Chitra Dinakar

All Publications

• Management of acute loss of asthma control: yellow zone strategies CURRENT OPINION IN ALLERGY AND CLINICAL IMMUNOLOGY Polk, B. I., Dinakar, C. 2019; 19 (2): 154–60

  View details for DOI 10.1097/ACI.0000000000000512

  View details for Web of Science ID 000467725100012

• Needs Assessment Survey for a Food Allergy Control Tool. The journal of allergy and clinical immunology. In practice Lippner, E., Sicherer, S. H., Land, M. H., Schatz, M., Dinakar, C. 2018

  View details for PubMedID 30317004

• The Health Effects of Electronic Cigarettes. The New England journal of medicine Dinakar, C. n., O'Connor, G. T. 2016; 375 (14): 1372–81

  View details for PubMedID 27705269

• The transforming power of proximity food challenges. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakar, C. n., Shroba, J. n., Portnoy, J. M. 2016; 117 (2): 135–37

  View details for PubMedID 27499540

• Quality measures in allergy, asthma, and immunology. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakar, C. n., Lang, D. M. 2015; 114 (6): 435–39

  View details for PubMedID 25890450

• TeleAllergy: a new way to manage asthma. The journal of allergy and clinical immunology. In practice Portnoy, J. n., Waller, M. n., Dinakar, C. n. 2014; 3 (2): 302–3

  View details for PubMedID 25754720

• Electronic cigarettes: navigating the vapor. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Nickels, A. S., Joshi, A. Y., Dinakar, C. n. 2014; 112 (6): 481–83

  View details for PubMedID 24731875

• Empowering the child and caregiver: yellow zone Asthma Action Plan. Current allergy and asthma reports Dinakar, C. n., Portnoy, J. M. 2014; 14 (11): 475

  Abstract

  Current guidelines, both national and international, elegantly describe evidence-based measures to attain and maintain long-term control of asthma. These strategies, typically discussed between the provider and patient, are provided in the form of written (or electronic) instructions as part of the green zone of the color-coded Asthma Action Plan. The red zone of the Asthma Action Plan has directives on when to use systemic corticosteroids and seek medical attention. The transition zone between the green zone of good control and the red zone of asthma exacerbation is the yellow zone. This zone guides the patient on self-management of exacerbations outside a medical setting. Unfortunately, the only recommendation currently available to patients per the current asthma guidelines is the repetitive use of reliever bronchodilators. This approach, while providing modest symptom relief, does not reliably prevent progression to the red zone. In this document, we present new, evidence-based, yellow zone intervention options.

  View details for PubMedID 25183364

• From the Pages of Allergy Watch: December 2019. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Oppenheimer, J. J., Chipps, B. E., Dinakar, C., Fineman, S. M. 2019

  View details for DOI 10.1016/j.anai.2019.09.015

  View details for PubMedID 31562938

• Allergic rhinitis is 'nothing to sneeze at' (Nov-Dec 2018) ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Oppenheimer, J. J., Dinakar, C., Fineman, S. M. 2019; 123 (3): 319

  View details for Web of Science ID 000484010300024

• AllergyWatch ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Oppenheimer, J. J., Dinakar, C., Fineman, S. M. 2019; 123 (3): 319

  View details for Web of Science ID 000484010300023

• Drug Allergy. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakar, C., Lang, D. M., Fineman, S. M. 2019; 123 (1): 112–14

  View details for DOI 10.1016/j.anai.2019.04.004

  View details for PubMedID 31255191

• Allergy Watch. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Oppenheimer, J. J., Dinakar, C., Fineman, S. M., Dinakar, C. 2019

  View details for DOI 10.1016/j.anai.2019.06.014

  View details for PubMedID 31247305

• Race and Allergy ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Fineman, S. M., Khan, D. A., Dinakar, C. 2019; 122 (5): 543–45

  View details for DOI 10.1016/j.anai.2019.02.008

  View details for Web of Science ID 000466368000025

• From the pages of AllergyWatch May 2019. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Fineman, S. M., Khan, D. A., Dinakar, C. 2019

  View details for PubMedID 30772388

• Needs assessment survey for a food allergy control tool JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE Lippner, E., Sicherer, S. H., Land, M. H., Schatz, M., Dinakar, C. 2019; 7 (2): 701-+

  View details for DOI 10.1016/j.jaip.2018.09.035

  View details for Web of Science ID 000457641700057

• American Academy of Allergy, Asthma and Immunology response to the EAACI/GA(2)LEN/EDF/WAO guideline for the definition, classification, diagnosis, and management of Urticaria 2017 revision ALLERGY Wood, R. A., Khan, D. A., Lang, D. M., Fasano, M., Peden, D. B., Busse, P. J., Carter, M. C., Demain, J. G., Dinakar, C., Grayson, M. H., Markovics, S. B., Sicherer, S. H., Stone, K. D., Sullivan, K. E., Williams, P. V., Fleisher, T. A., Casale, T. B. 2019; 74 (2): 411–13

  View details for DOI 10.1111/all.13636

  View details for Web of Science ID 000458896800027

• Informatics Analysis of Cross-Reactivity of Food Allergens in South Asian Cuisine Agusala, V., Dinakar, C., Dinakarpandian, D. MOSBY-ELSEVIER. 2019: AB238

  View details for DOI 10.1016/j.jaci.2018.12.727

  View details for Web of Science ID 000457771200716

• Management of acute loss of asthma control: yellow zone strategies. Current opinion in allergy and clinical immunology Polk, B. I., Dinakar, C. 2019

  Abstract

  PURPOSE OF REVIEW: Asthma exacerbations are associated with a significant burden to both the individual patient and to the healthcare system. Patients often step-up home therapies in response to increased asthma symptoms, and the asthma action plan was created to empower patients to self-manage their asthma care. The yellow (intermediate) zone of the asthma action plan is frequently poorly defined, and current Expert Panel Report 3 guideline recommendations are not effective for all patients. This article reviews the evidence behind various recommended yellow zone intervention strategies.RECENT FINDINGS: There are many potential methods of delivering yellow zone therapy, and recent studies have assessed preventive efficacy of a scheduled increase in controller medication(s), reliever medication(s), or a symptom-driven combination of both. The literature suggests that, in certain asthma subpopulations, some methods may be more efficacious than others.SUMMARY: Multiple yellow zone approaches may be beneficial, and the yellow zone is not a 'one size fits all' narrative.

  View details for PubMedID 30649012

• Biallelic mutations in DNA ligase 1 underlie a spectrum of immune deficiencies JOURNAL OF CLINICAL INVESTIGATION Maffucci, P., Chavez, J., Jurkiw, T. J., O'Brien, P. J., Abbott, J. K., Reynolds, P. R., Worth, A., Notarangelo, L. D., Felgentreff, K., Cortes, P., Boisson, B., Radigan, L., Cobat, A., Dinakar, C., Ehlayel, M., Ben-Omran, T., Gelfand, E. W., Casanova, J., Cunningham-Rundles, C. 2018; 128 (12): 5489–5504

  View details for DOI 10.1172/JCI99629

  View details for Web of Science ID 000452071300032

• Biallelic mutations in DNA ligase 1 underlie a spectrum of immune deficiencies. The Journal of clinical investigation Maffucci, P., Chavez, J., Jurkiw, T. J., O'Brien, P. J., Abbott, J. K., Reynolds, P. R., Worth, A., Notarangelo, L. D., Felgentreff, K., Cortes, P., Boisson, B., Radigan, L., Cobat, A., Dinakar, C., Ehlayel, M., Ben-Omran, T., Gelfand, E. W., Casanova, J., Cunningham-Rundles, C. 2018

  Abstract

  We report the molecular, cellular, and clinical features of 5 patients from 3 kindreds with biallelic mutations in the autosomal LIG1 gene encoding DNA ligase 1. The patients exhibited hypogammaglobulinemia, lymphopenia, increased proportions of circulating gammadeltaT cells, and erythrocyte macrocytosis. Clinical severity ranged from a mild antibody deficiency to a combined immunodeficiency requiring hematopoietic stem cell transplantation. Using engineered LIG1-deficient cell lines, we demonstrated chemical and radiation defects associated with the mutant alleles, which variably impaired the DNA repair pathway. We further showed that these LIG1 mutant alleles are amorphic or hypomorphic, and exhibited variably decreased enzymatic activities, which lead to premature release of unligated adenylated DNA. The variability of the LIG1 genotypes in the patients was consistent with that of their immunological and clinical phenotypes. These data suggest that different forms of autosomal recessive, partial DNA ligase 1 deficiency underlie an immunodeficiency of variable severity.

  View details for PubMedID 30395541

• Penicillin allergy. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Lang, D., Dinakar, C., Oppenheimer, J. J., Hernandez-Trujillio, V. 2018; 121 (5): 637–39

  View details for PubMedID 30389083

• Penicillin allergy ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Lang, D., Dinakar, C., Oppenheimer, J. J., Hernandez-Trujillio, V. 2018; 121 (5): 637–39

  View details for DOI 10.1016/j.anai.2018.08.011

  View details for Web of Science ID 000448665400027

• AAAAI Response to the EAACI/GALEN/EDF/WAO Guideline for the Definition, Classification, Diagnosis and Management of Urticaria 2017 Revision. Allergy Wood, R. A., Khan, D. A., Lang, D. M., Fasano, M. B., Peden, D. B., Busse, P. J., Carter, M. C., Demain, J. G., Dinakar, C., Grayson, M. H., Markovics, S. B., Sicherer, S. H., Stone, K. D., Sullivan, K. E., Williams, P. V., Fleisher, T. A., Casale, T. B. 2018

  View details for PubMedID 30338538

• Pharmacotherapy ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Fineman, S. M., Khan, D. A., Dinakar, C., Lang, D., Tilles, S. A. 2018; 121 (1): 22–23

  View details for PubMedID 29777743

• Recent advances in our understanding of the environment's role in allergy ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Dinakar, C., Fineman, S. M., Chipps, B. E., Khan, D. A., Tilles, S. A. 2018; 120 (5): 465–67

  View details for PubMedID 29577979

• Biologics ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Dinakar, C., Khan, D. A., Fineman, S. M., Lang, D., Tilles, S. A. 2018; 120 (4): 354–56

  View details for PubMedID 29625663

• Recent advances in asthma ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Chipps, B. E., Dinakar, C., Fineman, S. M., Tilles, S. A. 2018; 120 (2): 128–30

  View details for PubMedID 29413335

• The importance of reducing risk in peanut allergy: Current and future therapies ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Shreffler, W. G., Baumert, J. L., Remington, B. C., Koppelman, S. J., Dinakar, C., Fleischer, D. M., Kim, E., Tilles, S. A., Spergel, J. M. 2018; 120 (2): 124–27

  View details for PubMedID 29289463

• Recent advances in atopic dermatitis ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Dinakar, C., Fineman, S. M., Tilles, S. A. 2018; 120 (1): 8–9

  View details for DOI 10.1016/j.anai.2017.11.009

  View details for Web of Science ID 000418485100004

  View details for PubMedID 29273133

• Treatment of seasonal allergic rhinitis An evidence-based focused 2017 guideline update ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Dykewicz, M. S., Wallace, D. V., Baroody, F., Bernstein, J., Craig, T., Finegold, I., Huang, F., Larenas-Linnemann, D., Meltzer, E., Steven, G., Bernstein, D. I., Blessing-Moore, J., Dinakar, C., Greenhawt, M., Horner, C. C., Khan, D. A., Lang, D., Oppenheimer, J., Portnoy, J. M., Randolph, C. R., Rank, M. A. 2017; 119 (6): 489-+

  View details for DOI 10.1016/j.anai.2017.08.012

  View details for Web of Science ID 000417481100006

  View details for PubMedID 29103802

• American College of Allergy, Asthma & Immunology Position Paper on the Use of Telemedicine for Allergists ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Elliott, T., Shih, J., Dinakar, C., Portnoy, J., Fineman, S. 2017; 119 (6): 512–17

  Abstract

  The integration of telecommunications and information systems in health care first began 4 decades ago with 500 patient consultations performed via interactive television. The use of telemedicine services and technology to deliver health care at a distance is increasing exponentially. Concomitant with this rapid expansion is the exciting ability to provide enhancements in quality and safety of care. Telemedicine enables increased access to care, improvement in health outcomes, reduction in medical costs, better resource use, expanded educational opportunities, and enhanced collaboration between patients and physicians. These potential benefits should be weighed against the risks and challenges of using telemedicine. The American College of Allergy, Asthma, and Immunology advocates for incorporation of meaningful and sustained use of telemedicine in allergy and immunology practice. This article serves to offer policy and position statements of the use of telemedicine pertinent to the allergy and immunology subspecialty.

  View details for PubMedID 29103799

• Combining anti-IgE with oral immunotherapy PEDIATRIC ALLERGY AND IMMUNOLOGY Lin, C., Lee, I. T., Sampath, V., Dinakar, C., DeKruyff, R. H., Schneider, L. C., Nadeau, K. 2017; 28 (7): 619–27

  Abstract

  Food allergy is a significant medical problem that affects up to 8% of children in developed countries. At present, there are no curative therapies available in routine practice and management of food allergy involves strict allergen avoidance, education, and prompt treatment upon accidental exposure. Oral immunotherapy (OIT) is an efficacious experimental approach to food allergy and has been shown to provide a substantial benefit in terms of allergen desensitization. However, OIT is associated with high rates of allergic reactions, and the period of protection offered by OIT appears to be limited and highly variable. Recurrence of allergen sensitivity after a period of treatment discontinuation is commonly observed. With the aim of overcoming these limitations of OIT, several trials have studied omalizumab (anti-IgE monoclonal antibody) as an adjuvant treatment for patients undergoing OIT. Results from these trials have shown that the addition of omalizumab to OIT leads to a significant decrease in the frequency and severity of reactions, which allows for an increase in the threshold of tolerance to food allergens. This review provides a summary of the current literature and addresses some of the key questions that remain regarding the use of omalizumab in conjunction with OIT.

  View details for PubMedID 28782296

• Inadequacy of current pediatric epinephrine autoinjector needle length for use in infants and toddlers. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Kim, H., Dinakar, C., McInnis, P., Rudin, D., Benain, X., Daley, W., Platz, E. 2017; 118 (6): 719-725 e1

  Abstract

  Epinephrine injection represents the standard of care for anaphylaxis treatment. It is most effective if delivered intramuscularly, whereas inadvertent intraosseous injection may be harmful. The needle length in current pediatric epinephrine autoinjectors (EAIs) is 12.7 mm; however, the ideal needle length for infants and toddlers weighing less than 15 kg is unknown.To determine the skin-to-bone distance (STBD) and skin-to-muscle distance (STMD) at baseline and after simulated EAI application in infants and toddlers (weighing 7.5-15 kg).Study participants recruited from 2 North American allergy clinics underwent baseline and compression (10-lb pressure) ultrasonography of the anterolateral thigh with a modified ultrasound transducer mimicking the footprint and maximum pressure application of an EAI device. Ultrasound images, with clinical data masked, were analyzed offline for STBD and STMD in short-axis approach.Of 53 infants (mean age, 18.9 months; 54.7% male; 81.1% white; mean weight, 11.0 kg), 51 had adequate images for short-axis STBD measurements. In these infants, the mean (SD) baseline STBD was 22.4 (3.8 mm), and the mean (SD) STMD was 7.9 (1.7) mm. With 10-lb compression, the mean (SD) STBD was 13.3 (2.1) mm, and the mean (SD) STMD was 6.3 (1.2) mm. An EAI with a needle length of 12.7 mm applying 10-lb pressure could strike the bone in 43.1% of infants and toddlers in this cohort.Our data suggest that the optimal EAI needle length for infants and toddlers weighing 7.5 to 15 kg should be shorter than the needle length in currently available pediatric EAIs to avoid accidental intraosseous injections.

  View details for DOI 10.1016/j.anai.2017.03.017

  View details for PubMedID 28483294

• Patient-Centered Outcomes in Food Allergy. Current allergy and asthma reports Polk, B. I., Dinakar, C. 2017; 17 (6): 39-?

  Abstract

  Food allergy prevalence is increasing very rapidly, causing a significant disease burden. The threat of severe allergic reactions occurring unexpectedly and in settings that are not equipped to recognize and treat anaphylaxis is a constant source of worry for individuals and families with food allergies. Inadequate knowledge and understanding in the community significantly impairs the overall quality of life of these individuals and families. Additionally, families face challenges in finding and affording appropriate allergen-free foods.Advancements have been made in understanding the impact of food allergies on patient-centered outcomes such as quality of life and economic impact, and attempts have been made to develop tools to assess patient-centered variables. Innovative national and regional initiatives are helping to spread awareness of the disease condition and to create resources, including access to allergen-free foods. While there is a growing momentum toward recognition of food allergic disorders as a condition that profoundly impacts activities of daily living, greater effort needs to be expounded to develop validated tools and interventions that can adequately address these issues.

  View details for DOI 10.1007/s11882-017-0708-z

  View details for PubMedID 28516366

• Ara h2 levels in dust from homes of individuals with peanut allergy and individuals with peanut tolerance ALLERGY AND ASTHMA PROCEEDINGS Shroba, J., Barnes, C., Nanda, M., Dinakar, C., Ciaccio, C. 2017; 38 (3): 192-196

  Abstract

  Approximately 1% of the U.S. population has a peanut allergy. Previous studies that measured peanut protein in house dust support the hypothesis that household peanut consumption may lead to clinical sensitization through transdermal exposure.The aim of this pilot study was to characterize Ara h2 levels in house dust from homes with and without individuals with peanut allergy.Household dust was obtained from homes with an individual with peanut allergy and from homes with no individual with peanut allergy. Ara h2 levels were determined by using a monoclonal antibody-based immunoassay with a level of determination of 150 ng per gram of dust. Peanut consumption information was obtained by questionnaire.A total of 85 dust samples were collected: 38 from homes with a individual with peanut allergy and 47 from control homes. The median Ara h2 level in homes with an individual with peanut allergy was 1236 ng/g (interquartile range [IQR], 256-1342 ng/g), whereas the median Ara h2 level in homes without an individual with peanut allergy was 650 ng/g (IQR, 163-2201 ng/g). Ara h2 levels in dust from homes of individuals with peanut allergy were not significantly lower than in dust from control homes. Of the homes with an individual with peanut allergy, 15 reported complete avoidance of peanut in the home (39%). Ara h2 levels in homes that completely avoided peanuts were not significantly lower than Ara h2 levels in homes that did not restrict peanuts (p = 0.531).Although families may restrict peanuts and peanut products in the home, there was still detectable Ara h2 levels found in homes. Each subject's definition of restriction may vary, there seemed to be peanut protein entering the home, although the protein origin is not known. Possibilities include cross-reactivity with another antigen or transport into the home on some vector. Further investigation of hypotheses regarding cross-reactivity and environmental exposure to Ara h2 is necessary.

  View details for DOI 10.2500/aap.2017.38.4049

  View details for Web of Science ID 000401128300011

  View details for PubMedID 28441989

• Immunodeficiency-associated Lymphoid Hyperplasia as a Cause of Intussusception in a Case of activated PI3K-delta Syndrome FRONTIERS IN PEDIATRICS Mettman, D., Thiffault, I., Dinakar, C., Saunders, C. 2017; 5

  Abstract

  Activated PI3K-δ syndrome refers to a recently described primary immunodeficiency syndrome consisting of recurrent sinopulmonary infections, lymphadenopathy, mucosal lymphoid aggregates, increased susceptibility to Epstein-Barr virus and cytomegalovirus, and increased incidence of B-cell lymphomas. Variants in PIK3CD, which encodes the phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit delta isoform, enhance membrane association and kinase activity, resulting in increased signal transduction through the PI3K-Akt pathway. Whole-exome sequencing revealed a pathogenic PIK3CD variant in a patient with history of immunologic impairment, recurrent sinopulmonary infections, and lymphoid hyperplasia presenting as intussusception. This case illustrates that while lymphoid hyperplasia secondary to immunodeficiency is most often unsurprising and non-threatening, it can present as an emergency-like intussusception.

  View details for DOI 10.3389/fped.2017.00071

  View details for Web of Science ID 000399620700001

  View details for PubMedID 28469999

• Food Allergy-Related Risk-Taking and Management Behaviors Among Adolescents and Young Adults. journal of allergy and clinical immunology. In practice Warren, C. M., Dyer, A. A., Otto, A. K., Smith, B. M., Kauke, K., Dinakar, C., Gupta, R. S. 2017

  Abstract

  Food allergy (FA) affects 8% of children and adolescents in the United States. Nearly 40% of those affected have experienced severe reactions. Fatal food-induced anaphylaxis is most common among adolescents and young adults (AYA); however, FA-related risk behaviors persist in this population and factors associated with these behaviors remain unclear.To characterize FA-related risk-taking and self-management behaviors of AYA with FA.A cross-sectional survey was administered to 200 AYA with FA. Latent class analysis was used to identify distinct behavioral risk classes and predictors of risk class membership.Two distinct FA behavioral risk classes were identified, representing less (N = 120) and more (N = 80) risky subpopulations. After adjusting for age, sex, and anaphylaxis history, odds of more risky class membership were significantly reduced for AYA with peanut allergy (odds ratio [OR], 0.27; 95% CI, 0.11-0.65), supportive female friends (OR, 0.27; 95% CI, 0.07-0.99), overprotective mothers (OR, 0.42; 95% CI, 0.18-0.97), teachers who are aware of their FA (OR, 0.39; 95% CI, 0.17-0.91), a history of being bullied (OR, 0.22; 95% CI, 0.09-0.51), and an established 504 education plan (OR, 0.35; 95% CI, 0.15-0.81). AYA also reported numerous positive outcomes of their FA, such as greater responsibility, empathy, and improved diet, which was significantly associated with reduced odds of risky class membership (OR, 0.38; 95% CI, 0.18-0.80).Among AYA, increased FA-related risk-taking was associated with clinical, demographic, and social factors, including peanut allergy, greater age, as well as absence of social support and specific school FA policies. These associations may be used to inform future interventions designed to address FA-related risk and management behaviors.

  View details for DOI 10.1016/j.jaip.2016.12.012

  View details for PubMedID 28132799

• Stinging insect hypersensitivity A practice parameter update 2016 ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Golden, D. B., DeMain, J., Freeman, T., Graft, D., Tankersley, M., Tracy, J., Blessing-Moore, J., Bernstein, D., Dinakar, C., Greenhawt, M., Khan, D., Lang, D., Nicklas, R., Oppenheimer, J., Portnoy, J., Randolph, C., Schuller, D., Wallace, D. 2017; 118 (1): 28-54

  View details for DOI 10.1016/j.anai.2016.10.031

  View details for Web of Science ID 000396430600007

  View details for PubMedID 28007086

• Evaluating proteins for potential allergenicity using bioinformatic approaches. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakarpandian, D. n., Dinakar, C. n. 2017; 119 (3): 197–98

  View details for PubMedID 28890013

• Comparison of allergens collected from furnace filters and vacuum floor dust. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Allenbrand, R., Barnes, C. S., Mohammed, M., Gard, L., Pacheco, F., Kennedy, K., DiDonna, A., Portnoy, J., Dinakar, C. 2017; 118 (1): 108-109

  View details for DOI 10.1016/j.anai.2016.10.001

  View details for PubMedID 27839669

• Prevalence of food allergies in South Asia. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Arakali, S. R., Green, T. D., Dinakar, C. 2017; 118 (1): 16-20

  Abstract

  To evaluate the published medical literature on the prevalence and types of food allergies in South Asia.A PubMed search was performed using the keywords India and food allergy, Asia and food allergy, and South Asia and food allergy for any period. Articles cited in selected studies were reviewed for their appropriateness of inclusion into this review.Publications were included that were original research and fit the topic of food allergy and South Asia. South Asia is defined as region inclusive of India, Pakistan, Bangladesh, and Sri Lanka.A total of 169 articles were initially identified, and 47 were reviewed in detail for inclusion in this review. The primary focus was placed on 10 studies that consisted of case reports of newly reported or documented food allergy, survey studies that investigated food allergy prevalence in specific demographics, and prospective and cross-sectional studies with case controls, all of which investigated food allergy prevalence by allergy testing in a selected population.The medical literature on the prevalence and types of food allergy in South Asia indicates that there is a variety of unusual and unique allergens and an overall low incidence of food allergy. There is also an association of increased food allergy prevalence in individuals who live in metropolitan regions or who migrate to communities that have adopted westernization.

  View details for DOI 10.1016/j.anai.2016.09.441

  View details for PubMedID 27864090

• Association of tree nut and coconut sensitizations. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Polk, B. I., Dinakarpandian, D., Nanda, M., Barnes, C., Dinakar, C. 2016; 117 (4): 412-416

  Abstract

  Coconut (Cocos nucifera), despite being a drupe, was added to the US Food and Drug Administration list of tree nuts in 2006, causing potential confusion regarding the prevalence of coconut allergy among tree nut allergic patients.To determine whether sensitization to tree nuts is associated with increased odds of coconut sensitization.A single-center retrospective analysis of serum specific IgE levels to coconut, tree nuts (almond, Brazil nut, cashew, chestnut, hazelnut, macadamia, pecan, pistachio, and walnut), and controls (milk and peanut) was performed using deidentified data from January 2000 to August 2012. Spearman correlation (ρ) between coconut and each tree nut was determined, followed by hierarchical clustering. Sensitization was defined as a nut specific IgE level of 0.35 kU/L or higher. Unadjusted and adjusted associations between coconut and tree nut sensitization were tested by logistic regression.Of 298 coconut IgE values, 90 (30%) were considered positive results, with a mean (SD) of 1.70 (8.28) kU/L. Macadamia had the strongest correlation (ρ = 0.77), whereas most other tree nuts had significant (P < .05) but low correlation (ρ < 0.5) with coconut. The adjusted odds ratio between coconut and macadamia was 7.39 (95% confidence interval, 2.60-21.02; P < .001) and 5.32 (95% confidence interval, 2.18-12.95; P < .001) between coconut and almond, with other nuts not being statistically significant.Our findings suggest that although sensitization to most tree nuts appears to correlate with coconut, this is largely explained by sensitization to almond and macadamia. This finding has not previously been reported in the literature. Further study correlating these results with clinical symptoms is planned.

  View details for DOI 10.1016/j.anai.2016.07.023

  View details for PubMedID 27566863

• Telemedicine is as effective as in-person visits for patients with asthma. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Portnoy, J. M., Waller, M., De Lurgio, S., Dinakar, C. 2016; 117 (3): 241-245

  Abstract

  Access to asthma specialists is a problem, particularly in rural areas, thus presenting an opportunity for management using telemedicine.To compare asthma outcomes during 6 months in children managed by telemedicine vs in-person visits.Children with asthma residing in 2 remote locations were offered the choice of an in-person visit or a telemedicine session at a local clinic. The telemedicine process involved real-time use of a Remote Presence Solution (RPS) equipped with a digital stethoscope, otoscope, and high-resolution camera. A telefacilitator operated the RPS and performed diagnostic and educational procedures, such as spirometry and asthma education. Children in both groups were assessed initially, after 30 days, and at 6 months. Asthma outcome measures included asthma control using validated tools (Asthma Control Test, Childhood Asthma Control Test, and Test for Respiratory and Asthma Control in Kids) and patient satisfaction (telemedicine group only). Noninferiority analysis of asthma control was performed using the minimally important difference of an adjusted asthma control test that combined the 3 age groups.Of 169 children, 100 were seen in-person and 69 via telemedicine. A total of 34 in-person and 40 telemedicine patients completed all 3 visits. All had a small, although statistically insignificant, improvement in asthma control over time. Telemedicine was noninferior to in-person visits. Most of the telemedicine group subjects were satisfied with their experience.Children with asthma seen by telemedicine or in-person visits can achieve comparable degrees of asthma control. Telemedicine can be a viable alternative to traditional in-person physician-based care for the treatment and management of asthma.

  View details for DOI 10.1016/j.anai.2016.07.012

  View details for PubMedID 27613456

• Updated epinephrine autoinjector labeling. The journal of allergy and clinical immunology. In practice Dinakar, C. n. 2016; 4 (5): 1020–21

  View details for PubMedID 27406970

• The talking card: Randomized controlled trial of a novel audio-recording tool for asthma control ALLERGY AND ASTHMA PROCEEDINGS Cowden, J. D., Wilkerson-Amendell, S., Weathers, L., Gonzalez, E. D., Dinakar, C., Westbrook, D. H., Williams, A. R. 2015; 36 (5): E86-E91

  Abstract

  Asthma care plans typically include complicated written instructions. Customized, audio-recorded instructions may bridge health literacy gaps and improve treatment plan understanding.To measure the effects of a recordable greeting card-style tool (Talking Card) on asthma control and parental care of children with asthma.Multisite randomized trial in two primary care clinics, including children 4-11 years old with uncontrolled asthma and their parents. Parent-child dyads were randomized to usual care of asthma or usual care plus the Talking Card. Dyads completed three asthma-focused visits over 3 months. At the visit, card recipients received customized instructions recorded by the pediatrician onto an audio chip in the card. Asthma control was measured by using the Childhood Asthma Control Test. Card use and parental satisfaction were measured by parental survey (card arm only). Outcomes were analyzed by using generalized estimating equations and frequency distributions.Sixty-four dyads participated and attended 166 clinic visits. Card use was associated with a 1.6-point increase in Childhood Asthma Control Test score (p = 0.02) and a clinic visit regardless of card use with a three-point increase (p < 0.001). Satisfaction and self-efficacy were high among the card users. The mean satisfaction score was 8.9 of 10, with 96% agreeing or strongly agreeing that the card helped them take better care of asthma.The Talking Card, a novel audio communication tool, was associated with improved asthma control and deemed highly desirable by parents and children struggling to control asthma. This inexpensive portable tool may be useful in other chronic disorders and in locales with low literacy and poor access to digital technology.

  View details for DOI 10.2500/aap.2015.36.3881

  View details for Web of Science ID 000371873500002

  View details for PubMedID 26314809

• Analysis of Open Oral Food Challenges Performed in a Pediatric Allergy Clinic Shroba, J. A., Suenram, D., Bandelier, C., Dinakar, C. MOSBY-ELSEVIER. 2015: AB69

  View details for DOI 10.1016/j.jaci.2014.12.1159

  View details for Web of Science ID 000361129600223

• Co-Sensitization Patterns to Tree Nuts in a Pediatric Population Polk, B. I., Dinakar, C., Barnes, C. S., Shroba, J. A., Preston, K. A., Osnas, J. D., Humphrey, A. L., Jara, D. A., Hanson, J. R., Patel, N. N., Ciaccio, C. E. MOSBY-ELSEVIER. 2015: AB34

  View details for DOI 10.1016/j.jaci.2014.12.1040

  View details for Web of Science ID 000361129600105

• Overview of Immunodeficiency Disorders. Immunology and allergy clinics of North America Raje, N. n., Dinakar, C. n. 2015; 35 (4): 599–623

  Abstract

  The spectrum of primary immunodeficiency disorders (PIDs) is expanding. It includes typical disorders that primarily present with defective immunity as well as disorders that predominantly involve other systems and show few features of impaired immunity. The rapidly growing list of new immunodeficiency disorders and treatment modalities makes it imperative for providers to stay abreast of the latest and best management strategies. This article presents a brief overview of recent clinical advances in PIDs.

  View details for PubMedID 26454309

  View details for PubMedCentralID PMC4600970

• Management of acute loss of asthma control in the yellow zone: a practice parameter ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY Dinakar, C., Oppenheimer, J., Portnoy, J., Bacharier, L. B., Li, J., Kercsmar, C. M., Bernstein, D., Blessing-Moore, J., Khan, D., Lang, D., Nicklas, R., Randolph, C., Schuller, D., Spector, S., Tilles, S. A., Wallace, D. 2014; 113 (2): 143-159

  View details for DOI 10.1016/j.anai.2014.05.017

  View details for Web of Science ID 000341301000006

  View details for PubMedID 25065350

• Sailing to the port of best practice on the A/I practice parameters Mayflower. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakar, C. n., Portnoy, J. n. 2014; 113 (2): 123–24

  View details for PubMedID 25065348

• Simulation in pediatrics. Missouri medicine Sharma, J., Myers, D., Dinakar, C. 2013; 110 (2): 147-149

  View details for PubMedID 23724489

• Office-based exhaled nitric oxide measurement in children 4 years of age and older. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Hanson, J. R., De Lurgio, S. A., Williams, D. D., Dinakar, C. n. 2013; 111 (5): 358–63

  Abstract

  Fractional exhaled nitric oxide (FENO) is increasingly being used in the office-based management of asthma, but data in children are limited.To report FENO values in 4- to 7-year-old children with suspected asthma and characterize their relation to clinical variables and describe the relation among FENO levels, age, and sex in 4- to 18-year-old children with suspected asthma.Retrospective data in 4- to 18-year-old children (n = 825) who underwent FENO testing using the NIOX MINO device were collected and analyzed. Chart reviews were performed for the 4- to 7-year-old children (n = 75).FENO values ranged from less than or equal to 5 to 89 ppb in 75 4- to 7-year-old children and less than or equal to 5 to 300 ppb in 750 > 7 to 18-year-old children. Approximately one tenth of 4- to 7-year-old children and one third of > 7 to 18-year-old children had FENO values indicative of eosinophilic/allergic inflammation (>35 ppb). In regression analysis of the 4- to 7-year-old children, increasing age (P = .03) and asthma severity (P = .01) were associated with higher FENO levels. Atopic dermatitis was significantly associated (P = .03), whereas allergic rhinitis was marginally associated (P = .06), with higher FENO levels. Inhaled corticosteroid use was associated with lower FENO levels (P = .02).This study characterizes the largest cohort of 4- to 7-year-old children to undergo FENO testing in ambulatory asthma management. Correlations between FENO levels and clinical variables were consistent with established findings in older children. This preliminary real-world study suggests that FENO assessment may be feasible and useful in the office-based asthma management of children as young as 4 years.

  View details for PubMedID 24125141

• Interpretation of food specific immunoglobulin E levels in the context of total IgE. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Federly, T. J., Jones, B. L., Dai, H. n., Dinakar, C. n. 2013; 111 (1): 20–24

  Abstract

  Food specific immunoglobulin E (IgE) (fsIgE) cut points are used in the evaluation of food allergies. Concomitant measurement of total IgE (tIgE) is traditionally not obtained. We anecdotally observed elevations in fsIgE mirroring tIgE increases, which may confound accurate interpretation.To determine whether changes in tIgE were associated with fsIgE and whether predictions of fsIgE could be formulated based on tIgE.We studied children younger than 18 years who had both tIgE and fsIgE (egg, n = 136; milk, n = 123; peanut, n = 201; soy, n = 55) obtained simultaneously on 1 or more occasion between January 2008 and February 2011. After institutional review board approval, natural log-transformed (ln) tIgE and fsIgE levels were analyzed using univariate and multivariate regression models to assess associations and predict fsIgE using tIgE and other covariates.Soy IgE levels were strongly correlated (ρ = 0.85, P < .001), whereas egg, milk, and peanut IgE levels were substantially correlated (ρ = 0.69, 0.69, and 0.66, respectively, P < .001) with tIgE. A 1-unit increase in ln(tIgE) was significantly correlated with unit increases in ln(egg IgE) (0.77), ln(milk IgE) (0.84), ln(peanut IgE) (0.87), and ln(soy IgE) (0.89) (P < .001). The ln(tIgE)-based univariate models could predict fsIgE in the validation data with strong (soy) and substantial (egg, milk, and peanut) predictive ability (P < .001).Our study found significant and parallel relationships between tIgE and fsIgE levels to egg, milk, peanut, and soy. It underscores the importance of examining fsIgE levels in context of tIgE while making diagnostic and management decisions in children with food allergies.

  View details for PubMedID 23806455

• Exhaled nitric oxide in asthma management. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakar, C. n. 2012; 108 (4): 219–22

  View details for PubMedID 22469439

• Anaphylaxis in children: current understanding and key issues in diagnosis and treatment. Current allergy and asthma reports Dinakar, C. n. 2012; 12 (6): 641–49

  Abstract

  Anaphylaxis is a severe allergic reaction that is rapid in onset and may cause death. Since it is unpredictable and potentially fatal, prompt recognition and treatment are vital to maximize a positive outcome. The occurrence of anaphylaxis is increasing across all ages in the United States, with increased risk of worse outcome in teenagers/young adults and in those with comorbid conditions such as asthma. Gaps in the assessment of patient-specific risk factors, identification and prevention of triggers, recognition of signs/symptoms, and pharmacologic treatment of anaphylaxis have been identified at the physician and caregiver/patient level. A PubMed literature search (January 2000-December 2011) was conducted to identify publications on childhood anaphylaxis using the following terms: food allergy, food allergens, food hypersensitivity, epinephrine, epinephrine auto-injectors, anaphylactic triggers, and anaphylaxis. This review will critically appraise these key issues and highlight strategies that might result in improved management of anaphylaxis in children.

  View details for PubMedID 22815131

  View details for PubMedCentralID PMC3492692

• Pediatric pay-for-performance in asthma: who pays? Current allergy and asthma reports Johnson, R. n., Dinakar, C. n. 2010; 10 (6): 405–10

  Abstract

  Pay-for-performance is a term referring to a system that uses incentives to reward health care providers for producing an improvement in performance based on quality measures. It has become part of a growing movement to improve the quality of the health care system. The purpose of this article is to review and discuss pay-for-performance and how it relates to pediatrics and asthma.

  View details for PubMedID 20725813

• Exhaled nitric oxide in pediatric asthma. Current allergy and asthma reports Dinakar, C. n. 2009; 9 (1): 30–37

  Abstract

  Exhaled nitric oxide can now be measured in a clinical setting as a noninvasive, reproducible, facile, point-of-service test to measure airway inflammation, a central component of asthma that had not been assessed previously. An excellent surrogate marker of steroid-responsive eosinophilic airway inflammation, it serves to identify steroid-sensitive asthmatic patients and enables clinical monitoring of the response to steroid therapy and titration of the dose. Standardization of methodology and technological advances, such as the recent availability of handheld analyzers, individualized patient cards to store serial test measurements, and the assignment of coding procedural terminology, make this a necessary adjunct to clinical and functional assessment of airway obstruction and hyperresponsiveness in ambulatory pediatric and adult asthma practices.

  View details for PubMedID 19063822

• Social perceptions and preferences of youth with asthma. Missouri medicine Dinakar, C., Brimer, A. G., Adams, C. D., Malhi, K. 2006; 103 (5): 553-556

  Abstract

  Peers are a primary source of psychosocial support in youth. Chronic disease such as asthma can make youth feel different and impinge on their adherence to treatment. We investigated factors that make the asthmatic adolescent feel different from peers, and explore their willingness to belong to a peer social-group such as an asthma club. Sixty-six youth (ages 8-18 years) with asthma completed an anonymous questionnaire that included both multiple-choice and open-ended questions designed to explore the feelings of the respondents. Almost one-third of our sample reported negative feelings regarding their asthma. Nearly 27% reported that their diagnosis made them feel different from their healthy peers, while over 25% admitted feeling uncomfortable using their inhaler in front of their friends. Almost one-half of adolescents felt restricted or excluded from school activities, athletics, or social clubs. While most respondents (93.9%)

  View details for PubMedID 17133762

• Monitoring of asthma control in children. Current opinion in allergy and clinical immunology Dinakar, C. n. 2006; 6 (2): 113–18

  Abstract

  The focus in managing asthma has undergone a paradigm shift from the concept of assessing severity to assessing control. The recent Practice Parameter on attaining optimal asthma control highlights the need to titrate the step-care management of asthma to the level of control assessed at each clinic encounter.Recent advances in the monitoring of asthma control in children include the use of questionnaires such as the Childhood Asthma Control Test, use of biomarkers such as fractional concentration of exhaled nitric oxide, sophisticated hand-held electronic monitoring of lung function such as peak flow and forced expiratory volume, indicators of lung growth and bronchial hyper-responsiveness such as post-bronchodilator forced expiratory volume, outcomes-utilization data, markers of atopy, and electronic measures of adherence.Three recent proof-of-concept studies in adults have demonstrated the relevance of criteria other than guidelines-recommended asthma symptoms and pulmonary function tests. These studies used airway hyper-responsiveness, sputum eosinophilia, and fraction of exhaled nitric oxide as indices to facilitate fine-tuning of asthma control and use of controller-inhaled steroids. The next logical step would be to determine the applicability of these and other measures to children in both research and clinical settings.

  View details for PubMedID 16520675

• Learning preferences of caregivers of asthmatic children. The Journal of asthma : official journal of the Association for the Care of Asthma Dinakar, C. n., Adams, C. n., Brimer, A. n., Silva, M. D. 2005; 42 (8): 683–87

  Abstract

  People learn in different ways: visually, aurally, by reading/writing, and kinesthetically. In our clinic, we use color-coded Asthma Action Cards to educate our patients and their caregivers on asthma management. Our teaching is largely aural based, with the cards providing reading and visual stimulation and hands-on practice with devices offering kinesthetic stimulation.We sought to determine the learning styles of the caregivers of our asthmatic children.Caregivers in our Asthma/Allergy Clinic completed the Visual-Aural-Read/Write-Kinesthetic (VARK) questionnaire anonymously, and the responses were evaluated on the basis of previously validated scoring instructions.Analysis of 98 respondents showed that 42% had a single learning modality preference, and the remaining 58% were multimodal learners. Of those who reported a single mode of learning, 61% preferred kinesthetic, 27% preferred reading/writing, and less than 1% each preferred aural or visual stimuli. Of all 98 caregivers, 82% included kinesthetic as a learning preference, 59% included read/write, 50% included aural, and 41% included visual.The majority of caregivers preferred the kinesthetic learning method, whether as a single learning preference or in combination with other approaches. Incorporating kinesthetic methods of learning, such as role plays and problem-solving case scenarios, into standardized asthma education curricula may be beneficial to patients and families in terms of understanding and using their regimen.

  View details for PubMedID 16266961

• Real-life environmental tobacco exposure does not affect exhaled nitric oxide levels in asthmatic children. The Journal of asthma : official journal of the Association for the Care of Asthma Dinakar, C. n., Lapuente, M. n., Barnes, C. n., Garg, U. n. 2005; 42 (2): 113–18

  Abstract

  Serial measurement of exhaled nitric oxide (eNO) has been shown to be a good noninvasive marker of asthma control. Active smoking decreases eNO levels. The effect of real-life environmental exposure to tobacco smoke (ETS) on eNO levels is not known. Our objective was to study the impact of environmental tobacco exposure on eNO levels in asthmatic and non-asthmatic children. Single breath off-line collection of eNO was performed in asthmatic and non-asthmatic children with and without ETS. Urine was collected for cotinine/nicotine analysis. Fifty-seven children were enrolled, of which 25 were asthmatic and 32 had smoke exposure. One active smoker was excluded from the data analysis. The mean eNO was 11.1 ppb (n = 31; SD = 18.5) in those passively exposed vs. 11.1 ppb (n = 25; SD = 19.9) among the unexposed (not statistically significant). The mean eNO was 6.1 (n = 32; SD = 4.4) among the non-asthmatics and 17.8 (n = 24; SD = 27.4) among the asthmatics (p = 0.02; CI: 1.9-21.6). Real-life environmental tobacco exposure does not appear to decrease eNO levels in asthmatic children. Off-line collection of exhaled nitric oxide with a Mylar collection device helps differentiate asthmatics from non-asthmatics.

  View details for PubMedID 15871443

• Urticaria and angioedema. Immunology and allergy clinics of North America Baxi, S. n., Dinakar, C. n. 2005; 25 (2): 353–67, vii

  Abstract

  Urticaria and angioedema are commonly encountered complaints in children. Although the diagnosis is clear, establishing an etiology, especially with respect to chronic urticaria, can be challenging. A significant proportion of chronic urticarial cases are now considered to have an autoimmune etiology. This article reviews progress in the field of urticaria and angioedema including developments in pathogenesis, description of laboratory testing, and review of medications. Urticaria and angioedema can usually be controlled by avoidance of triggers, a variety of supportive medications, and reassurance.

  View details for PubMedID 15878460

• Effective management of home exacerbations (yellow zone) of asthma. Missouri medicine Dinakar, C. 2004; 101 (3): 212-217

  Abstract

  The NIH guidelines recommends hat practitioners give asthmatics written action plans with instructions on management of home (yellow zone) exacerbations. There is ambiguity regarding the definition of the yellow zone in patient-appropriate terms, and paucity of data on the efficacy of the different pharmacological interventions that can be used. This article reviews available data and attempts to incorporate these guidelines into clinical practice.

  View details for PubMedID 15311575

• Allergen immunotherapy in the prevention of asthma. Current opinion in allergy and clinical immunology Dinakar, C., Portnoy, J. M. 2004; 4 (2): 131-136

  Abstract

  Asthma is a disease causing significant morbidity and mortality. In the recent past, there has been an explosion of pharmacotherapeutic options attempting to control the disease. Unfortunately, none of the current options offers the promise of prevention or a permanent cure. However, there appear to be exciting, new data emerging to support the hypothesis that the prevention or early treatment of allergic rhinitis, such as with the use of allergen immunotherapy, may help mitigate the severity of bronchial symptoms and even prevent the development of asthma. In this paper, we review recent research published proposing immunotherapy as a means of preventing the development of, or at least ameliorating, allergic asthma.There is evidence that the upper and lower airways may be considered a single unit, with the nasal and bronchial mucosa having features in common. Epidemiological, pathophysiological and clinical studies have shown that they can be affected by similar inflammatory triggers, with interconnected mechanisms amplifying the inflammatory cascade. Allergic rhinitis is interrelated to, and is a risk factor for, the development of asthma. An evidence-based review validates the successful use of allergen immunotherapy in treating allergic rhinitis and asthma. There is promising evidence advocating its use in the prevention of clinical asthma.This article explores current research pertaining to the use of immunomodulation, such as by using allergen immunotherapy, to ameliorate and prevent the development of allergic asthma.

  View details for PubMedID 15021067

• How frequent are asthma exacerbations in a pediatric primary care setting and do written asthma action plans help in their management? The Journal of asthma : official journal of the Association for the Care of Asthma Dinakar, C. n., Van Osdol, T. J., Wible, K. n. 2004; 41 (8): 807–12

  Abstract

  In the National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma, the expert panel recommends that a written asthma action plan be provided for all patients with asthma. Studies evaluating the usefulness of the asthma action plan in children are limited. We aim to determine exacerbation frequency and usefulness of the asthma action plan in managing exacerbations that occur in a pediatric primary care setting.Caretakers of asthmatic children attending the general pediatric clinic in an inner-city hospital completed a one-page questionnaire covering topics such as asthma severity, frequency of exacerbations, and possession/usefulness of an asthma action plan. Although controversy exists over the definition of yellow and red zone exacerbations, we defined the yellow zone as symptoms that require albuterol more than three times a day or more than two nights in succession. The red zone was defined as symptoms requiring systemic corticosteroids and/or an urgent physician visit.Seventy of 75 subjects completed the survey. Almost 80% of respondents carried the diagnosis of persistent asthma, whereas the remainder had intermittent asthma. Exacerbation frequency over a 3-month period was determined. Approximately 80% of children experienced at least one yellow zone episode: 42% had one or two yellow zone episodes, and 39.6% had between three and five episodes. Sixty-three percent of patients did not experience a single red zone exacerbation. Almost 75% (44 of 59) of subjects possessed an asthma action plan. Ninety percent (37 of 41) of respondents with action plans found the plan to be useful in managing exacerbations.Approximately four of every five asthmatic children seen in this primary care setting experienced a yellow zone exacerbation at least once during a 3-month period. One third experienced at least one red zone episode. Nine of every 10 caretakers with an action plan reported the asthma action plan to be of value in managing exacerbations.

  View details for PubMedID 15641630

• Review of cetirizine hydrochloride for the treatment of allergic disorders. Expert opinion on pharmacotherapy Portnoy, J. M., Dinakar, C. n. 2004; 5 (1): 125–35

  Abstract

  Cetirizine hydrochloride is an orally-active and selective histamine (H(1))-receptor antagonist. It is a second-generation antihistamine and a human metabolite of hydroxyzine. Therefore, its principal effects are mediated via selective inhibition of peripheral H(1) receptors. The antihistaminic activity of cetirizine has been documented in a variety of animal and human models. In vivo and ex vivo animal models have shown negligible anticholinergic and antiserotonergic activity. In clinical studies, however, dry mouth has been seen more commonly with cetirizine than with placebo. In vitro receptor binding studies have shown no measurable affinity for receptors other than H(1) receptors. Auto-radiographical studies with radiolabelled cetirizine in the rat have shown negligible penetration into the brain. Ex vivo experiments in the mouse have shown that systemically administered cetirizine does not significantly occupy cerebral H(1) receptors. Impairment of CNS function is comparable to other low-sedating antihistamines at the recommended dose of 10 mg/day for adults. It has anti-inflammatory properties that may play a role in asthma management. It does not interact with concomitantly administered medications, it has no cardiac adverse effects, and it does not appear to be associated with teratogenicity. Cetirizine is predominantly eliminated by the kidneys with a mean elimination half-life is 8.3 h. It is rapidly absorbed, and significant clinical inhibition of a wheal and flare response occurs in infants, children and adults within 20 min of a single oral dose and persists for 24 h. No tolerance to the wheal and flare response occurs even after 1 month of daily treatment. The clinical efficacy of cetirizine for allergic respiratory diseases has been established in numerous trials. There is evidence that cetirizine improves symptoms of urticaria. Concomitant use of cetirizine also decreases the duration and amount of topical anti-inflammatory preparations needed for the treatment of atopic dermatitis. Interestingly, several clinical studies suggest that cetirizine may be useful in the treatment and prevention of mild asthma.

  View details for PubMedID 14680442

• The yellow zone in asthma treatment: is it a gray zone? Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Dinakar, C. n., Reddy, M. n. 2004; 92 (1): 7–16; quiz 16–17, 79

  Abstract

  To review the available literature on methods of preventing and minimizing exacerbations and to target problems for improvement.PubMed and Cochrane Review searches of the English-language literature using the following key yellow zone terms: asthma exacerbation, self-management plans, inhaled corticosteroids, and acute management of asthma exacerbations.Articles relevant to our yellow zone intervention inquiry.The National Institutes of Health (NIH) guidelines advocate that physicians give patients written action plans with instructions on managing home (yellow zone) exacerbations. However, the criteria used to identify the yellow zone are ambiguous and often confusing to patients and physicians. In addition, apart from a passing mention that doubling doses of inhaled corticosteroids may be an option in asthma step-up care, the guidelines contain no recommendations for yellow zone treatment strategies. This deficiency is directly related to the paucity of organized evidence on the efficacy of the various pharmacological interventions that can be used during an exacerbation.Translating the NIH guidelines into realistic clinical practice requires a clearer and more patient-friendly definition of the yellow zone, and this improved definition will facilitate the prescription of effective interventions in the management of yellow zone exacerbations.

  View details for PubMedID 14756459

• Pediatric asthma: a look at adherence from the patient and family perspective. Current allergy and asthma reports Adams, C. D., Dreyer, M. L., Dinakar, C. n., Portnoy, J. M. 2004; 4 (6): 425–32

  Abstract

  Although extensive research has been done in an effort to understand and promote adherence in pediatric asthma, little progress has been made in reducing the prevalence of nonadherence. Some researchers argue that a paradigm shift is necessary to advance the adherence field. Despite the recent trend for increasing the role of families in determining treatment plans, a patient-centered approach has been lacking in adherence to a daily regimen. It is clear that, although patients and families show evidence of inadvertent nonadherence (eg, forgetfulness), they also engage in volitional or intentional nonadherence, via reasoned and purposeful decisions. Patients conduct "experiments" with their regimen components in an effort to balance the burden of disease with the burden of treatment. These experiments typically involve some degree of nonadherence. Perhaps, if researchers strive to better understand the decision-making process involved in these experiments, health care providers can guide families in making adherence decisions that would lead to attainment of treatment goals, improvement in quality of life, and realization of positive clinical outcomes.

  View details for PubMedID 15462707

• Exhaled nitric oxide in the clinical management of asthma. Current allergy and asthma reports Dinakar, C. n. 2004; 4 (6): 454–59

  Abstract

  Management of asthma has gradually evolved from the concept of controlling bronchial hyperresponsiveness to focusing on control of inflammation. The awareness of airway remodeling, and the emergence of data suggesting irreversibility of some of these changes, despite standard-of-care pharmacotherapies such as inhaled steroids, has highlighted the need for early detection; effective diagnosis and treatment; monitoring responses and adhering to treatment; and predicting exacerbations. Pre-clinical intervention strategies targeted toward picking up early suggestions of asthma before irreversible airway changes occur may open the door to primary prevention approaches. Although invasive methods, such as bronchial biopsy, remain the gold standard to understanding and treating asthma, there is a preference for noninvasive techniques for reasons of convenience, ease of use, and patient comfort. In this article, recent data that support the use of exhaled nitric oxide as a noninvasive biomarker of inflammation in clinical practice are reviewed.

  View details for PubMedID 15462711

• A pilot study to evaluate the effect of passive tobacco exposure on exhaled nitric oxide levels in children measured using Mylar balloons Dinakar, C., Lapuente, M., Garg, U., Barnes, C. S., Laskowski, D. MOSBY, INC. 2002: S32

  View details for DOI 10.1016/S0091-6749(02)81177-0

  View details for Web of Science ID 000173744800041

• The impact of temperature and rainfall on airborne ragweed pollen Dinakar, C., Barnes, C. S., Hu, F., Pacheco, F., Portnoy, J. MOSBY, INC. 2001: S171

  View details for Web of Science ID 000167172300559

• Building a Targeted Asthma Education and Management Program. Missouri medicine Murphy, H. n., Wolverton, J. n., Dinakar, C. n. ; 113 (5): 409–14

  Abstract

  For individuals with asthma, self-management at home can be complex and overwhelming. The National Asthma Guidelines recommend education, ongoing assessment of control, and identification of those at high risk, as integral elements of improving outcomes for these individuals. Children's Mercy implemented standardized, patient-centered asthma education interventions along with institution of asthma control assessment tools and targeted management of high risk asthmatics. Many of these tools are applicable for use in primary care ambulatory practices.

  View details for PubMedID 30228510

• Food Allergy Care: "It Takes a Team". Missouri medicine Dinakar, C. n., Warady, B. n. ; 113 (4): 314–19

  Abstract

  In 2011, the Division of Allergy/Immunology at Children's Mercy published a themed mini-series1 including an article on food allergies that recommended allergen avoidance and prevention/treatment of anaphylaxis as the key pillars of management.2 Since then, the escalating food allergy "epidemic" has stimulated diagnostic and therapeutic advances, as well as coordinated multidisciplinary approaches to treat nutritional imbalances and psychosocial issues. We aim to highlight the team approach to food allergy care in this article.

  View details for PubMedID 30228485

• Update on asthma step-therapy. Allergy and asthma proceedings Dinakar, C. n. ; 31 (6): 444–51

  Abstract

  The 2007 NAEPP guidelines elegantly outline an evidence-based stepwise approach to evaluate, attain, and sustain asthma control. A conceptual paradigm shift in the 2007 guidelines is the focus on achievement of current asthma control to minimize future risk. Recently, the Food and Drug Administration (FDA) has revoiced concerns regarding asthma pharmacotherapy-related safety issues. In particular, they give guidance on stepping down of asthma therapy after control is achieved. Unfortunately, there are no published randomized controlled trials addressing this question, and current National Asthma Education and Prevention Program recommendations on this topic are evidence category D. This manuscript reviews some of the recent studies published since release of the Expert Panel Report 3 and FDA warnings that may add to our understanding of this issue.

  View details for PubMedID 21708055

• Changes in exhaled nitric oxide levels with immunotherapy. Allergy and asthma proceedings Dinakar, C. n., Van Osdol, T. J., Barnes, C. S., Dowling, P. J., Zeigler, A. W. ; 27 (2): 140–44

  Abstract

  The mechanisms by which immunotherapy (IT) modulates allergic airway response are not entirely clear. Exhaled nitric oxide (eNO) is a sensitive marker of airway inflammation in allergic respiratory disorders. We hypothesize that eNO may serve as a barometer of the immunomodulatory changes occurring during IT. We aimed to characterize the pattern of eNO levels in children undergoing traditional IT (TradIT) and rush IT (RushIT). Off-line measurements of eNO were obtained in children electing to undergo RushIT or TradIT at a University-based Allergy/Asthma Clinic. The eNO was measured before IT (pre-IT, week 0) was initiated, and at 2, 4, 6, 8, and 12 weeks after starting IT. Nine children received TradIT and 10 children received RushIT. Pre-IT eNO in the RushIT group averaged 12.6 parts per billion (ppb). This was followed by a rise to 17.7 ppb at week 2. The elevated eNO levels persisted till week 8, and then dramatically dropped below the pre-IT values to 8.9 ppb at week 12 (p = 0.038). Similar changes in eNO were not seen in the TradIT group. The difference in eNO levels between the two groups was most marked at 4 weeks (p = 0.014). Initiation of IT produces significant immunomodulatory changes such as a rise in eNO levels. Temporally, the changes appear to be accelerated in the RushIT group compared with the TradIT group, with return to baseline as maintenance IT levels are achieved.

  View details for PubMedID 16724633