Friday June 23, 2017



October 30

2011 Publications In Peer Reviewed Journals

Dr. Bielory’s Recent Publications 2011

Bielory, L., Y. Chun, et al. (2011). "Impact of mometasone furoate nasal spray on individual ocular symptoms of allergic rhinitis: a meta-analysis." Allergy.

To cite this article: Bielory L, Chun Y, Bielory BP, Canonica GW. Impact of mometasone furoate nasal spray on individual ocular symptoms of allergic rhinitis: a meta-analysis. Allergy 2011; DOI: 10.1111/j.1398-9995.2010.02543.x. ABSTRACT: Background: Intranasal corticosteroids (INSs) are a mainstay of treatment of allergic rhinitis (AR) nasal symptoms. The INS mometasone furoate nasal spray (MFNS) has well-documented efficacy and safety for the treatment and prophylaxis of nasal symptoms of seasonal AR (SAR) and for the treatment of nasal symptoms of perennial AR (PAR). Increasing interest has focused on whether INSs, including MFNS, may have beneficial effects on the ocular symptoms frequently associated with AR. Methods: We performed a meta-analysis of 10 randomized, placebo-controlled trials of the efficacy of MFNS 200 mcg daily in relieving ocular allergy symptoms, including itching/burning, redness, and tearing/watering in both SAR and PAR. Four PAR studies and six SAR studies are included in the analysis. A fixed-effect inverse variance model was used to calculate weighted mean differences, 95% confidence intervals (CIs) for each comparison, and a combined overall treatment effect (Z) with P-value. Results: In both analyses of SAR and PAR studies, including 3132 patients, all individual ocular symptoms were reduced in patients treated with MFNS. Overall treatment effect was significant for all three individual ocular symptoms in the SAR studies (Z = 9.18 for tearing, Z = 10.15 for itching, and Z = 8.88 for redness; P < 0.00001 for all) and in the PAR studies (Z = 5.94, P < 0.00001 for tearing; Z = 2.43, P = 0.02 for itching; and Z = 2.42, P = 0.02 for redness). Conclusions: Our findings add to the growing body of literature supporting the positive class effect of INSs, including MFNS, on ocular symptoms associated with SAR and PAR.

Hong, J., B. Bielory, Bielory, L. (2011). "Efficacy of intranasal corticosteroids for the ocular symptoms of allergic rhinitis: A systematic review." Allergy and asthma proceedings : the official journal of regional and state allergy societies 32(1): 22-35.

Current treatment options for allergic rhinoconjunctivitis include topical antihistamines, vasoconstrictors, mast cell stabilizers, intranasal corticosteroids (INCS), and nonsteroidal anti-inflammatory drugs that are generally used as a supplement to oral or intranasal therapies, necessitating the use of multiple treatments for the different symptoms of allergic rhinitis (AR). To assess the efficacy of INCS for ocular symptoms (OS) of AR. A search was performed of clinical trials (n = 32) from 1973 to 2009 of English articles (Medline, Embase, and PubMed) using "intranasal corticosteroid," "allergic rhinitis," "ocular symptoms," "allergic conjunctivitis," and "rhinoconjunctivitis" as key words. Quality assessment for the 32 eligible studies was performed using the Jadad score. Statistical analysis for continuous data was done by weighted mean difference or standardized mean difference. Thirty-two trials were included and separated into three different groups. The overall weighted mean was obtained from the Jadad score and came out to 9.29 (95% CI, 8.7-9.88). For meta-analysis for total OS scores and individual symptoms (10 parallel studies) the weighted mean was 10.17 (95% CI, 9.34-11). In the parallel studies, meta-analysis of individual symptoms (nine studies) gave a weighted mean of 10.09 (95% CI, 9.55-10.63). For eye symptoms but no individual symptoms (13 studies), the weighted mean was 8.56 (95% CI, 7.66-9.46). To date, clinical studies conducted statistically showed the efficacy of INCS on the OS of AR as evidenced by the meta-analysis results for the studies reporting total OSs.


Ziska, L., K. Knowlton, et al Bielory, L., Frenz, D.. (2011). "Recent warming by latitude associated with increased length of ragweed pollen season in central North America." Proceedings of the National Academy of Sciences of the United States of America.

A fundamental aspect of climate change is the potential shifts in flowering phenology and pollen initiation associated with milder winters and warmer seasonal air temperature. Earlier floral anthesis has been suggested, in turn, to have a role in human disease by increasing time of exposure to pollen that causes allergic rhinitis and related asthma. However, earlier floral initiation does not necessarily alter the temporal duration of the pollen season, and, to date, no consistent continental trend in pollen season length has been demonstrated. Here we report that duration of the ragweed (Ambrosia spp.) pollen season has been increasing in recent decades as a function of latitude in North America. Latitudinal effects on increasing season length were associated primarily with a delay in first frost of the fall season and lengthening of the frost free period. Overall, these data indicate a significant increase in the length of the ragweed pollen season by as much as 13-27 d at latitudes above approximately 44 degrees N since 1995. This is consistent with recent Intergovernmental Panel on Climate Change projections regarding enhanced warming as a function of latitude. If similar warming trends accompany long-term climate change, greater exposure times to seasonal allergens may occur with subsequent effects on public health.




October 29

2011 Influenza Season

The influenza vaccination recommendation this year is simple: Everyone 6 months of age and older should receive influenza vaccine. The annual "universal" influenza vaccination recommendation was first established in 2010 to expand protection against influenza to more people.

Patients who were vaccinated last season about still need an annual influenza vaccination because the influenza vaccine virus strains included in the 2011-2012 influenza vaccines are the same as those in last year's vaccines. It's not common for all 3 vaccine virus strains to be unchanged from one season to the next -- this has happened only 8 times since 1969. However, CDC has always recommended that people get vaccinated every year.

Annual influenza vaccination, even when the vaccine strains are unchanged, is important because a person's immune protection from influenza vaccination declines over time. Immunity acquired from vaccine administered last season will have declined and may not be enough to prevent infection this season. So, annual influenza vaccination is recommended for optimal protection.

Increasingly, there are influenza vaccination options. There are 3 trivalent inactivated vaccines (TIV) as well as live attenuated influenza virus vaccine (LAIV or the nasal spray vaccine).

Trivalent inactivated vaccine has been around for decades and is approved for use in people 6 months and older, including people with high-risk medical conditions and pregnant women. It is administered intramuscularly. Different formulations of this vaccine are available from various manufacturers, and the minimum age varies from one formulation to another. Consult the package insert to ensure that a specific vaccine is suitable for your patient's age. In addition, the 2011-2012 Advisory Committee on Immunization Practices (ACIP) Influenza Vaccine Recommendations should be consulted. For example, ACIP recommends that the TIV Afluria® (Merck & Co., Whitehouse Station, New Jersey) not be given to children aged less than 9 years, although it is approved for children aged 5 years and older.

The high-dose TIV was introduced in 2010 for people 65 years and older. It contains 4 times the amount of antigen as other influenza vaccines to prompt a stronger immune response. The high-dose influenza vaccine is also administered intramuscularly.

October 29

2010 Publications In Peer Reviewed Journals

Dr. Bielory’s Recent Publications 2010

 Bielory, B. and L. Bielory (2010). "Atopic dermatitis and keratoconjunctivitis." Immunology and Allergy Clinics of North America 30(3): 323-336.

Atopic dermatitis, a chronic disease seen by allergist-immunologists, has both dermatologic and ocular manifestations. The ocular component is often disproportionately higher than the dermatologic disease. Even if skin abnormalities seem well controlled, these patients require ophthalmic evaluation. Atopic keratoconjunctivitis in atopic dermatitis patients is characterized by acute exacerbations and requires maintenance therapy for long-term control. Future studies will continue to emphasize the use of steroid-sparing, immunomodulating agents that have the potential to provide long-lasting anti-inflammatory control with a more favorable side-effect profile.

Bielory, B. P., V. L. Perez,  Bielory, L. (2010). "Treatment of seasonal allergic conjunctivitis with ophthalmic corticosteroids: in search of the perfect ocular corticosteroids in the treatment of allergic conjunctivitis." Current Opinion in Allergy and Clinical Immunology 10(5): 469-477.

PURPOSE OF REVIEW: Corticosteroids are an effective short-term treatment option for seasonal allergic conjunctivitis (SAC). Their use has been limited due to their side effects and has led to the development of modified 'soft', 'smart' ophthalmic corticosteroid formulations that retain their anti-inflammatory mechanism of action with an improved safety profile. RECENT FINDINGS: Similar to the development of the prodrug concept for the nose and lung that led to the development of ciclesonide, a chloromethyl-ester group substitution at the carbon-20 (C-20) position of the traditional corticosteroid has led to the development of a family of potential ophthalmic corticosteroids including loteprednol etabonate that has demonstrated similar efficacy to the C-20 ketone corticosteroids in the treatment of the signs and symptoms of ocular allergies, but less likely to induce elevations in intraocular pressure (IOP) or the formation of cataracts. The C-20 ester corticosteroid, loteprednol etabonate has been designed to be rapidly converted to an inactive, nontoxic metabolite, thus minimizing adverse effects, and loteprednol etabonate (0.2%) is currently the only ophthalmic corticosteroid specifically developed for and approved by the Food and Drug Administration for treatment of SAC. SUMMARY: The development of modified or soft, smart corticosteroids such as loteprednol etabonate provides an avenue for expanding the treatment of the inflammation associated with signs and symptoms in patients with chronic forms or severe acute exacerbations of allergic conjunctivitis. Modified corticosteroids are an effective and well tolerated option for the short-term treatment of the inflammation and signs and symptoms associated with SAC.

Bielory, L. (2010). "Allergic conjunctivitis and the impact of allergic rhinitis." Current Allergy and Asthma Reports 10(2): 122-134.

Although nasal allergy has been prominent in allergy research, ocular allergy is increasingly recognized as a distinct symptom complex that imposes its own disease burden and reduction in patients' quality of life. In the past year, knowledge of the relationships between allergic conjunctivitis and allergic rhinitis has increased. Allergic conjunctivitis is highly prevalent and has a close epidemiologic relationship with allergic rhinitis. Both conditions also exhibit similar pathophysiologic mechanisms. Pathways of communication are thought to increase the likelihood of an inflammatory reaction at both sites following allergen exposure of nasal or ocular tissue. Clinical trials of intranasal therapies have demonstrated efficacy in allergic conjunctivitis and rhinitis. Newer intranasal steroids decrease ocular symptoms, potentially achieving efficacy by suppressing the naso-ocular reflex, downregulation of inflammatory cell expression, or restoration of nasolacrimal duct patency. Proposed pathophysiologic interactions between allergic rhinitis and ocular allergy underscore the need for therapies with efficacy in both symptom sets.

Bielory, L. (2010). "American Academy of Allergy, Asthma and Immunology (AAAAI)-2010 annual meeting. 26 February-2 March 2010, New Orleans, LA, USA." IDrugs : the investigational drugs journal 13(5): 304-307.

The 2010 American Academy of Allergy, Asthma and Immunology (AAAAI) meeting, held in New Orleans, included topics covering new therapeutic developments in the fields of allergy, asthma and immunological diseases. This conference report highlights selected presentations on potential treatments for food and other allergies, as well as therapies for asthma and other immunological diseases. Investigational drugs discussed include Oralair Mites (Stallergenes SA/Paladin Labs Inc), PF-03654746 (Pfizer Inc) and AMG-853 (Amgen Inc).

Breitbart, S. I. and L. Bielory(2010). "Acquired angioedema: Autoantibody associations and C1q utility as a diagnostic tool." Allergy and asthma proceedings : the official journal of regional and state allergy societies 31(5): 428-434.

Acquired Angioedema (AAE) is a rare condition classified into two subtypes: Type I, which is associated with lymphoproliferative disorders, and Type II, which is linked with autoantibodies against C1-esterase inhibitor (C1-INH). Unlike Type I AAE, Type II has no correlation with lymphoproliferative disorders. We report the evaluation of angioedema that was associated with an underlying lymphoproliferative disorder for the purpose of discussing the relationship between C1q and a diagnosis of AAE. A literature review was completed for the purpose of assessing the diagnostic value of C1q when used in the workup of AAE. A PubMed/Web of Science search (1976-2010) produced 78 references (yielding 167 individual cases of AAE) using terminology "AAE." The case described a patient with a depressed C1q (

Lee, J. and L. Bielory (2010). "Complementary and alternative interventions in atopic dermatitis." Immunology and Allergy Clinics of North America 30(3): 411-424.

The burden of atopic diseases, including atopic dermatitis (AD), is significant and far-reaching. In addition to cost of care and therapies, it affects the quality of life for those affected as well as their caretakers. Complementary and alternative therapies are commonly used because of concerns about potential adverse effects of conventional therapies and frustration with the lack of response to prescribed medications, be it due to the severity of the AD or the lack of appropriate regular use. Despite the promising results reported with various herbal medicines and biologic products, the clinical efficacy of such alternative therapies remains to be determined. Physicians need to be educated about alternative therapies and discuss benefits and potential adverse effects or limitations with patients. A systematic approach and awareness of reputable and easily accessible resources are helpful in dealing with complementary and alternative medicine (CAM). The use of CAM interventions is common among individuals with AD. Epidemiologic data have been a motivating drive for better elucidation of the efficacy of CAM interventions for allergic disease. Herbal medicines and biologics for AD treatment and, more recently, prevention comprise a major area of clinical investigation. Potential mechanisms of therapeutic effect elucidated by animal models and human clinical studies implicate modulation of TH2-type allergic inflammation and induction of immune tolerance. Population-based research regarding the use of CAM for allergic diseases underscores the increasing challenge for care providers with respect to identifying CAM use and ensuring safe use of allopathic and complementary medicines in disease management.

Singh, K., S. Axelrod, Bielory, L. (2010). "The epidemiology of ocular and nasal allergy in the United States, 1988-1994." The Journal of allergy and clinical immunology 126(4): 778-783 e776.

BACKGROUND: Allergies give rise to the fifth-leading group of chronic diseases. However, the specific prevalence of ocular allergy is poorly described. OBJECTIVE: We sought to provide a more accurate representation of the epidemiology of ocular allergy in the United States. METHODS: The National Health And Nutrition Examination Survey III performed in the United States from 1988-1994 was the source for the data collected. Items from the questionnaire regarding ocular and nasal allergy symptoms in relation to skin prick testing were stratified by age, race, region, and sex. RESULTS: The sample size is 20,010: 1,285 (6.4%) reported ocular symptoms, 3,294 (16.5%) reported nasal symptoms, 5,944 (29.7%) reported both ocular and nasal symptoms, and 9.487 (47.4%) were asymptomatic. Forty percent of the population reported at least 1 occurrence of ocular symptoms in the past 12 months. Those 50 years and older have a higher frequency of isolated ocular symptoms (P < .001). There is an increase in the frequency of symptoms in those younger than 50 years in the populations of subjects with ocular and nasal symptoms combined and isolated nasal symptoms (P < .001). Ocular symptoms are more frequent than nasal symptoms in relation to animals (P < .001), household dust (P < .001), and pollen (P < .001). CONCLUSION: This analysis provides the first representation of the epidemiology of ocular allergy in the United States. Up to 40% of the population, the highest reported to date, have experienced ocular symptoms at least once in their lifetime, with a peak of symptoms in the months of June and July.


Weinstein, M. E., A. H. Wolff, Bielory, L. (2010). "Efficacy and tolerability of second- and third-generation antihistamines in the treatment of acquired cold urticaria: a meta-analysis." Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology 104(6): 518-522.

BACKGROUND: Acquired cold urticaria (ACU) is a form of physical urticaria that has been treated with first-generation antihistamines; there is a paucity of data regarding second- and third-generation antihistamines for the treatment of ACU. OBJECTIVE: To perform a systematic review of the literature to determine the efficacy of second- and third-generation antihistamines in the treatment of ACU. METHODS: Data were extracted via a MEDLINE search of the literature between 1950 and May 2009. We included double-blind, randomized, placebo-controlled studies comparing the treatment of patients with ACU with second- and third-generation antihistamine medications vs placebo. RESULTS: Overall, 98 patients were identified from 4 included studies. Two trials indicated that second- and third-generation antihistamines significantly eliminated the presence of wheals after treatment vs placebo (odds ratio [OR], 8.88; 95% confidence interval [CI], 4.35 to 18.13). Two trials demonstrated a reduction in wheal area after treatment with a second- or third-generation antihistamine compared with placebo (mean difference, -347.99 mm2; 95% CI, -489.43 to -206.54 mm2). Two trials demonstrated significant elimination of pruritus with second- or third-generation antihistamine treatment vs placebo (OR, 10.44; 95% CI, 4.39 to 24.84). All 4 studies assessed the tolerability of a second- or third-generation antihistamine vs placebo and found an increased rate of adverse events (OR, 3.04; 95% CI, 1.53 to 6.06), although the complaints were mild. CONCLUSIONS: The newer, less-sedating antihistamines seem to be effective in the treatment of ACU in terms of their ability to significantly reduce the presence of wheals and pruritus after cold exposure. These medications are usually well tolerated, with only mild adverse effects

Zuraw, B. L., P. J. Busse, et al. Bielory, L.(2010). "Nanofiltered C1 inhibitor concentrate for treatment of hereditary angioedema." The New England journal of medicine 363(6): 513-522.

BACKGROUND: Hereditary angioedema due to C1 inhibitor deficiency is characterized by recurrent acute attacks of swelling that can be painful and sometimes life-threatening. METHODS: We conducted two randomized trials to evaluate nanofiltered C1 inhibitor concentrate in the management of hereditary angioedema. The first study compared nanofiltered C1 inhibitor concentrate with placebo for treatment of an acute attack of angioedema. A total of 68 subjects (35 in the C1 inhibitor group and 33 in the placebo group) were given one or two intravenous injections of the study drug (1000 units each). The primary end point was the time to the onset of unequivocal relief. The second study was a crossover trial involving 22 subjects with hereditary angioedema that compared prophylactic twice-weekly injections of nanofiltered C1 inhibitor concentrate (1000 units) with placebo during two 12-week periods. The primary end point was the number of attacks of angioedema per period, with each subject acting as his or her own control. RESULTS: In the first study, the median time to the onset of unequivocal relief from an attack was 2 hours in the subjects treated with C1 inhibitor concentrate but longer than 4 hours in those given placebo (P=0.02). In the second study, the number of attacks per 12-week period was 6.26 with C1 inhibitor concentrate given as prophylaxis, as compared with 12.73 with placebo (P

October 28

Food Allergen Avoidance _ Good or Bad?

The standard of care for the management of food allergy has been strict allergen avoidance. This advice is based upon the suppositions that exposure could result in allergic reactions and avoidance may speed recovery. Recent studies challenge these assumptions. Studies now demonstrate that most children with milk and egg allergy tolerate extensively heated forms of these foods. Moreover, clinical trials of oral immunotherapy show that oral exposure can lead to desensitization. Additionally, recent epidemiologic studies fail to support the notion that delaying introduction of highly allergenic foods to infants and young children prevents the development of food allergy. In fact, the data suggest that delays may increase risks.

Recent data indicate that strict allergen avoidance is not always necessary for treatment, exposure may be therapeutic, and extended delay in introduction of food allergens to the diet of young children may increase allergy risks. However, in many circumstances strict avoidance is clearly necessary for treatment. Additional studies are needed to determine the risks and benefits of exposure to tolerated allergen, including identification of biomarkers to identify patients who may benefit.

October 27

Asthma CDCStudy

More than 24 million people in the United States now suffer from asthma, a 12.3 percent increase over the rate in 2001, a new Centers for Disease Control and Prevention study found. The study, which reviewed the number of asthma cases between 2001 and 2009, found that 9.6 percent of children had asthma and that the rate is highest among poor children. Fully 17 percent of black children had asthma, according to the findings, which were published in CDC's Morbidity and Mortality Weekly Report on May 3 and as a Vital Signs report. The study's authors said it is not clear why the number of cases of asthma has increased by more than 12 percent. CDC and the Environmental Protection Agency have said in the past that climate change and air pollution could be a contributing factor to asthma, as could mold spores and other environmental issues. The new study points to a need for people to better manage their asthma, and said physicians play a large part in that. But the report found disparities in access to care as well. People without health insurance reported more trouble seeing or talking with a primary care physician or specialist than people with health insurance, and many uninsured people said they could not afford to buy prescription medications.

Asthma, which is characterized by episodes of wheezing, chest tightness, shortness of breath and coughing, is not curable, but its symptoms can be controlled to some extent through a number of measures, including limiting contact with dust and dander, prohibiting smoking by or near a person with asthma and use of asthma control medication, according to the CDC study.

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Location: Springfield, NJ
Today's Date: June 23, 2017
Station Director: Leonard Bielory, M.D
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