhalers (metered dose inhaler, turbuhaler, and diskus).
We enrolled 40 third-year medical students who are on hospital training course. The participants received 25 to 35 minutes of instruction from a trained nurse educator for asthma. Three month later, we assessed their knowledge and skill regarding inhaler use. They were asked to discriminate each type of 3 devices and to demonstrate the use of each device using placebo inhalers. Also, they were asked about the prevention and management for local adverse reaction induced by inhaled corticosteroids (ICS). Participants's inhaler skill was assessed into 3 levels as good, inadequate, and poor for each device type.
Only 12.5% (5/40) of medical students could explain the merits of inhalation therapy compared to oral route. 67.5% (27/40) of participants could not discriminate all types of inhaler devices. With regards to prevention and treatment option for ICS-related local side effects, only 22.5% (9/40) answered correctly. Subjects with good performance grade were found in 12.5% for metered dose inhaler, 40.0% for turbuhaler, and 57.5% for diskus.
We conclude that large percent of medical students were deficient in knowledge and proficiency regarding the inhalers. A brief educational session with demonstration by trained asthma nurse was not effective in enhancing inhaler technique or increasing knowledge on inhaler treatment.
PMCID: PMC3513172
24.  Association of asthma and hay fever with irregular menstruation 
Thorax  2005;60(6):445-450.
Background: There is some evidence that asthmatic women are more likely to have abnormal sex hormone levels. A study was undertaken to determine whether asthma and allergy were associated with irregular menstruation in a general population, and the potential role of asthma medication for this association.
Methods: A total of 8588 women (response rate 77%) participated in an 8 year follow up postal questionnaire study of participants of the ECRHS stage I in Denmark, Estonia, Iceland, Norway, and Sweden. Only non-pregnant women not taking exogenous sex hormones were included in the analyses (n = 6137).
Results: Irregular menstruation was associated with asthma (OR 1.54 (95% CI 1.11 to 2.13)), asthma symptoms (OR 1.47 (95% CI 1.16 to 1.86)), hay fever (OR 1.29 (95% CI 1.05 to 1.57)), and asthma preceded by hay fever (OR 1.95 (95% CI 1.30 to 2.96)) among women aged 26–42 years. This was also observed in women not taking asthma medication (asthma symptoms: OR 1.44 (95% CI 1.09 to 1.91); hay fever: OR 1.27 (95% CI 1.03 to 1.58); wheeze preceded by hay fever: OR 1.76 (95% CI 1.18 to 2.64)). Irregular menstruation was associated with new onset asthma in younger women (OR 1.58 (95% CI 1.03 to 2.42)) but not in women aged 42–54 years (OR 0.62 (95% CI 0.32 to 1.18)). The results were consistent across centres.
Conclusions: Younger women with asthma and allergy were more likely to have irregular menstruation. This could not be attributed to current use of asthma medication. The association could possibly be explained by common underlying metabolic or developmental factors. The authors hypothesise that insulin resistance may play a role in asthma and allergy.
PMCID: PMC1747439  PMID: 15923242
25.  Frequently asked questions in allergy practice 
Asia Pacific Allergy  2014;4(1):48-53.
Over the last 10-20 years, international guidelines and consensus statements for the management of common allergic diseases (e.g. allergic rhinitis and asthma) have been developed and disseminated worldwide. However, their impact on knowledge and standard of clinical practice among primary care physicians and specialists is unknown.
To investigate need for an improvement in the dissemination of international guidelines for the diagnosis and management of allergic rhinitis.
Seven medical students who attended 3-day 1st International Basic Allergy Course (2010) took down all questions raised during the entire course. A systemic analysis of these questions was performed to identify areas for improvement in diagnosis and management of allergic diseases mainly in the Association of Southeast Asian Nations (ASEAN) region.
268 participants, 143 males and 125 females, comprising Ear, Nose and Throat (ENT) specialists (n = 106) and trainees (n = 34), general practitioners (n = 87), and other healthcare professionals (n = 41) attended the course. Of the 103 questions recorded, 59 were regarding treatment modalities in allergy practice such as immunotherapy (n = 38), pharmacologics (n = 15), nasal surgery (n = 2), and others (n = 4). 41 questions (39.8%) have answers based in the Allergic Rhinitis and its Impact on Asthma guidelines (2001 and 2008). Certain questions were selected for further analysis because they appeared to be (a) more commonly asked (e.g. immunotherapy) or (b) were deemed to be challenging or, even controversial (e.g. food allergy and differential diagnosis between vasovagal and anaphylaxis reaction), as the recommendations in current international guidelines were less well-defined.
Our study identified several problems that, if tackled, could help minimize confusion and provide better care for patients suffering from allergic diseases especially in the ASEAN region.
PMCID: PMC3921870  PMID: 24527411
Allergic diseases; International guidelines; Management; Immunotherapy; Vasovagal and anaphylaxis reaction; Food allergy

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