| 
Over 1 million joint replacements occur annually in the United States. One in 10 joint replacements requires revision. The causes of implant failure include infection, biomechanical problems and allergy. As the numbers of knee and hip replacements increase, the number of revisions will also surge.
Allergy patch testing is the gold standard diagnostic tool available for determining metal or bone cement allergy. The performing allergist must carry a comprehensive inventory of testing components for both the metal and bone cement used in joint replacements. Most importantly, the providers should be board certified and have abundant experience in executing and interpreting the allergy patch testing. Consider seeing an allergist for allergy patch testing if you have:
· unexplained chronic pain and/or swelling following a joint replacement OR
· have a prior history of metal or artificial nail sensitivity prior to joint replacement OR
· if there is any concern for metal or bone cement allergy prior to joint replacement
As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
Dr. Ananth Thyagarajan (Dr. T.)
|
| 
As allergists, we are frequently asked about herbal, homeopathic, ayurvedic or non-medicine based treatments for seasonal allergies. These, as well as other non-traditional treatments, fall under the category of complementary and alternative medicines or “CAM” for short. CAM has been defined as a group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine. Examples include natural products (i.e. herbs, probiotics), mind and body medicine (i.e. yoga, acupuncture), as well as manipulative and body-based practices (i.e. spinal manipulation, massage therapy). The 2007 National Health Interview Survey showed that approximately 38% of adults and 12% of children use CAM. Because of the increased use of these practices, the federal government created the Office of Alternative Medicine in 1991 that was re-established as the National Center for Complementary and Alternative Medicine (NCCAM) in 1998. Their mission is “to define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine interventions and their roles in improving health and health care.” The NCCAM is one of the 27 institutes and centers that make up the National Institutes of Health (NIH) within the Department of Health and Human Services. NCCAM recently hosted an online chat via their Twitter account regarding the use of CAM for seasonal allergies that was the inspiration for this blog post. The different treatments include:
1. Natural Products
The herb butterbur may decrease allergy symptoms, but concerns have been raised about its safety. A randomized controlled trial of butterbur versus cetirizine (aka Zyrtec) from2002 showed that the effects were similar for both treatments in terms of reducing symptoms of seasonal allergies. Regarding its safety, the raw, unprocessed butterbur plant contains chemicals called pyrrolizidine alkaloids (PAs). PAs can cause liver damage and can result in serious illness. Only butterbur products that have been processed to remove PAs and are labeled or certified as PA-free should be used. Several studies, including a few studies of children and adolescents, have reported that PA-free butterbur products are safe and well tolerated when taken by mouth in recommended doses for up to 12 to 16 weeks. The safety of longer-term use has not been established. Also, butterbur may cause allergic reactions in people who are sensitive to plants such as ragweed, chrysanthemums, marigolds and daisies.
A general note of caution regarding dietary supplements; although these products are regulated through the Food and Drug Administration (FDA), the rules for dietary supplements are not the same as those for prescription or over-the-counter drugs. In general, the regulations for dietary supplements are less strict; for example, a manufacturer does not have to prove the safety and effectiveness of a dietary supplement before it is marketed. Once a dietary supplement is on the market, the FDA monitors safety and product information (label claims and package inserts), and the Federal Trade Commission (FTC) monitors advertising.
2. Acupuncture
A randomized control trial of acupuncture for allergies was published in 2013. They took over 400 patients with seasonal allergies and divided them into 3 treatment groups: one that received acupuncture, one that received sham (fake) acupuncture and one that received no acupuncture. Acupuncture led to statistically significant improvements in symptoms and antihistamine use after 8 weeks, but the improvements may not be significant because there was NO difference after 16 weeks. This study combined with a couple of others point towards the preliminary suggestion that the use of acupuncture for seasonal allergies has not been shown to incur any meaningful benefit
3. Local Honey
Many people believe that eating local honey will make them immune to pollen. The theory that eating so-called "natural" honey benefits those with allergies is purely anecdotal. There are several concerning issues related to the ingestion of honey for allergies. First, much of the pollen in honey is not the type that humans are allergic to (flowers and other blooming plants). Humans are normally allergic to tree, grass or weed pollen which is not contained in honey. Second, local honey likely contains many substances to which the patient is NOT allergic. Subsequently, a susceptible individual who frequently consumes honey may develop an allergy to these other substances. Anaphylactic allergic reactions to honey have been seen, so there are potentially serious risks associated with it. Finally, babies under the age of 1 should not be given honey, Clostridium botulinum spores in honey can grow in intestines and cause botulism poisoning.
4. Sinus Irrigation
Daily sinus irrigation (one type being neti pots) remains a potentially effective treatment for allergies and sinus infections in many patients. Washing the nasal cavities with saline reduces postnasal drainage, removes secretions and rinses away allergens/irritants. Sinus irrigation is associated with improvement in a variety of rhinitis conditions (with some studies showing benefits in children and pregnant women). Patients should use distilled, sterilized or previously boiled water because a small number of cases of primary amebic meningoencephalitis (PAM) have been contracted from using tap water that was contaminated with the amoeba Naegleria fowleri to perform sinus irrigation.
Unfortunately, there is a real lack of well-designed studies which makes it difficult for clinicians to recommend most CAM therapies with confidence. Patients who do wish to pursue CAM should consider the financial costs (which may be substantial) and be aware that long-term safety data on most of these therapies are lacking. For those patients who seek advice about what brand of herbal medicine to use, they can visit an independent source such as Consumer Labs which tests various brands of herbal therapies for content and quality.
As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
Dr. Ananth Thyagarajan (Dr. T.)
|
| 
Every year around April or May, I see many patients, especially children, who come to my office with puffy red itchy eyes. It seems to be associated with the grass pollen season more than the tree pollen season, perhaps because the grass pollen grains are larger and possibly more irritating than the tree pollen grains. What happens is that after a number of exposures, allergy-prone individuals become sensitized to various pollens resulting in the production of IgE, or allergic antibodies. I like to call IgE the “Evil Antibody” – “E” for “evil.” The Y-shaped IgE antibodies then attach to mast cells –allergic “effector” cells, that reside in the mucous membranes in the nose and eyes and bronchi. If allergenic proteins “bridge” two or more IgE molecules (attach to both at once), the mast cells open up and release many chemicals which cause allergic reactions. One of these chemicals is histamine, which is notorious for causing itching, swelling, tearing and (in the nose and bronchi) increased mucous production. For a great illustration of this phenomenon, see this link.
Once this allergic reaction happens, the eyes become itchy and red and the lids become puffy. There is also a dusky hue to the tissues beneath the eye. This appearance is called allergic shiners. A good way to distinguish between an allergic reaction in the eyes and an infection is the presence of itching in the allergic reaction as opposed to burning in the infectious type of conjunctivitis. Also, an infectious conjunctivitis may have pus or a yellow creamy discharge coming from the inner corners of the eyes and/or “sandman” grit gluing the lids together in the morning.
So what can be done about it?
As with allergic nose disease, there are three steps:
1) Avoidance: If you can avoid it, don’t go outside on high pollen days, especially if it is windy. It is better to stay inside with the windows closed and the air conditioning on (air conditioning filters out 95% of the pollen). If you have been outside on a high pollen day and then come in, use contact lens saline solution, eye wash or artificial tears to wash the pollen out of the eyes. You might consider also taking a shower, washing your hair and changing your clothes. After that, cool compresses may help.
2) Medication: Avoid the OTC drops such as Visine, Opcon A or Naphcon A, which contain vasoconstrictors. Advertisements claim that Visine “get the red out” and it does. The trouble is that these medications do this by constricting the blood vessels. The tissues then feel starved for oxygen and when the medication wears off, the redness comes back, often to a worse degree. OTC preparations that are helpful include those that contain ketotifen, such as Zaditor or Alaway or CVS Eye Itch Relief. Prescription eye drops for allergic eye disease include antihistamines (Elestat, Optiver); nonsteroidal anti-inflammatory agents (Acular) and dual acting mast cell stabilizer/antihistamine drips (patanol, Pataday, Bepreve). If none of these work, Alrex, which contains a mild steroid, can be used for a maximum of 7 days. Any stronger steroid needs to be monitored by an ophthalmologist.
3) Immunotherapy (or allergy shots). Allergy shots are like “vaccinating” you against your allergies in that they change the way your immune system responds, similar to a flu shot. The difference is that your doctor can’t give you the dose you need right at the beginning because you are being given something to which you are allergic. That is why your allergist will start with small quantities and increase the dose gradually as your body tolerates it. Immunotherapy works 85% of the time and reduces your symptoms and the need for medications. It can also be cheaper than medications in the long run.
As always, you can keep checking this site for new blogs and also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
Dr. Elaine Turner
|
| 
There has been a dramatic increase in the prevalence of both environmental and food allergies over the past several decades. Could this be related to additives in commonly used products? My partner, Dr. Thyagaragan, previously wrote a blog on the relation between bisphenol A and allergic inflammation. Bispenol A is one of a group of chemicals, known as EDCs (Endocrine-disrupting compounds). Triclosan and parabens are also EDCs. “Triclosan has been used since 1972, and it is present in soaps (0.10-1.00%), deodorants, toothpastes, mouth washes, and cleaning supplies, and is infused in an increasing number of consumer products, such as kitchen utensils, toys, bedding, socks, and trash bags” (see reference). Parabens can be found in shampoos, commercial moisturizers, shaving gels, personal lubricants, topical/parenteral pharmaceuticals, spray tanning solution, makeup,[1] and toothpaste. They are also used as food additives. (See reference)
In 2012, Jessica Savage and colleagues at Johns Hopkins did a study to see whether the increase in food allergy could be correlated with allergic sensitization. They used data from the 2005-2006 National Health and Nutrition Examination Survey where they could find information on urinary levels of various EDCs and the amount of allergic sensitization. A total of 10,348 subjects participated in NHANES 2005-2006. Children aged 6 to 18 years were included in the analyses because childhood is when most sensitization develops. A random 1/3 of participants in the study 6 years and older were selected to have urinary EDC levels measured. Dr. Savage and her colleagues were interested in this subgroup. Of those, 860 subjects had enough data to be analyzed for relation between environmental allergen sensitization and urinary EDCs and 859 had enough data to be analyzed for a relation with food sensitization.
In the NHANES study, Food-specific allergic sensitization was measured using the ImmunoCAP system (a type of blood test) for milk, egg, peanut, and shrimp. Allergic sensitization was measured using the same method for environmental allergens including cat, dog, mouse, rat, dust mites, cockroach, ragweed, thistle, rye, Bermuda, oak, birch and two kinds of molds.
The research group looked for correlations between levels of urinary EDCs and the amount of allergic sensitization. They found that there was a significant correlation between urinary levels of triclosan and parabens and levels of allergic sensitization. Other EDCs were not associated with an increased risk of sensitization, though Bisphenol was associated with increased allergic inflammation. The odds of environmental allergen sensitization increased with exposure to triclosan and parabens for both males and females. The odds of sensitization to foods increased only for males.
Because of these and other concerns, the FDA is now reviewing the use of Triclosan in US products. As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
Dr. Elaine Turner
|
| 
On April 1, 2013, the World Health Organization (WHO) first reported 3 human infections with a new influenza A (H7N9) virus in China. Since then, additional cases have been reported. As of April 12, 2013, China has now reported a total of 43 cases of human infection with the new influenza A (H7N9) virus; 11 of which have resulted in death. There are no reported cases of H7N9 in the United States or anywhere else outside of China.
This new H7N9 virus is an avian (bird) influenza (flu) virus. Human infections with avian influenza are rare but have occurred in the past, most commonly after exposure to infected poultry. After the first human infections with H7N9 were detected, Chinese authorities detected H7N9 viruses in poultry in the same area where human infections have occurred. Many of the people with confirmed H7N9 have had contact with poultry, but some have not. The scientists in China are examining close contacts of these individuals to assess whether or not human-to-human spread of the virus is occurring. This is important because if sustained spread of the virus is occurring from person to person, then that leads to an influenza pandemic. So far, these investigations suggest that there is no sustained spread of this virus from person to person. Based on the current available data and on previous experience, it’s likely that some limited human-to-human spread of this H7N9 virus will be detected. For now, that is OK and has happened many times before without widespread disease.
According to the CDC, “Human-to-human transmission ranges along a continuum; from occasional, ‘dead-end’ human-to-human transmission, to efficient and sustained human-to-human transmission. ‘Dead end’ transmission usually refers to when a virus from an animal host infects a person and then there is some subsequent transmission that eventually burns out. Efficient and sustained (ongoing) transmission in the community is needed for an influenza pandemic to begin. There is no evidence that the H7N9 virus in China is spreading in a sustained, ongoing way at this time.”
Chinese scientists are to be congratulated for the speed with which the H7N9 virus was identified and for the fact that whole viral genome sequences were made publicly available in a relatively short period of time. Additionally, they have provided the CDC with a viral isolate that will be used to develop a vaccine, further improve a diagnostic test to pick up the virus, develop other tests to see if our population already has some immunity to the virus and conduct additional testing to determine the susceptibility of the H7N9 virus to existing antiviral drugs.
The clinical features for those infected may include symptoms similar to the more common flu illnesses that we experience like fever, chills, cough, sore throat, runny/stuffy nose, muscle/body aches, headaches, fatigue (tiredness), vomiting and diarrhea. At this point, there are NO confirmed cases in the United States. If you are feeling these symptoms, consider seeing your trusted health care provider but do not panic since we have not seen the H7N9 virus on this side of the world.
As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
Dr. Ananth Thyagarajan (Dr. T.)
|
| 
Was the death of a pharaoh the first report of an insect sting reaction?
In 1989, an article in Hospital Practice by Ovary stated that the death of Pharaoh Menes after a wasp sting in 2600 BC was the first reported account of an anaphylactic reaction to insect stings. According to Krombach, this was based on hieroglyphs found on his sarcophagus and tomb. Dynasties that came after Menes believed him to be the first Pharaoh and he is credited with many things, including the introduction of papyrus and writing. But Krombach and his fellow authors argue that he was likely a mythical figure who may not have even lived. Oh well -- so much for exotic origins. No matter when the first reaction was, it is likely that insect sting allergy started a very long time ago.
Statistics about insect sting reactions
Anaphylactic or systemic reactions to stinging insects occur in .3-3.0% of the general population. Fatalities are more likely to occur in adults. Insects like bees and wasps that sting fall into the category of Hymenoptera. Hymenoptera anaphylaxis causes about 40-50 deaths per year in the United States. The most common perpetrator is yellow jacket. This is all according to an article by Koterba and Greenberger.
The natural history of insect sting reactions
Most authorities say that the risk of a repeat anaphylactic reaction to another insect sting is about 60%, however if a number of years have passed since the initial reaction, the rate may be less. Robert Reisman of the Allergy Research Laboratory at the State University of Buffalo studied the results of re-stings that occurred years after the initial reactions in patients who had positive skin tests or blood tests to insect venoms. There were two studies – one that looked at stings inflicted a mean of 4.5 years and and another that looked at re-stings a mean of 7.3 years after the initial anaphylactic reaction. After 4.3 years, the reaction rate was 50% per patient. After 7.3 years, the reaction rate was only 12% per patient. Factors which were likely to lead to a greater likelihood of a repeat reaction included older age and the presence of cardiovascular or respiratory reactions with the first sting reaction. It was also noted that large local reactions (see types of reactions below) re-stings generally involved repeat large local reactions and not anaphylaxis.
What are the different kinds of reactions to insect stings?
· A normal reaction with less than 2 inches of redness and swelling right around the sting and which subsides in less than a day. For this, cold compresses and analgesics are sufficient treatment.
· A large local reaction with extensive redness and swelling, generally more than 5 inches in size and lasting 1-10 days. These reactions can involve large areas – for example, a whole arm. Analgesics, ice and sometimes prednisone is the usual treatment.
· Anaphylaxis includes swelling that skips a joint area or occurs at areas of the body distant from the site of the sting. Hives can also accompany this reaction. The patient may have life threatening occurrences such as swelling of the larynx (which may cut off breathing) or cardiac involvement. Treatment includes urgent use of epinephrine (generally administered by an EpiPen), antihistamines and calling EMS for a trip to the emergency room. Patients who have these reactions should be skin tested and considered for desensitization to the venom or venoms to which they are shown to be allergic. If the reaction is only hives in a child less than 16 years old, life threatening reactions usually do not develop on re-sting so desensitization may not be necessary in this case.
· Rare reactions: These include serum sickness with hives, fever, malaise and joint pain that occurs 7 days after the sting. Some of these patients may experience anaphylaxis on subsequent stings, so desensitization is suggested.
· Toxic reactions: These happen with multiple simultaneous stings such as may occur in an attack by Africanized honey bees. Hypotension, cardiovascular collapse and death may occur.
How can you tell which kind of insect stung you?
• Yellow jackets are black with yellow markings, found in various climates. Their nests are usually located underground, but sometimes found in the walls of buildings, cracks in masonry or in woodpiles.
• Honeybees have round, fuzzy bodies with dark brown and yellow markings. They can be found in honeycombs in trees, old tires or other partially protected sites. Honeybees are the only Hymenoptera insects that leave their stinger in the skin after a sting.
• Paper wasps are slender with black, brown, red and yellow markings. They live in a circular comb under eaves, behind shutters or in shrubs and woodpiles.
• Hornets are black or brown with white, orange or yellow markings. Their nests are gray or brown and are usually found in trees.
Why is it important for you to be able to identify the type of insect that stung you when you have had a reaction? It is important because your allergist at Allergy Partners uses this information in conjunction with skin tests to determine which type of venom to use for desensitization.
How can your allergist diagnose which particular insects caused your allergic reaction?
Your allergist at Allergy Partners of Richmond can test you for all five different kinds of Hymenoptera venom allergies. If you have had an all-over type of reaction to an insect sting, please make an appointment.
Is there anything that can be done?
If you are skin test positive to one or more venoms after you have had a systemic or anaphylactic reaction to an insect sting, your allergist can prescribe desensitization injections which will reduce the likelihood of a reaction to 3% from 60%. It takes about 15 injections, barring local or systemic reactions to the shots, to get to a “maintenance” dose. Once maintenance is reached, injections can be given once per month during the first year and every 6-8 weeks during the subsequent three years or until skin tests become negative. I once was asked to see a patient in the emergency room that had had a severe reaction to yellow jacket stings. He had been working in his yard when he ran the lawn mower over a yellow jacket nest. The insects swarmed up his pants legs and stung him multiple times. He knew he was allergic to yellow jackets, so he called his wife to get the car and ran inside to change to clothes that did not have the insects inside them. The hospital was about 15 minutes away. He walked through the door of the emergency room and collapsed in cardiac arrest. After he was resuscitated, they called me to see the patient. When I saw him, he had a gash on his forehead from his fall that had been stitched up by the plastic surgeon and a yellow jacket sitting on his big toe! I skin tested him in the office and started him on venom injections. After he reached maintenance, he was stung again. I asked him if he had had a reaction. His reply: “Less of a reaction than I get to your silly little shots!”
By Elaine S. Turner, MD, FACP, FAAAAI
|
| Click on the link below to watch the video:
|
|  Spring is finally here after a prolonged unusual cold spell. With the new season we are starting to see high levels of spring time pollens and increased symptoms of allergies and asthma. Check out the links below for helpful information on managing your allergies:
As always, you can also follow us on Facebook and Twitter for daily pollen counts, office information, patient education and more. If you enjoyed this post please “Like” us on Facebook and “Share” the article.
Dr. Ananth Thyagarajan (Dr. T.)
|
BLOB Info javascript:window.location= '{SiteUrl}/_layouts/StorageEdge/BLOBDetails.aspx?ItemId={ItemId}&ListId={ListId}&Source=' + window.location 0x0 0x40000000 ContentType 0x0101 65536 |
|
|
|
 |
Welcome to our blog site! Stay tuned to get the latest news. We will share tips and techniques for living with and managing your Allergies & Asthma. We look forward to sharing useful resources with our patients! |
|
|
BLOB Info javascript:window.location= '{SiteUrl}/_layouts/StorageEdge/BLOBDetails.aspx?ItemId={ItemId}&ListId={ListId}&Source=' + window.location 0x0 0x40000000 ContentType 0x0101 65536 |
|
|
|