Avoidance Of Triggers Research Articles

Urticaria and angioedema

Urticaria (hives) is a common disorder that often presents with angioedema (swelling that occurs beneath the skin). It is generally classified as acute, chronic or physical. Second-generation, non-sedating H1-receptor antihistamines represent the mainstay of therapy for both acute and chronic urticaria. Angioedema can occur in the absence of urticaria, with angiotensin-converting enzyme (ACE) inhibitor-induced angioedema and idiopathic angioedema being the more common causes. Rarer causes are hereditary angioedema (HAE) or acquired angioedema (AAE). Although the angioedema associated with these disorders is often self-limited, laryngeal involvement can lead to fatal asphyxiation in some cases. The management of HAE and AAE involves both prophylactic strategies to prevent attacks of angioedema (i.e., trigger avoidance, attenuated androgens, tranexamic acid, and plasma-derived C1 inhibitor replacement therapy) as well as pharmacological interventions for the treatment of acute attacks (i.e., C1 inhibitor replacement therapy, ecallantide and icatibant). In this article, the authors review the causes, diagnosis and management of urticaria (with or without angioedema) as well as the work-up and management of isolated angioedema, which vary considerably from that of angioedema that occurs in the presence of urticaria.

PS17 - 84. Avoidance only of dietary diabetogenic triggers seems not enough to prevent type 1 diabetes (T1D). An experimental study in the DP-BB rat animal model for T1D

It is debated whether avoidance of dietary diabetogenic triggers is enough to prevent T1D or that additional effects regarding intestinal barrier function, gut microbiota composition or mucosal immunity are required.

Managing Stomatitis in Patients Treated With Mammalian Target of Rapamycin Inhibitors

Mammalian target of rapamycin (mTOR) inhibitors are a class of targeted cancer therapeutic agents with clinical benefit for multiple tumor types. Oral ulcerations are a common side effect of mTOR inhibitors; however, the clinical findings resemble aphthous stomatitis rather than the mucositis seen with chemotherapy. Consequently, the appearance of aphthous-like oral ulcerations has been referred to as mTOR inhibitor-associated stomatitis (mIAS). The severity of mIAS can be minimized by following common preventive steps and initiating treatment at the first sign of mouth discomfort, thereby reducing the likelihood of treatment discontinuation. mIAS can be managed through prophylactic measures, such as patient education in oral hygiene and avoidance of triggers. Patients who develop mIAS may be treated topically using rinses or other local therapies, including corticosteroids. In severe cases, dose modifications may be required. Oncology nurses have an important role in the management of patients with cancer and are well positioned to offer strategies for minimizing the occurrence and impact of mIAS.

Insect Allergy

Anaphylaxis is a life-threatening allergic condition. The 3 most common triggers for anaphylaxis are food, medications, and insects. All of these triggers are the sources of considerable morbidity and mortality, but of the 3, only insect allergy is treatable through means other than trigger avoidance. Because ≥ 40 deaths per year are attributed to insect stings, it is critical that healthcare providers and the public understand the proper diagnosis as well as the long-term treatment of this potentially life-threatening allergy. Unlike food and medication allergy, which are managed primarily by allergen avoidance, Hymenoptera allergy is managed prospectively using venom immunotherapy; this results in a protective level of up to 98%. Insects of the order Hymenoptera include bees, wasps, hornets, yellowjackets, and ants. They are responsible for the majority of the fatal and near-fatal sting events. Understanding the biology and habitat of the various Hymenoptera species is helpful in recommending insect-avoidance strategies. The diagnosis of insect allergy relies on a history of a systemic allergic reaction with appropriate testing for venom-specific immunoglobulin E. If the history of a systemic reaction to an insect sting and the presence of venom specific immunoglobulin E is confirmed, venom immunotherapy is indicated. The proper and primary means of treating acute anaphylaxis is immediate epinephrine-and studies suggest that it is underutilized in the acute setting. However, it is venom immunotherapy, a disease-modifying therapy, that provides the affected individual with the most effective protection against future sting reactions. Long-term management of insect allergy and anaphylaxis includes appropriate referral to an allergist familiar with insect allergy and, if indicated, venom immunotherapy.

Migräne - Klinik, Diagnostik, Therapie und Prophylaxe

Migraine is a chronic. disabling, biologically determined, inherited brain disorder rendering life much less tolerable. The International Headache Society (IHS) offers guidelines for the classification and diagnosis of migraine headaches, in a document called 'The International Classification of Headache Disorders, 2nd edition' (ICHD-2). Migraine affects 10-16% of the population world-wide. For the 20-30% of migraine sufferers who experience migraine with aura, this aura comprises focal neurological phenomena that precede or accompany the attack. There are three main aspects of treatment: trigger avoidance, acute symptomatic control, and pharmacological prevention. Acute medications are more effective if used earlier in an attack. The goals of preventive therapy are to reduce the frequency, painfulness, and/or duration of migraines, and to increase quality of life.

Implications of Current Clinical Trials Focused on Medication Overuse and Therapeutic Prophylaxis

Chronic migraine (CM) is a complex disorder requiring a multifaceted management approach encompassing lifestyle modification, trigger avoidance, behavioral therapy, pharmacotherapy, patient education and support, management of expectations, and close follow-up. The lack of pharmacotherapies approved by the US Food and Drug Administration (FDA) hinders CM prophylaxis and management. Topiramate, gabapentin, tizanidine, fluoxetine, amitriptyline, and onabotulinumtoxinA have been evaluated for prophylactic treatment of CM in randomized, double-blind, placebo-controlled or active comparator-controlled trials. Additional well-designed, placebo-controlled studies are needed to assess the effectiveness of new and existing treatment options for CM. Understanding current clinical trial design and management guidelines is critical to designing future trials that overcome the challenge of consistent use of sensitive and clinically meaningful outcome measures. Topiramate is approved for episodic migraine management and has been studied for CM management. A growing body of evidence has shown it to be safe, effective, and well-tolerated in specific patient populations. However, intolerable adverse effects and inadequate efficacy associated with topiramate may lead to poor adherence. The efficacy, safety, and tolerability of onabotulinumtoxinA have been demonstrated in studies in various migraine patient populations, leading to recent FDA approval of onabotulinumtoxinA for the prophylactic treatment of CM in adults. These studies included patients with or without medication overuse, which may affect 30% to 80% of CM patients in the USA. In this program, we will analyze and discuss recent clinical trials investigating topiramate and onabotulinumtoxinA for CM.

Predictors of Parental Accommodation in Pediatric Obsessive-Compulsive Disorder: Findings from the Pediatric Obsessive-Compulsive Disorder Treatment Study (POTS) Trial

Few studies have examined predictors of parental accommodation (assessed with the Family Accommodation Scale-Parent Report) among families of children with obsessive-compulsive disorder (OCD). No studies have examined this phenomenon using empirically derived subscales of the Family Accommodation Scale-Parent Report (i.e., Caregiver Involvement, Avoidance of Triggers). Ninety-six youths (and their families) were included in the present study. Parents were asked to complete the Family Accommodation Scale-Parent Report. Families also completed several additional measurements assessing child- and parent-level variables of interest. Regression analyses were used to examine potential predictors of accommodation. Results support prior research suggesting that accommodation is ubiquitous among the families of children with OCD. Analyses revealed that several child-level (i.e., compulsion severity, oppositional behavior, and frequency of washing symptoms) and one parent-level (i.e., symptoms of anxiety) predictors work jointly to provide significant predictive models of parental accommodation. Clinicians and researchers should be aware of the impact of specific child- and parent-level variables on family accommodation in pediatric OCD and in turn their implications for treatment compliance, adherence, and, by extension, outcome. Study limitations warrant replication and extension of these findings; in particular, researchers may seek to obtain a better understanding of how the various facets of parental accommodation may differentially affect treatment.

Disparities in Risk Communication: A Pilot Study of Asthmatic Children, Their Parents, and Home Environments

Parents' knowledge and control of asthma triggers in home environments can help reduce risks associated with asthmatic children's respiratory health. This pilot study used both qualitative and quantitative methods to determine parental knowledge of their children's asthma triggers in home environments, control of those triggers, and information received and trusted. Twelve parents of asthmatic children in the greater Pittsburgh area--8 white and 4 African American--participated in one-on-one interviews about home exposures to asthma triggers. All parents described the link between asthma symptoms and both environmental tobacco smoke (ETS) and pet dander exposures. House dust mites and mold were also commonly identified asthma triggers. All 8 white parents reported receiving information from physicians about controlling home environmental triggers of asthma, but the 4 African American parents reported having received no such information. However, all 12 parents reported having greater trust in information received from physicians than from other sources. White parents were significantly more aware of potential asthma triggers and performed significantly more actions to control the triggers in their homes. African American parents noted stressful experiences with primary and secondary care, less recall of information sharing about asthma triggers, and a focus on symptom management vs trigger avoidance.

Management of vestibular migraine

Vestibular migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo. The duration of attacks varies from seconds to days, usually lasting minutes to hours, and they mostly occur independently of headaches. Long-lasting individual attacks are treated with generic antivertiginous and antiemetic drugs. Specific antimigraine drugs are unlikely to be very effective for rescue. The mainstay of the management of vestibular migraine is prophylactic medication. To date, there are no controlled trials available; the body of knowledge builds on case series and retrospective or observational studies. Most drugs are also used for the prevention of migraine headaches. The choice of medication should be guided by its side effect profile and the comorbidities of patients. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. Calcium antagonists include verapamil and flunarizine. If patients have anxiety, tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam are recommended. Acetazolamide is effective in rare genetic disorders related to migraine-like episodic ataxia; however, its place in vestibular migraine is still to be established. Nonpharmacological measures such as diet, sleep, hygiene and avoidance of triggers are recommended as they are for migraine. Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence.

Occupational Asthma: Review of Assessment, Treatment, and Compensation

Occupational asthma refers to asthma induced by exposure in the working environment to airborne dusts, vapors, or fumes, with or without preexisting asthma. Potential triggers of occupational asthma are diverse and involve a variety of postulated mechanisms. After confirming the presence of asthma, diagnosis hinges on obtaining a detailed and accurate occupational and environmental history and documenting a temporal association of symptoms or signs with workplace exposure. Management of occupational asthma centers on prescribing standard asthma therapies in conjunction with instituting preventive strategies, such as appropriate avoidance of environmental triggers, providing work restrictions, and using environmental controls and/or personal respiratory protection. If a worker is determined to be ill or injured, there are a variety of compensation systems that are designed to protect workers financially from disability related to respiratory impairments; however, the administrative process is frequently difficult to navigate for patients and their providers. Focusing on obtaining a detailed occupational and environmental history, establishing clear objective data to substantiate illness, and estimating or apportioning workplace contribution to the condition is important for the diagnosis and treatment of this relatively common form of asthma.

World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis

The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010.The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously).The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.

Anxiety: Trait/Sate, Sensation Seeking and Marital Satisfaction in Married Women

The aim of this research was to investigate the relationship of the Trait-state anxiety and sensation seeking with marital satisfaction in married women. For this reason, 150 participants have been selected as research sample. ENRICH marital satisfaction scale, trait-state anxiety inventory and Zuckerman sensation seeking scale were used for collecting of data. The results showed that there was negative correlation between trait anxiety and marital satisfaction and state anxiety and marital satisfaction. the trait anxiety strongly predicts marital satisfaction and explains %74 of marital satisfaction variance but the role of state anxiety in predicting of marital satisfaction is low. Also, there was positive correlation between sensation seeking and marital satisfaction and sensation seeking predicts marital satisfaction. The role of sensation seeking in predicting of marital satisfaction as state anxiety was low. These results suggest that trait anxiety as a consistent personality facet trigger stress, anger, avoidance behavior, attention and memory disorder and these conditions influence marital satisfaction. Thus, it is important to be attend to trait anxiety in clinical services, couple therapy and prevention.

Hereditary Angioedema: A Clinical Review for the Otolaryngologist

Hereditary angioedema (HAE) is a relatively rare genetic disorder that is usually characterized by either low levels of C1 esterase inhibitor (C1-INH) or the presence of dysfunctional C1-INH. It can present with relatively mild and self-limiting symptoms, but it is also potentially fatal; the most common cause of death is asphyxiation secondary to edema of the upper airway. The diagnosis of HAE, especially in the emergency situation, is not straightforward. HAE must be distinguished from several other types of angioedema that require different management approaches. Management approaches include trigger avoidance and pharmacologic therapy; the latter has traditionally involved the administration of attenuated androgens and antifibrinolytics. Recently, a new class of agent—C1-INH—has been introduced in the United States. This article provides an update on the pathophysiology, clinical picture, diagnosis, prophylaxis, and acute treatment of HAE. We must keep HAE in mind as a possible diagnosis whenever we are faced with a case of unexplained angioedema if we are to take advantage of the effective and more specific therapies that are becoming available.

Trigger recognition and management in poorly controlled asthmatics

Previous studies using cross-sectional designs suggest that asthma trigger recognition and management are suboptimal in clinical practice. The objective of this study was to assess gaps between asthma guideline recommendations and clinical practice regarding asthma trigger recognition and management by tracking poorly controlled asthma patients over a 2-year period. A retrospective cohort study of a representative sample of 102 children and adult residents of Olmsted County, MN, with poor asthma control in 2003-2004 was performed. All medical records from each asthma-related visit were examined for documented asthma trigger inquiries, specific trigger avoidance advice, and for adherence to the trigger avoidance advice. One hundred two subjects made 686 asthma-related visits that were included for analysis. At least 1 trigger inquiry occurred in 83% of visits, with an average of 2.0 triggers queried per visit. The most common trigger inquiries were for infection (47%), environmental tobacco smoke (41%), and allergens (29%). The mean number of triggers queried was higher during exacerbation visits versus nonexacerbation visits (2.1 versus 1.8; p < 0.001) and in the emergency care settings compared with outpatient settings (2.4 versus 1.7; p < 0.001). Advice for managing asthma triggers was given in 30% of visits and adherence to trigger advice was evaluated at 6% of visits. Future interventions for improving asthma trigger management should be targeted to routine asthma outpatient visits, where trigger avoidance advice is infrequent and rarely addressed in follow-up visits.

Tackling allergic rhinitis

Management involves trigger avoidance, topical nasal preparations and patient education

Treatment of Vasovagal Syncope: An Update

Vasovagal syncope (VVS) remains the most common cause of syncope and transient loss of consciousness in all age groups. The treatment of VVS focuses on measures that interrupt or prevent its pathophysiologic mechanism, as well as on avoidance of triggers. Although the evidence supporting an increase in salt and water intake is weak, it is a cost-effective and safe strategy that should always be used as first-line therapy. Patients should be educated on how to respond to further episodes of syncope, especially if they experience prodromal warning signs. In these cases, counterpressure maneuvers in younger patients are clearly effective. Orthostatic training exercises may improve symptoms in patients with recurrent VVS; however, this strategy is only effective in younger, highly motivated patients. Multiple medications have been tested in small trials, and there is sparse evidence on efficacy. β-Adrenergic antagonists and selective serotonin reuptake inhibitors have shown contradictory results on efficacy in a variety of studies; thus, their use should be restricted. Midodrine is the only drug proven to prevent VVS recurrence; however, no consistent prescription guidelines exist. The ongoing Second Prevention of Syncope Trial (POST II) is investigating the benefits of fludrocortisone in this population. In the meantime, measures such as increased salt and water intake and counterpressure maneuvers should be used in all cases if no contraindications are present. Pharmacologic treatment should be restricted to midodrine and fludrocortisone, with the other treatments as options in highly refractory cases. Implantation of a permanent pacemaker should be a measure of last resort in highly refractory cases, particularly in the cardioinhibitory type of VVS.

Examining the Psychometric Properties of the Family Accommodation Scale-Parent-Report (FAS-PR).

Growing research has examined parental accommodation among the families of children with obsessive-compulsive disorder (OCD). However, these studies have utilized a parent-report (PR) version of a measure, the Family Accommodation Scale (FAS) that has never received proper psychometric validation. In turn, previously derived subscales have been developed via clinical rather than empirical evidence. This study aims to conduct a comprehensive psychometric analysis of the FAS-PR utilizing data collected from 96 youths with OCD. Exploratory factors analysis was conducted and revealed a 12-item scale yielding two separate, yet related subscales, Avoidance of Triggers (AT) and Involvement in Compulsions (IC). Subsequent analyses revealed good internal consistency and convergent and discriminant validity. These findings suggest that future research should seek to examine factors that may impact various facets to accommodation as well as the role these facets plays in predicting treatment outcome. Limitations are discussed.

Asthma in Pregnancy

Asthma is an increasingly common problem during pregnancy. Mild and moderate asthma can be associated with excellent maternal and perinatal pregnancy outcomes, especially if patients are managed according to contemporary recommendations of National Asthma Education and Prevention Program. Severe and poorly controlled asthma may be associated with increased prematurity, need for cesarean delivery, preeclampsia, and growth restriction. Severe asthma exacerbations can result in maternal morbidity and mortality, and can have commensurate adverse pregnancy outcomes. The management of asthma during pregnancy should be based upon objective assessment, trigger avoidance, patient education, and step therapy. Asthma medications should be continued during pregnancy and while breast-feeding.

A new Na v1.7 sodium channel mutation I234T in a child with severe pain

Dominant gain-of-function mutations that hyperpolarize activation of the Na v1.7 sodium channel have been linked to inherited erythromelalgia (IEM), a disorder characterized by severe pain and redness in the feet and hands in response to mild warmth. Pharmacotherapy remains largely ineffective for IEM patients with cooling and avoidance of triggers being the most reliable methods to relieve pain. We now report a 5 year old patient with pain precipitated by warmth, together with redness in her hands and feet. Her pain episodes were first reported at 12 months, and by the age of 15–16 months were triggered by sitting as well as heat. Pain has been severe, inducing self-mutilation, with limited relief from drug treatment. Our analysis of the patient’s genomic DNA identified a novel Na v1.7 mutation which replaces isoleucine 234 by threonine (I234T) within domain I/S4–S5 linker. Whole-cell voltage-clamp analysis shows a I234T-induced shift of −18 mV in the voltage-dependence of activation, accelerated time-to-peak, slowed deactivation and enhanced responses to slow ramp depolarizations, together with a −21 mV shift in the voltage-dependence of slow-inactivation. Our data show that I234T induces the largest activation shift for Na v1.7 mutations reported thus far. Although enhanced slow-inactivation may attenuate the gain-of-function of the I234T mutation, the shift in activation appears to be dominant, and is consistent with the severe pain symptoms reported in this patient.

Treatment of Acute Migraine in the Pediatric Population

The recognition of the diagnosis of migraine in the pediatric population is increasing. Early and aggressive treatment of migraine in children and adolescents with the use of over-the-counter medications has proven effective. In addition, the off-label use of many migraine-specific medications is often accepted in the absence of sufficient evidence-based trials. Mild to severe cases of migraine should be treated with NSAIDs, with triptans used for moderate to severe headaches that are unresponsive to over-the-counter therapy. Rescue medication including dihydroergotamine (DHE) should be used for intractable migraines, preferably in the hospital setting. In patients with associated symptoms of nausea and vomiting, antiemetics with antidopaminergic properties can be helpful through their action on central migraine generation. Furthermore, patients and families should be educated about nonpharmacologic aspects of management such as preventing episodic migraine through lifestyle modification and avoidance of triggers.