Growing up with allergies: Transitioning from adolescence to adulthood

Allergic disease management for adolescents and young adults requires consideration of unique psychosocial challenges and opportunities. Erik Erikson's model for the Stages of Psychosocial Development is a useful lens through which we can understand adolescent and young adult experiences with allergic and immunologic disease, particularly with regard to identity and relationship development. It is important to provide anticipatory guidance for patients who are transitioning environments (eg, home to college), with attention to the anxiety-provoking demands for increased responsibility on top of new stressors such as academic and vocational demands. It is critical that health care professionals use an empathetic, shared decision-making approach regarding the emotional impact of allergy on a patient's social engagement. A patient's ability to develop positive lifelong habits is also shaped by their environment's "culture of wellness," and clinicians can encourage habits to promote healthy choices and effective disease management. Social media provides opportunities and challenges as a conduit for both social connection and possible misinformation. Overall, allergic disease management in adolescents and young adults is a "high-risk, high-reward" period of time-and with awareness, anticipation, and proactive action, health care professionals can better serve patients by leveraging this transitional period to promote positive approaches to management of allergies and asthma, trusting relationships, and personal responsibility.

Beyond Confirmed Mast Cell Activation Syndrome: Approaching Patients With Dysautonomia and Related Conditions

Allergist-immunologists face significant challenges as experts in an ever-evolving field of neuroimmunology. Among these challenges is the increasingly frequent need to counsel patients with suspected mast cell activation disorders about perceived comorbidities, which may include hypermobile Ehlers-Danlos syndrome, amplified pain syndrome, fibromyalgia, burning sensation syndromes, migraines, irritable bowel syndrome, and postural orthostatic tachycardia syndrome. Patients may experience comorbid anxiety, panic disorder, and depression associated with disturbed sleep, fatigue, and cognitive impairment that often worsen when their physical symptoms increase in severity. These conditions may mimic mast cell activation disorders and are emotionally taxing for patients and clinicians because they are often accompanied by vague diagnostic courses, perceived unmanageability, social stigma, and significant impairment in quality of life. Combined with relatively poorly researched therapies, it is no surprise that clinicians may feel overwhelmed or find it difficult to provide consistently compassionate care for this population. In this article, we review available therapies for these conditions, which run the gamut from physical therapy to antidepressants to multimodal pain control. We highlight the benefit of multidisciplinary care within the primary care home, which includes an important role by the allergist-immunologist. By outlining simple approaches to initial treatment, we hope to empower clinicians with the tools needed to curb emotional burnout and embrace this patient population with compassion.

Economic evaluation of epinephrine auto-injectors for peanut allergy

BACKGROUND

Three commercial epinephrine auto-injectors were available in the United States in the summer of 2016: EpiPen, Adrenaclick, and epinephrine injection, USP auto-injector.

OBJECTIVE

To describe the variation in pharmacy costs among epinephrine auto-injector devices in New England and evaluate the additional expense associated with incremental auto-injector costs.

METHODS

Decision analysis software was used to evaluate costs of the most and least expensive epinephrine auto-injector devices for children with peanut allergy. To evaluate regional variation in epinephrine auto-injector costs, a random sample of New England national and corporate pharmacies was compared with a convenience sample of pharmacies from 10 Canadian provinces.

RESULTS

Assuming prescriptions written for 2 double epinephrine packs each year (home and school), the mean costs of food allergy over the 20-year model horizon totaled $58,667 (95% confidence interval [CI] $57,745-$59,588) when EpiPen was prescribed and $45,588 (95% CI $44,873-$46,304) when epinephrine injection, USP auto-injector was prescribed. No effectiveness differences were evident between groups, with 17.19 (95% CI 17.11-17.27) quality-adjusted life years accruing for each subject. The incremental cost per episode of anaphylaxis treated with epinephrine over the model horizon was $12,576 for EpiPen vs epinephrine injection, USP auto-injector. EpiPen costs were lowest at Canadian pharmacies ($96, 95% CI $85-$107). There was price consistency between corporate and independent pharmacies throughout New England by device brand, with the epinephrine injection, USP auto-injector being the most affordable device.

CONCLUSION

Cost differences among epinephrine auto-injectors were significant. More expensive auto-injector brands did not appear to provide incremental benefit.

Indocyanine green and fluorescein angiography of surgically excised macular choroidal neovascularizations: correlations with histopathologic and ultrastructural findings

BACKGROUND

Informations are expected from the histopathological study of surgically excised choroidal neovascular membranes (CNMs), particularly in relation to the angiographic aspects of vascular architecture.

METHODS

Fluorescein and indocyanine green (ICG) angiograms were studied together with the histopathological features of 12 surgically excised subfoveal CNMs in eyes affected by age-related macular degeneration (ARMD).

RESULTS

Instead of the early and delayed diffuse hyperfluorescence secondary to CNMs observed on fluorescein angiography (seven were well defined, five scar evolved), ICG revealed (a) very early hypofluorescence of the membrane bulk over the fluorescence of the outer choroidal vascular bed and (b) late hyperfluorescence gradually increasing and partially defining the border of membranes. CNMs with well-defined hyperfluorescent aspects were characterized by fibrovascular bulk lined on one side by retinal pigment epithelium. Fibrosis reaction predominated over the vascular components in scar-evolved membranes.

CONCLUSIONS

Fluorescein and ICG angiographic differences in the appearance of CNMs could depend on (a) the morphological structure and size of the CNM (b) its location within the chorioretinal layers and (c) different molecular characteristics of the dyes used.

Study of photoablation of rabbit corneas by Er:YAG laser

BACKGROUND AND OBJECTIVE

This work studied the ablation mechanisms of rabbit corneas by the Erbium:YAG laser. The occurrence of thermal and mechanical damages in the tissue as a function of the laser fluence was also investigated.

STUDY DESIGN/MATERIALS AND METHODS

The experiments were performed both on enucleated eyes and in vivo. An ultrafast imaging technique was used to investigate the dynamic evolution of the ablation. The treated samples underwent histological and ultrastructural study.

RESULTS

A single high fluence laser shot led to the complete removal of the epithelium by a photomechanical effect. In eyes whose epithelium was manually removed, high fluence pulses resulted in evident tears in the stroma, whereas low fluence pulses led to few microns deep incisions, characterized by limited mechanical and thermal damages.

CONCLUSION

The photomechanical action plays a significant role in the ablation of the cornea by Erbium laser. Precise control of the fluence is required to avoid cracking phenomena in the stroma.

Diode and Nd:YAG laser contact transscleral cyclophotocoagulation in a human eye: a comparative histopathologic study of the lesions produced using a new fiber optic probe

We compared the contact cyclodestructive effects (both gross and histologic) achieved with diode and Nd:YAG laser wavelengths (810 and 1064 nm, respectively), using equivalent energy doses, released by means of a new optical delivery system in a human eye that was soon to be enucleated because of a choroidal melanoma. For both lasers, a fiber optic system (400 microns) with a focusing microlens placed at the end of the fiber was used. The center of the beam was placed 1.5 mm from the corneoscleral limbus. At medium (5.2 to 6.6 J) and higher (7.8 J) energy levels, the cyclodestructive thermal damage produced by the diode laser appeared more widespread than that created by the Nd:YAG laser. At lower levels (3.6 to 3.9 J), both laser treatments produced similar lesions. The new delivery system proved to be safe and effective in achieving the desired cyclodestructive effects at both wavelengths.

Corneal nerve damage and regeneration after excimer laser photokeratectomy in rabbit eyes

PURPOSE

To investigate corneal nerve damage and its subsequent regeneration after excimer laser photokeratectomy in rabbit eyes.

METHODS

Corneal photokeratectomy was performed on the right eyes of 34 pigmented rabbits, while the left eyes were used as a control. A Summit UV 200 excimer laser (Summit Technology, Waltham, MA) was used to produce a 100 microns depth phototherapeutic keratectomy (4.5 mm diameter). The rabbits were killed at 0, 1, 2, 3, 4, 5, 7, 8, 10, 15, and 20 days and 1, 2, 3, and 4 months after treatment. Corneal nerve regeneration was investigated using a monoclonal antibody directed against a 150 kD subunit of neurofilaments, in combination with acetylcholinesterase staining.

RESULTS

At time 0, the subepithelial plexus had disappeared completely from the photoablated area. One day after treatment, some regenerating nerves sprouting within the treated area were visualized by a monoclonal antibody directed against a 150 kD subunit of neurofilaments. Acetylcholinesterase staining was detectable 7 days later. One month after surgery the subepithelial plexus had already reappeared, but was morphologically disorganized. Four months after treatment, the newly formed subepithelial plexus had considerably thickened in comparison with that of the control eye.

CONCLUSIONS

This study shows that corneal nerve regeneration after excimer laser photoablation in rabbit eyes, although more intense, is similar to that produced after other surgical procedures involving the epithelium and the anterior stroma or one of the two.

Endophotocoagulation through perfluorodecalin in rabbit eyes

Retinal laser endophotocoagulation through perfluorodecalin was studied in six eyes of three Dutch-belted rabbits after vitrectomy. Both the energy density threshold (EDT/50) and the energy threshold necessary to obtain a therapeutic lesion were evaluated. Both argon and semiconductor diode laser endophotocoagulators were used. The amount of laser power energy and the histology of chorioretinal lesions were similar when photocoagulating through perfluorodecalin, compared to photocoagulation through balanced salt citrate-buffered solution. This experimental study indicates that no extra care is necessary when retinal endophotocoagulation is performed through perfluorodecalin, as long as circular spots are obtained and energy is delivered symmetrically to the target site.

Teaching job independence and flexibility to mentally retarded students through the use of a self-control package

We examined mentally retarded individuals' use of picture cues and self-monitoring to initiate a series of tasks of varying type and order. Four severely to moderately retarded high school students participating in a vocational training program were trained to use a picture-cue system. The system consisted of photographs of vocational tasks that were inserted in the assigned order in a photoalbum sheet; self-management was accomplished by marking off each photo after its corresponding task was completed. Students were assigned seven tasks from a pool of 13 each day. Results indicated that the students quickly learned to use the picture-cue system to change tasks throughout their workday without trainer prompts and that performance was maintained as trainer feedback and presence were decreased. At the end of the study, two students who were exposed to novel photographs were able to initiate independently after only minimal training, suggesting that the use of the picture-cue system had become a generalized skill.