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Child’s fear of choking again can lead to weight loss and eating issues

Child’s fear of choking again can lead to weight loss and eating issues

Some children who have endured a scary choking incident may suffer from what’s called Avoidant-Restrictive Food Intake Disorder. The disorder was recently reviewed in The New England Journal of Medicine and presents as a condition associated with weight loss due to eating difficulties following a choking incident.

The child basically fears having another choking episode. This leads to avoiding solid food, preferring or demanding only soft food or liquids such as milkshakes, puddings and oatmeal. Weight loss follows because the child also restricts the quantity consumed and receives inadequate calories.

This is a different condition than anorexia because its cause is the antecedent choking, but the result can be the same.

It seems that children who were “picky eaters” as toddlers are more prone to this condition if they choke. The condition is most commonly seen between the ages of 4 and 16.

More than weather events, summer storms can trigger allergic asthma

More than weather events, summer storms can trigger allergic asthma

Nine people died and 8,500 more recently were hospitalized with severe asthma in Australia in a single week of thunderstorms. Said storms occurred during the peak of rye grass pollen season. The rain caused the pollen to become saturated, and the electrical discharges caused fragmentation of the pollen grains into tiny particles.  More typically, pollen grains are filtered out by the nose/sinus area, leading to hay fever symptoms. But tiny fragments created by the storms were able to slip right through the upper airways, landing in the lungs, precipitating sudden, severe allergic asthma. In addition, many of the victims had no prior history of asthma, just allergic hay fever.

Dear Dr. Sasha K: Do I really need my appendix out?

Dear Dr. Sasha K: Do I really need my appendix out?

First of all, we don’t really need an appendix, which is why it is often removed as a precaution against future appendicitis during other abdominal surgery. However, appendectomy for appendicitis is still the most common surgery done by acute-care surgeons, and has been the mainstay for centuries for treating appendicitis. The first appendectomy was in 1735. In fact, ask any physician, surgeon or non-surgeon how to treat appendicitis and the universal answer will be, “cut it out.” But that response may be changing. Already in Europe several research trials have looked at the use of antibiotics for unruptured appendicitis. The rationale for these trials is that appendicitis is much akin to another intestinal malady – diverticulitis, which in most cases can be treated with antibiotics. In these trials 75% of the patients recovered without needing surgery. A large-scale, randomized trial is also underway in the U.S. If results are similar, it may give patients a new option — perhaps one especially useful for high-surgery-risk patients with appendicitis who have severe pulmonary or cardiovascular disease. So, if you see me in the ER at Tampa General and I’m calling for a surgeon for your acute appendicitis, don’t be afraid to ask me for a Plan B.

Q – Tips: PUPS

Q – Tips: PUPS

PUPS, also known as papular urticaria of pregnancy syndrome is the appearance of hives during pregnancy. It is a benign condition and causes no harm to the baby. Seventy percent of the time the child is male, leading some researchers to believe it is due to the male DNA irritating the mother.

Better efficiency noted in flu vaccines for persons over 50

Better efficiency noted in flu vaccines for persons over 50

Remember the word “recombinant” as it relates to flu vaccines for those over 50 years old.

The definition of the term is a little “medical,” but progress in the research for a better flu vaccine to protect that age group is definitely worth cheering on. The current flu vaccine confers only 36% to 80% protection.

This new DNA technology, as recently reported in The New England Journal of Medicine, was successfully used by the researchers to vaccinate with only the viral marker protein, instead of the whole virus. The patients receiving the “recombinant” vaccine had better antibody response – and fewer cases of influenza – than the patients receiving the standard vaccine.

Flu vaccines currently are produced by growing the virus in eggs, inactivating it and using it to vaccinate. Recombinant DNA technology involves inserting the DNA encoding only for the viral marker protein into a bacterial cell and allowing the bacteria to produce the marker. This gets purified and used to vaccinate.

Allergy to medical implants on the rise

Allergy to medical implants on the rise

Biomedical implants are becoming more and more common in today’s world of modern medicine. For instance, roughly one-million knee replacement surgeries were done in the U.S. last year. With these numbers, it’s not a surprise that allergic reactions to the implants is also increasing.  Diagnostic features of metal hypersensitivity to an implant include: rash developing in the skin overlying the implant, generalized skin rash beginning weeks to months after the implant, unexplained pain and/or failure of the implant, positive patch test to the metal used in the implant and complete resolution of symptoms after removal/replacement of the offending implant.

The most common causes of metal hypersensitive reactions are orthopedic devices. Next most common are dental-related metals. Much less common are vascular stents, cardiac pacemakers and gynecologic implants, such as intrauterine devices (IUDs).  The metal type causing the most problems is stainless steel — which contains nickel, cobalt and chromium – all known potential allergens. Less troublesome are titanium alloys and zirconium.

The most common allergic symptom seen with cardiovascular stents is rapid re-stenosis of the “stented” artery. In the case of pacemakers/internal defibrillators, it is a rash in the skin overlying the device. Unfortunately, there are no standardized test kits for metal testing. Currently, skin-patch testing with a small piece of the implant metal, and a blood test to see if white blood cells react are in use, but results can vary from lab to lab. Most vexing is the fact that the allergy can develop after the implant. However, any implant candidates with previous allergic issues with the proposed metal should undergo pre-testing — including reactions to piercings, tattoo ink, jewelry or metal snaps.

Eczema relief: Dupixent approved; Nemolizumab research encouraging

Eczema relief: Dupixent approved; Nemolizumab research encouraging

The Food & Drug Administration (FDA) has just recently approved the drug Dupixent for treating atopic dermatitis (eczema). It is a human monoclonal antibody (dupilumab) that targets two inflammatory molecules – IL-4 and IL-13 – the main driving forces for the rash and itch that characterize eczema. This drug is intended for people with moderate-to-severe eczema that is not otherwise controlled by antihistamines or topical steroids.

The medicine is administered by subcutaneous injection from a pre-filled syringe. The current recommendation is that initial therapy be done in a doctor’s office, but once safety is established, it can be done at home.

The main side effects reported by the FDA are local injection site reactions, conjunctivitis and eye dryness and activation of oral herpes. Very rarely allergic reactions occurred.

So far, it is only approved for non-pregnant adults. The drug trials demonstrated fairly dramatic results with 40% of participants having complete clearing of their rash within 16 weeks.

Nemolizumab is an investigational monoclonal antibody that is showing real promise in treating moderate-to-severe atopic dermatitis (eczema). It inactivates Interleukin 31 (an inflammatory molecule associated with the often-intense itch of eczema).

Yellow jacket sting vs risk of immunization — relative

Yellow jacket sting vs risk of immunization — relative

Dear Dr. K:  My father, who is 70, has had two near-fatal anaphylactic reactions to yellow jacket stings. His cardiologist says he shouldn’t see an allergist for venom immune therapy (VIT) because he‘s on a beta-blocker since he had a heart attack. What should I tell him?

Tell him it’s a matter of relative risk and he should see an allergist. This is a complex problem, but not a rare one, so a little explanation will help.

First of all, when studies are done on people who die from insect stings, it is actually more frequent in people over 50. It seems that the anaphylaxis from the sting is more liable to be fatal because of underlying cardio-vascular disease. Your father falls into this category.

When VIT was first introduced in the 1970s the standard recommendation was to not give it to people on beta-blockers. The reason for this is that there is greater risk for a severe reaction to the shot itself as it’s being built up. Keep in mind VIT involves giving the venom that caused anaphylaxis (via the sting) in the first place.

However, as time has passed and more deaths have occurred in untreated patients, this recommendation has been re-thought.

In fact, a number of academic research centers have undertaken controlled trials of VIT in patients on beta-blockers. From their vantage point it has been learned that VIT can be safely done. A large study by the University of Bern found that their patients on beta-blockers had fewer shot reactions than their patients not on beta-blockers, and there were no deaths.

Which brings us back to the concept of relative risk. Your father has much greater risk from the sting than from the shot.

In general, when VIT is done on patients on a beta-blocker a more gradual build-up is followed, thus reducing risk even further.