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The rate of epinephrine administration associated with allergy skin testing in a suburban allergy practice from 1997 to 2010
Swender, David A.
Chernin, Leah R.
Mitchell, Chris
Sher, Theodore
Hostoffer, Robert
Tcheurekdjian, Haig
Allergy & Rhinology
Allergy skin testing is considered a safe method for testing for IgE-mediated allergic responses although anaphylactic events can occur. Reported rates of anaphylaxis per patient are not consistent and range from 0.008 to 4%. The aim of this study was to determine the rate of epinephrine use associated with allergy skin-prick testing (SPT) and intradermal testing (IDT) in a suburban practice over 13 years. This retrospective chart review used billing and procedure coding records during the time period from January 1997 to June 2010 to identify encounters where epinephrine was administered after SPT or IDT. Patient encounters with procedure codes for skin testing plus either parenteral epinephrine, corticosteroid, antihistamine, or i.v. fluid administration were identified. These patient charts were reviewed to determine if epinephrine was administered, whether systemic reactions developed, and rates of epinephrine administration were calculated. There were 28,907 patient encounters for SPT and 18,212 for IDT. Epinephrine was administered in six patient encounters (0.02%) where SPT was performed; no IDT encounters led to epinephrine administration. There were no fatalities. Allergy skin testing to a variety of allergens, when administered by well-trained personnel, is a safe procedure. This study, involving the largest population to date, showed a rate of systemic reactions requiring epinephrine of 20 per 100,000 SPT visits. No epinephrine was given after IDT.
Adverse reactions; allergic rhinitis; anaphylactoid reactions; anaphylaxis; food allergy testing; idiopathic anaphylaxis; intradermal testing; skin-prick testing; systemic reactions; venom allergy testing
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Measurement of osteotomy force during endoscopic sinus surgery
Joice, Paul
Ross, Peter D.
Wang, Dong
Abel, Eric W.
White, Paul S.
Allergy & Rhinology
Greater understanding of the surgeon's task and skills are required to improve surgical technique and the effectiveness of training. Currently, neither the objective measurement of osteotomy forces during endoscopic sinus surgery (ESS) nor the validity of the properties of cadaver materials, are well documented. Measurement was performed of peak axial osteotomy force during ESS. A comparison was made of results with previously published cadaver data to validate the force properties of cadaver models. A prospective, consecutive cohort of 25 patients was compared with data from 15 cadaver heads. A modified Storz sinus curette measured osteotomy force from uncinate, bulla ethmoidalis, and ground lamella. Independent variables were osteotomy site, age, gender, indication for surgery, and side. Corresponding cadaver data were analyzed for the independent variables of osteotomy site, side, and gender and then compared with the live patient data. Mean osteotomy force in live patients was 9.6 N (95% CI, 8.9–10.4 N). Mean osteotomy force in the cadaver heads was 6.4 N (95% CI, 5.7–7.0 N). Ethmoid osteotomy of live patients required 3.2 N (95% CI, 2.1–4.3 N) more force than the cadaver heads (p = 0.0001). This relationship was statistically significant at the bulla ethmoidalis (p = 0.002) and the ground lamella (p = 0.0001) but not at the uncinate (p = 0.068). Osteotomy in female live subjects required 1.6 N (95% CI, 0.1–3.1 N) more force than male live subjects (p = 0.03). Cadaver tissue may underestimate the mean osteotomy force required in osteotomy of living ethmoid sinus lamellae by a factor of 1.5 times. Caution may be required in extrapolating force estimates from cadaver tissue to those required in living patients.
Biomechanics; curette; endoscopic surgical procedures; ergonomics; force; measurement techniques; osteotomy; otolaryngology; paranasal sinuses; surgical therapy
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Diffusion lung capacity of carbon monoxide: A novel marker of airways remodeling in asthmatic children?
Piacentini, Giorgio L.
Tezza, Giovanna
Cattazzo, Elena
Kantar, Ahmad
Ragazzo, Vincenzo
Boner, Attilio L.
Peroni, Diego G.
Allergy & Rhinology
Asthma is universally considered a chronic inflammatory disorder of the airways. Several noninvasive markers, such as exhaled nitric oxide (FeNO) and exhaled breath temperature (PletM), have been proposed to evaluate the degree of airway inflammation and remodeling in asthmatic children. The aim of this study was to evaluate the relationship between diffusion lung capacity of carbon monoxide (DLCO) and these inflammatory markers in asthmatic children. We compared data of FeNO, PletM, and DLCO collected in 35 asthmatic children at admission (T0) and discharge (T1) after a period spent in a dust-mite–free environment (Misurina, Italian Dolomites, 1756 m). PletM showed a reduction from 29.48°C at T0 to 29.13°C at T1 (p = 0.17); DLCO passed from 93 to 102 (p = 0.085). FeNO mean value was 29.7 ppb at admission and 18.9 ppb at discharge (p = 0.014). Eosinophil mean count in induced sputum was 4 at T0 and 2 at T1 (p = 0.004). Spearman standardization coefficient beta was 0.414 between eosinophils and FeNO and −0.278 between eosinophils and DLCO. Pearson's correlation index between DLCO and PletM was −0.456 (p = 0.019). A negative correlation between DLCO and PletM was found. However, DLCO did not show a significant correlation with FeNO and eosinophils in the airways. Additional studies are needed to clarify the role of DLCO as a potential tool in monitoring childhood asthma.
Breath temperature; childhood asthma; diffusion lung capacity; exhaled nitric oxide; inflammation; remodeling; sputum eosinophils
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Group 10 allergens (tropomyosins) from house-dust mites may cause covariation of sensitization to allergens from other invertebrates
Shafique, Rubaba Hamid
Inam, Muhammad
Ismail, Muhammad
Chaudhary, Farhana Riaz
Allergy & Rhinology
Group 10 allergens (tropomyosins) have been assumed to be a major cause of cross-reactivity between house-dust mites (HDMs) and other invertebrates. Despite all of the published data regarding the epidemiology, percent IgE binding and level of sensitization in the population, the role of tropomyosin as a cross-reactive allergen in patients with multiple allergy syndrome still remains to be elucidated. Homology between amino acid sequences reported in allergen databases of selected invertebrate tropomyosins was determined with Der f 10 as the reference allergen. The 66.9 and 54.4% identities were found with selected crustacean and insect species, respectively, whereas only 20.4% identity was seen with mollusks. A similar analysis was performed using reported B-cell IgE-binding epitopes from Met e1 (shrimp allergen) and Bla g7 (cockroach allergen) with other invertebrate tropomyosins. The percent identity in linear sequences was higher than 35% in mites, crustaceans, and cockroaches. The polar and hydrophobic regions in these groups were highly conserved. These findings suggest that tropomyosin may be a major cause of covariation of sensitization between HDMs, crustaceans, and some species of insects and mollusks.
Cross-reactivity of tropomyosins; group 10 allergens; HDM allergens; homology; IgE-binding epitopes; multiple allergy syndrome; tropomyosins
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Cadaveric analysis of nasal valve suspension
Bae, Jung Ho
Most, Sam P.
Allergy & Rhinology
This study was designed to measure the efficacy of a nasal valve suspension technique and determine the adequate traction length without creation of nasofacial fullness in a cadaveric model. Seven fresh frozen cadaveric heads were evaluated. Minimal cross-sectional (MCA) areas were measured with a transient-signal acoustic rhinometer (Ecco Vision; Hood Instruments, Pembroke, MA) before and after suspension. The adequate traction length, which did not cause obvious changes, was determined. Five millimeters of lateral nasal valve traction was determined to be the maximal traction achievable without creating facial fullness. After lateral nasal suspension, average MCA increased by 13.7%. Average distance to the MCA from the nostril changed from 1.57 to 1.76 cm. Postsuspension values were significantly higher than the presuspension values (p < 0.05). Nasal valve suspension with 5 mm of lateral traction has a significant impact on nasal valve area without obvious nasofacial changes.
Acoustic rhinometry; analysis; cadaver; complication; nasal obstruction; nasal valve; stenosis; surgery; suspension; traction length
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Signal transducer and activator of transcription 3 mutation with invasive eosinophilic disease
Crosby, Kara
Swender, David
Chernin, Leah
Hafez-Khayyata, Said
Ochs, Hans
Tcheurekdjian, Haig
Hostoffer, Robert
Allergy & Rhinology
Hyper-IgE syndrome (HIES), or Jobs disease, is a rare immunologic disorder characterized by the triad of staphylococcal abscesses, pneumonia with pneumatocele formation, and elevated IgE. It has been shown to have multiple modes of inheritance, autosomal dominant being more common than autosomal recessive, with sporadic cases as well. A mutation in signal transducer and activator of transcription 3 (STAT3) gene has been linked to the development of the sporadic and dominant forms of HIES. Peripheral eosinophilia, typically greater than two standard deviations from the normal population, is often seen in association with HIES. Despite these elevated levels of blood eosinophils, there have been no reported cases of invasive eosinophilic disease, such as eosonophilic esophagitic. Here we report the first description, to our knowledge, of a patient with HIES with a STAT3 mutation involving exon 12, Thr389Ile, and invasive eosinophilic disease of the esophagus. STAT3 modulates the expression of several genes that control central cell processes such as growth and death in response to external soluble stimuli. A mutation in the STAT3 molecule may affect the eosinophil's response to IL-5 and thus reduce the chemotaxic ability of those cells to migrate into tissues. This may then explain the paucity of eosinophilic infiltrative disease in patients with STAT3 mutations. The level of eosinophilic involvement may be related to the site or type of mutation within the STAT3 molecule. As more data are collected, we may be able to assess whether certain mutations dictate different clinical outcomes, which could prove helpful in directing therapy.
Eosinophilia; esophagitis; hyper-IgE; immunodeficiency; invasive; STAT3; Thr389Ile
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Displaced nasal dilator caused severe pain: Case report and literature review
Jungmark, Eva M.
Ellegård, Eva K.
Allergy & Rhinology
Internal nasal dilators are widely used but have not been reported to cause severe symptoms. We describe a case in which a male adult had accidentally, during sleep, inhaled a nasal dilator into his right nasal cavity, and we review the relevant literature. A PubMed search was performed of nasal dilators, especially of the internal types, including "Nasaline Snooze'" (ENTPro, Stockholm, Sweden). A foreign body in adults may be an inhaled nasal dilator. It may be overlooked on computed tomography scans, and thorough inspection of the nose is diagnostic.
Adult; computed tomography; foreign body; head ache; nasal dilator; nasal obstruction; sinusitis
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Quality of life comparison in common rhinologic surgeries
Naraghi, Mohsen
Amirzargar, Behrooz
Meysamie, Alipasha
Allergy & Rhinology
Various questionnaires are used in patients who undergo rhinologic surgeries but a unique comprehensive questionnaire is needed to evaluate quality of life (QOL) in rhinologic surgeries. The purpose of this study was to prepare a comprehensive questionnaire and compare QOL among four common rhinologic surgeries including functional endoscopic sinus surgery, septoplasty, septorhinoplasty, and septoplasty with turbinoplasty preoperatively and 6 months postoperatively. This was a prospective interventional before-and-after study. Preoperative and 6 months postoperative evaluations were performed with a Modified Health-Related Quality of Life (HRQL) questionnaire designed to cover all needed QOL aspects and the 22-item Sino-nasal Outcome Test questionnaire to cover all needed QOL aspects. The Modified HRQL included 33 items in six subgroups (nasal symptoms, sleep problems, headache, nonnasal symptoms, and practical and emotional problems) and general feeling. From 202 patients who completed the questionnaire before the procedures, 146 (72% of all patients) who were interviewed 6 months postoperatively were included in this study. Comparing preoperative data between followed up patients and missed patients showed no statistical difference among surgeries (p = 0.90). Comparison of patient's pre- and postoperative QOL showed a significant improvement in global QOL and in all questionnaire items (p < 0.0001 in all comparisons). Comparison of QOL changes before and after surgery among different surgeries revealed no statistical difference (p = 0.282). Our data showed a significant improvement in each surgery but the amount of improvement in different surgeries was almost constant.
Functional endoscopic sinus surgery; Modified Health-Related Quality of Life questionnaire; quality of life; rhinologic surgeries; septoplasty; septorhinoplasty; turbinoplasty
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Rhinologic issues in pregnancy
Goldstein, Gregg
Govindaraj, Satish
Allergy & Rhinology
The diagnosis and treatment of rhinitis, sinusitis, and epistaxis during pregnancy present unique challenges to the otolaryngologist. Poorly controlled sinonasal disease may have significant adverse effects on the mother's quality of life and pregnancy outcomes and the lack of adequately controlled safety data limits the clinician's ability to make informed decisions about management. At the conclusion of this discussion, the reader should be familiar with the available literature and evidence-based guidelines regarding the safety and indications for radiographic imaging, clinical testing, medical intervention, and surgical treatment of sinonasal disease in pregnant patients. A review was performed of pertinent guidelines regarding the management of gestational rhinitis, sinusitis, and epistaxis, including the diagnostic and therapeutic limitations and physiological changes specific to pregnancy. A study population of four patients was analyzed to highlight the steps of management by reviewing the patient charts including pertinent history, physical examination, clinical course, and operative reports. Two patients with epistaxis and two patients with rhinosinusitis ranging from 27 to 38 years of age and between 16 and 35 weeks gestation were analyzed. The treatment of sinonasal disease during pregnancy is challenging and a thorough knowledge of the available medical evidence and treatment guidelines is necessary to optimize pregnancy outcomes. When the severity of disease precludes the possibility of delaying treatment, the clinician should provide a limited intervention that optimizes the mother's health without placing the fetus at significant risk.
Advair; albuterol; allergic rhinitis; amoxicillin; anaphylaxis; Augmentin; azithromycin; budesonide; epistaxis; fluticasone; gestational rhinitis; montelukast; prednisone; pyogenic granuloma; rads; rhinitis medicamentosa; rhinitis of pregnancy; sinusitis
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Sensitization rate and clinical profile of Congolese patients with rhinitis
Nyembue, Tshipukane Dieudonné
Ntumba, Wivine
Omadjela, L. August
Muyunga, Christophe
Hellings, Peter W.
Jorissen, Mark
Allergy & Rhinology
In the African continent, the sensitization pattern and clinical profile are unknown in patients with rhinitis/rhinosinusitis attending the outpatient ear, nose, and throat (ENT) clinics. We therefore aimed to analyze the clinical characteristics of rhinitis/rhinosinusitis patients in Democratic Republic of Congo (DRC), classify allergic rhinitis (AR) according to the Allergic Rhinitis and Its Impact on Asthma criteria, and evaluate the sensitization profile and its associated factors. From January to May 2009, 423 patients with rhinitis symptoms attending the Outpatient ENT clinic of the University Hospital and Saint Joseph Hospital of Kinshasa were evaluated for allergy symptoms, severity, and duration of symptoms and underwent skin-prick tests (SPTs) for a panel of 15 allergens. Of 423 patients 35.2% had positive SPT results, with 40.9% showing polysensitization. Dermatophagoides pteronyssinus (DPT) (68.5%) and cockroach (36.2%) were the most common allergens among sensitized patients. Patients with rhinitis/rhinosinusitis mainly presented in decreasing order with sneezing, facial pain/pressure, nasal obstruction, postnasal discharge, nose itching, clear nasal discharge, and eye itching. Persistent and moderate/severe AR represented 61.4 and 69.3%, respectively. Sensitization was independently associated with younger age, rhinoconjunctivitis, and reaction to nonspecific trigger factors. In conclusion, 35.2% of patients attending the ENT Outpatient Clinic in DRC for rhinitis problems had a positive SPT to at least one allergen, with mainly DPT and cockroach allergens being involved; and a substantial portion showed persistent and moderate/severe AR. Therefore, allergy should not be neglected as an etiologic factor in rhinologic disease in the African continent.
Congo; rhinitis; rhinosinusitis; skin-prick testing; symptoms
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Mite-induced inflammation: More than allergy
Sánchez-Borges, Mario
Fernández-Caldas, Enrique
Capriles-Hulett, Arnaldo
Caballero-Fonseca, Fernan
Allergy & Rhinology
Clinical observations have suggested that there is an association of atopic conditions with hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). This relationship has been especially present in patients allergic to mites. This study was designed to review clinical and experimental evidence linking atopy, mite allergy, and hypersensitivity to aspirin and NSAIDs and discuss the possible mechanisms explaining this association. A review of the medical literature concerning the association of atopic diseases, mite hypersensitivity, and intolerance to NSAIDs using PubMed and other relevant articles is presented. NSAID-sensitive patients are frequently atopic and allergic to mites, and patients who develop oral mite anaphylaxis (OMA) show an increased prevalence of NSAID hypersensitivity. The study of atopic, mite-sensitive patients, who experience urticaria and angioedema when exposed to NSAIDs and patients with OMA suggests an interesting interaction between atopic allergy and disorders of leukotriene synthesis or metabolism. Various mechanisms that could be involved in this interaction are presented, including genetic factors, inhibition of cyclooxygenase-1, and other effects (not related to IgE sensitization) of mite constituents on the immune system. The association of mite hypersensitivity with aspirin/NSAIDs intolerance has been confirmed and provides additional clues to various nonallergic pathways that may contribute to the acute and chronic inflammatory process observed in atopic, mite-allergic, individuals. The clinical relevance of these observations is presently under investigation.
Aspirin; acetylsalicylic acid; angioedema; cysteinyl-leukotrienes; Dermatophagoides; immunoglobulin E; mites; leukotriene C4 synthase; nonsteroidal anti-inflammatory drugs; NSAIDs
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Regulation of dendritic cell functions against harmful respiratory pathogens by a cysteinyl leukotrienes receptor antagonist
Matsuse, Hiroto
Hirose, Hiroko
Fukahori, Susumu
Tsuchida, Tomoko
Tomari, Shinya
Kawano, Tetsuya
Fukushima, Chizu
Kohno, Shigeru
Allergy & Rhinology
Cysteinyl leukotriene receptor antagonist (LTRA) is a widely used medicine for asthma. Cysteinyl leukotrienes (cysLTs) are involved in the regulation of dendritic cell (DC) function. However, the effects of LTRA on DC-related antimicrobial immunity against harmful respiratory pathogens remain unknown. The purpose of this study was to examine the effects of LTRA administered in vivo on DC function against representative respiratory pathogens in vitro. Pulmonary DCs were isolated from four groups of mice: control, mite allergen sensitized (AS), and AS mice treated with the corticosteroid dexamethasone (Dex) or with the LTRA pranlukast (Prl). These DCs were incubated with mite allergen, lipopolysaccharide (LPS), Aspergillus fumigatus, or respiratory syncytial virus (RSV). IL-10 and IL-12 production was then determined. Dex treatment significantly inhibited lipopolysaccharide (LPS)-induced IL-10 and IL-12 production as well as baseline IL-12 production in AS mice. The Prl did not significantly inhibit LPS-induced IL-10 and IL-12 production in AS mice. More importantly, Prl significantly increased IL-10 and IL-12 in AS mice after RSV infection. This study shows that LTRA that is used for asthma potentially up-regulates antimicrobial immunity through modulation of DC function against some respiratory infections without immunosuppression.
Allergic airway inflammation; Aspergillus fumigatus; asthma; corticosteroids; cysteinyl leukotrienes receptor antagonist; cytokines; dendritic cell; Dermatophagoides farinae; lipopolysaccharide; respiratory syncytial virus
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Polymorphic variants of interleukin-13 R130Q, interleukin-4 T589C, interleukin-4RA I50V, and interleukin-4RA Q576R in allergic rhinitis: A pilot study
Yadav, Aravind
Govindasamy, Gopala Krishnan
Naidu, Rakesh
Allergy & Rhinology
The development of allergic rhinitis is considered to be caused by the complex interactions between genetic predisposition and environmental factors. Polymorphisms in the interleukin (IL)-13/4/4RA pathway have previously been shown to be associated with atopic diseases. The purpose of this study was to determine the association between IL-13 R130Q, IL-4 T589C, IL4 receptor alpha (IL-4RA) I50V, or IL-4RA Q576R polymorphisms and risk of allergic rhinitis in a hospital-based Malaysian population. A case-control pilot study was undertaken and genotyping of these polymorphisms was performed using polymerase chain reaction–restriction fragment length polymorphism on 54 allergic rhinitis patients and 45 healthy individuals. Polymorphism of IL-13 R130Q showed significant difference in genotype (p = 0.048) and allele (p = 0.002) frequencies in allergic rhinitis when compared with healthy controls. Individuals who were GA heterozygotes (adjusted odds ratio [ORadj] = 3.567; 95% CI, 1.211–10.509), and carriers of A allele genotype (ORadj = 3.686; 95% CI, 1.300–10.451) and A allele (ORadj = 3.071; 95% CI, 1.514–6.232) had an elevated risk of developing allergic rhinitis. The genotype and allele frequencies of IL-4 T589C, IL-4RA I50V, and IL-4RA Q576R polymorphisms were not significantly different between the allergic rhinitis patients and normal healthy individuals and did not show an associated risk with allergic rhinitis. Our findings indicate that polymorphic variant of IL-13 R130Q appears to be associated with increased risk for development of allergic rhinitis in a hospital-based Malaysian population but not IL-4 T589C, IL-4RA I50V, and IL-4RA Q576 polymorphisms. Additional studies using larger sample size are required to confirm our findings and its exact role in allergic rhinitis.
Allele; allergy; RFLP; genotyping; IL-13; IL-4; IL-4RA; PCR; polymorphism; rhinitis
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Locally destructive skull base lesion: IgG4-related sclerosing disease
Alt, Jeremiah A.
Whitaker, Graham T.
Allan, Robert W.
Vaysberg, Mikhail
Allergy & Rhinology
A unique case of IgG4+ sclerosing disease was diagnosed in the sphenoid sinus, a previously unreported location, and was treated in a novel manner. This study describes the clinical presentation and management of IgG4 sclerosing disease in the paranasal sinuses. A retrospective case review and review of the medical literature were performed. A 38-year-old woman with a 2-year history of constant frontal headaches presented to our clinic. Imaging showed bony destruction of the sphenoid sinus and sellar floor. The patient underwent a right-sided sphenoidotomy with debridement and biopsy. Pathological evaluation showed a dense plasmacytic infiltrate with >150 IgG4+ cells/high-power field. She was subsequently started on a nasal corticosteroid with improved patency of the sphenoid antrostomy. We report an unusual case of a middle-aged woman who presented with IgG4-sclerosing disease (IGSD) isolated to the sphenoid sinus. Although our knowledge concerning treatment in extrapancreatic organs is lacking, there is evidence that glucocorticoid treatment improves nasal sinus opacification on CT findings (Sato Y, Ohshima K, Ichimura K, et al., Ocular adnexal IgG4-related disease has uniform clinicopathology, Pathol Int 58:465–470, 2008). This case study and literature review adds to the growing literature describing IGSD in the head and neck and more specifically isolated to the sphenoid sinus with preliminary data concerning local control with topical steroids.
Corticosteroid; IgG4; IGSD; sclerosing disease; skull base; sphenoid; sphenoidectomy
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Congenital nasolacrimal duct cyst/dacryocystocele: An argument for a genetic basis
Barham, Henry P.
Wudel, Justin M.
Enzenauer, Robert W.
Chan, Kenny H.
Allergy & Rhinology
Embryogenesis of a congenital nasolacrimal duct (NLD) cyst is attributed to the failure of the Hasner membrane of the NLD system to cannulate. Prenatal diagnosis of congenital NLD cysts supports the argument for a developmental error, with a postnatal prevalence of 6%. The role of a genetic basis for this malformation has never been ascribed. We present a set of monozygotic twins with bilateral congenital NLD cysts as an argument for a genetic basis of this entity. A case report and literature review were performed. We present two cases of bilateral congenital NLD cysts occurring in a set of monozygotic twins. Patients were delivered at 37 weeks via cesarean section. The pregnancy was complicated by preterm labor at 33 weeks requiring administration of terbutaline and betamethasone. At presentation, twin A had bilateral eye discharge, erythema, and swelling medial to the medial canthi as well as nasal obstruction. Computed tomography (CT) showed classic bilateral cystic masses in the inferior meatus. The diagnosis of bilateral infected congenital dacryocystoceles was made. Twin B initially presented with only bilateral eye discharge and CT showed a dilated NLD system. Twin B subsequently developed early signs of bilateral dacryocystoceles the following day. Both patients underwent lacrimal probing and endoscopic marsupialization of the dacryocystoceles. Biopsies were consistent with dacryocystocele. Dacryocystocele is a common presentation of unresolved neonatal NLD obstruction. This case report in a set of identical twins is an argument for a genetic basis for the formation of this lesion.
Congenital; cyst; dacryocystocele; dacryocystorhinostomy; genetic; Hasner; nasolacrimal
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Efficacy of medical therapy in treatment of chronic rhinosinusitis
Young, Lee C.
Stow, Nicholas W.
Zhou, Lifeng
Douglas, Richard G.
Allergy & Rhinology
Uncomplicated chronic rhinosinusitis (CRS) is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed. However, there is considerable variation in the medical treatment regimens used and studies defining their efficacy are few. The aim of this study was to determine the proportion of patients treated medically who responded sufficiently well so that surgery was not required. Subgroup analysis to identify clinical features that predicted a favorable response to medical therapy was also performed. Eighty patients referred to the Otorhinolaryngology Clinic at North Shore Hospital were treated with a standardized medical therapy protocol (oral prednisone for 3 weeks, oral antibiotics and ongoing saline lavage and intranasal budesonide spray). Symptom scores were collected before and after medical therapy. Clinical features such as presence of polyps, asthma, and aspirin hypersensitivity were recorded. Failure of medical therapy was defined as the persistence of significant CRS symptoms, and those patients who failed medical therapy were offered surgery. Follow-up data were available for 72 (90%) patients. Of this group, 52.5%, (95% CI, 42.7%, 62.2%) failed to respond adequately to medical therapy and were offered surgery. The remaining patients (37.5%) were successfully treated with medical therapy and did not require surgery at the time of follow-up. The premedical therapy symptom scores were significantly higher than the postmedical therapy symptom scores (p < 0.01). The symptom scores of those patients postmedical therapy who proceeded to have surgery were significantly higher than the group who responded well to maximum medical therapy (MMT) and did not require surgery (p < 0.0001). There were no significant differences in the proportion of patients with asthma, aspirin sensitivity, or polyps between the groups failing or not failing MMT. In approximately one-third of patients with CRS, medical therapy improved symptoms sufficiently so that surgical therapy was avoided. Patients with more severe symptoms tended not to respond as well as those with less severe symptoms. Long-term follow-up is required for the group of responders to determine how many will eventually relapse.
Antibiotics; chronic rhinosinusitis; corticosteroid; intranasal steroid; macrolides; maximal medical therapy; medical therapy; prednisone; saline irrigation; symptom
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Effects of cromolyn sodium on isolated rat's trachea
Lin, Yuan-Yung
Chou, Ying-Liang
Chu, Yueng-Hsiang
Wu, Chi-Chung
Wang, Jia-Yi
Wang, Hsing-Won
Allergy & Rhinology
Cromolyn sodium (cromolyn) effectively inhibits both antigen- and exercise-induced asthma when used as an aerosol. Intranasal cromolyn is also recommended for preventing and treating allergic rhinitis. By inhibiting the degranulation of sensitized mast cells, cromolyn reduces the release of mediators that trigger inflammation and the allergic response. The precise pharmacologic activity of cromolyn has not been fully elucidated. This study evaluated the effect of cromolyn on isolated rat's trachea. The following assessments of cromolyn were performed: (1) effect on tracheal resting tension, (2) effect on contraction caused by 10−6 M of methacholine as a parasympathetic mimetic, and (3) effect of the drug on electrically induced tracheal contractions. The results indicated cromolyn could inhibit electrical field stimulation-induced spike contraction when the preparation was increased to 10−4M. Adding cromolyn at doses of ≥10−8 M did not elicit a relaxation or contraction response to 10−6 M of methacholine-induced contraction. It alone had a minimal effect on the basal tension of the trachea as the concentration increased. This study indicates cromolyn had no cholinergic or anticholinergic effect and high concentrations of cromolyn might actually inhibit parasympathetic function of the trachea. Inhibiting parasympathetic function of the trachea through stabilizing the presynaptic nerve by cromolyn may be responsible for protecting patients against antigen- and exercise-induced asthma.
Cromolyn; in vitro study smooth muscle; trachea
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Oral curcumin supplementation in patients with atopic asthma
Kim, Dennis H.
Phillips, Joshua F.
Lockey, Richard F.
Allergy & Rhinology
Oral curcumin is recognized to have anti-inflammatory properties and has been used by ancient traditional medicine for centuries to treat a variety of diseases. In vitro studies have confirmed the ability of curcumin to inhibit allergic inflammatory cytokine responses from lymphocytes; however, there are no in vivo studies of curcumin to treat inflammation associated with allergic asthma. This study was designed to determine the effect of oral curcumin supplementation on patients with stable, persistent, atopic asthma. Adult patients with stable, persistent asthma with evidence of allergic sensitization were randomized to receive 1000 mg of curcumin twice daily or placebo. Subjects were followed for 6 months and performed monthly spirometry (pre- and postbronchodilator); Asthma Control Test (ACT) scoring; and measurements for fractional excretion of nitric oxide (NO), serum eosinophil count, leukocyte count, total IgE, specific IgE to Dermatophagoides pteronyssinus (Der p) and Dermatophagoides farinae (Der f), use of rescue albuterol, and dose of inhaled corticosteroid. Nine patients were randomized into the treatment arm and six were randomized into the placebo group. No differential response was seen in the treatment and placebo groups regarding the primary end point, postbronchodilator forced expiratory volume in 1 second (FEV1). Similarly, all secondary end point evaluations were not significantly different. Despite in vitro evidence that curcumin has anti-inflammatory properties and can inhibit allergic cytokine responses from lymphocytes in vitro, curcumin, 1000-mg, twice daily supplementation did not significantly affect postbronchodilator FEV1, ACT scores, use of rescue bronchodilator, dose of inhaled corticosteroid, exhaled NO, serum IgE, total white blood cell count specific IgE to Der p or Der f, and blood eosinophils in patients with persistent atopic asthma.
Allergy; asthma; curcumin; herbal
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The use of antibiotics in septoplasty is a common practice among most ear, nose, and throat doctors; however, there are few studies proving the efficacy, which is considered as unnecessary by some authors. The aim of this pilot study was to evaluate the effect of two different kinds of antimicrobial agent on efficacy and safety after septoplasty surgery and to show that use of cephazolin, 1.0 g, postoperatively, might be sufficient for preventing infection after septoplasty procedure. Patients were randomly divided into two groups with a simple randomization method. The first group of 80 patients received cephazolin, 1.0 g i.v., once postoperatively and the second group of 80 patients received amoxicillin–clavulanate orally for 7 days postoperatively (1000 mg). An early and late postoperative questionnaire and nasal endoscopy evaluation was performed and patients were followed up in the outpatient service to investigate the presence of complications. There was no significant difference in postoperative pain between groups A and B, using visual analog scale scores at the 1st postoperative day. There were no differences related to the amount of purulent discharge found at the lower margin of the inferior turbinate through nasal endoscopy performed on the 14th day postoperatively. There were no statistical significances among groups for complications rates and postoperative endoscopic evaluation. Septoplasties are considered potentially contaminated surgeries, and cephazolin, 1.0 g i.v., given once postoperatively is enough to prevent potential complications with its easy and effective use.
Amoxicillin; antibiotics; cephazolin; complication; postoperative; septoplasty
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A case of uncontrolled asthma
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Yüksel, Cabir
Okçu Heper, Aylin
Yildiz, Oya
Kavukc̦u, Șevket
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A 48-year-old female patient with uncontrolled severe asthma was referred to our hospital for anti-IgE therapy. She was suffering with persistent wheezing and dyspnea after a severe asthma attack that had taken place 5 months previously. Her asthma had not been controlled with adequate asthma treatment, including budesonide at 320 μg + formoterol at 9 μg b.i.d. combination, montelukast at 10 mg/day, and oral steroids (30–40 mg/day of prednisolone), during this period. She was hospitalized for evaluation for anti-IgE therapy. Chest radiography revealed a left-sided hilar opacity. Fiberoptic bronchoscopy was performed and showed an endobronchial lesion obstructing the left lower bronchus lumen. Computed tomography also revealed a nodular lesion at the same location. The patient underwent left lower lobectomy and mediastinal lymph node dissection. Pathological examination concluded the diagnosis of typical carcinoid tumor. After surgery, her symptoms disappeared and she has had no recurrence. In conclusion, a diagnosis of severe asthma requires confirmation of asthma. Uncontrolled symptoms that linger despite aggressive therapy warrant evaluation to rule out other etiologies, such as a carcinoid tumor, before selecting new treatment options.
Asthma; carcinoid tumor; intrabronchial tumor; pulmonary carcinoids; severe allergic asthma; typical carcinoid tumor; uncontrolled asthma
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Erratum: Indoor fungal concentration in the homes of allergic/asthmatic children in Delhi, India.
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Role of ADAM33 gene and associated single nucleotide polymorphisms in asthma
Sharma, Neeraj
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Asthma is a multifactorial disorder, primarily resulting from interactions between genetic and environmental factors. ADAM33 gene (located on chromosome 20p13) has been reported to play an important role in asthma. This review article is intended to include all of the publications, to date, which have assessed the association of ADAM33 gene polymorphisms as well as have shown the role of ADAM33 gene in airway remodeling and their expression with asthma. A PubMed search was performed for studies published between 1990 and 2010. The terms "ADAM33," "ADAM33 gene and asthma," and "ADAM33 gene polymorphisms" were used as search criteria. Based on available literature we can only speculate its role in the morphogenesis and functions of the lung. Fourteen studies conducted in different populations were found showing an association of ADAM33 gene polymorphisms with asthma. However, none of the single nucleotide polymorphisms (SNPs) of ADAM33 gene had found association with asthma across all ethnic groups. Because higher expression of ADAM33 is found in the fibroblast and smooth muscle cells of the lung, over- or underexpression of ADAM33 gene may result in alterations in airway remodeling and repair processes. However, no SNP of ADAM33 gene showed significant associations with asthma across all ethnic groups; the causative polymorphism, if any, still has to be identified.
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There is a paucity of data regarding prevalence and characteristics of adult seafood allergy in United States cohorts. This study was designed to determine the characteristics of patient-reported seafood allergy in a large allergy referral adult population. Retrospective analysis was performed of laboratory and clinical characteristics of seafood-allergic patients in three allergy clinics in the Texas Medical Center between January 1, 1997 and January 30, 2010. Of 5162 patients seen in this adult allergy referral population, 159 had physician-diagnosed seafood allergy with an average age of diagnosis of 50.2 (18–81 years) years. Shellfish allergy (59.1%) was more frequent than fish allergy (13.8%). Crustacean allergy (82.6%) was more frequent than mollusk allergy (7.2%). Shrimp (72.5%), crab (34.8%), and lobster (17.4%) were the most common shellfish allergies and tuna (28.6%), catfish (23.8%), and salmon (23.8%) were the most common fish allergies. One-third of seafood-allergic patients reported reactions to more than one seafood. Shellfish-allergic adults were more likely to experience respiratory symptoms than fish-allergic adults (p < 0.05). The likelihood of having anaphylaxis (32%) was not statistically different between shellfish- and fish-allergic subjects. Severe reactions were 12.9 times more likely to occur within the 1st hour of ingestion compared with nonsevere reactions (p < 0.005). The percentage of seafood allergy in this adult allergy referral population was 3.08%.
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Note from the Editor
Gaines, Alan
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Is routine nasoendoscopy warranted in epistaxis patients after removal of nasal packing?
Makarawo, Tafadzwa P.
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Fiberoptic nasoendoscopy (FNE) is a powerful investigative tool in ear, nose, and throat practice in which its use in the management of epistaxis is varied among clinicians. The practice of assessing the nasal cavity after removal of nasal packs is common but its usefulness has not been evaluated. Therefore, we assessed the benefits of routine FNE after removal of nasal packs in epistaxis patients. Our study was performed retrospectively involving 62 adult patients admitted over a 6-month period between 2005 and 2006. Data regarding the emergent management of epistaxis cases on presentation, the use of FNE, and the final diagnosis and outcome of each patient were specifically investigated during the study. Anterior rhinoscopy was performed in 27 patients at initial presentation, of whom 45% (10/27) had anterior bleeding points identified. FNE examination after removal of nasal packs in eight patients yielded evidence of a posterior bleeding point in only one case (12.5%). Of those patients in whom anterior rhinoscopy revealed no anterior bleeding point at presentation (17/27), 12 patients went on to have FNE after removal of their nasal packs, and of these, 33% (4/12) of patients were found to have a posterior bleeding vessel. Overall, FNE was performed in 24 patients, of whom only 1 (1/24) had an active posterior bleeding vessel needing nasal repacking. Four patients (4/24) had prominent posterior vessels that required no intervention, 1 patient (1/24) had new pathology identified, and in the remaining 18 cases (18/24), FNE yielded no additional information to modify management. The routine performance of FNE in all epistaxis patients after pack removal does not appear to convey any additional benefit. We advocate the use of FNE when anterior bleeding has been excluded or bleeding is persistent and that careful nasal examination by anterior rhinoscopy should be the cornerstone of assessment.
Epistaxis; fibreoptic nasendoscopy
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Alder Creek Gift Basket - Large Ghirardelli Tray
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1977 Mercury CougarMint Condition Mercury CougarWhite Exterior Tan InteriorModified 351 Engine Original PartsManual Transmission 36880 MilesOriginal Paperwork and Manual still availableThis Classic Looks Great... More
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Most folks just think of the Cougar as Mercury's version of the Mustang but the truth is that they're very different cars with very... More
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We've stayed here before and gave an above average review (that's above average for an inexpensive motel). This year it was not so good. The room was clean, the beds were comfortable and the microwave and refrigerator worked. What is it with 30 watt bulbs in all the lamps? If it's to save on electricity it's not working. We turned... More
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Snake Dike (along with Royal Arches) is one of the classic long moderate routes of Yosemite. For many climbers, this is number one on the Yosemite tick list when they first come to the Valley. For others it is known as "Snake Hike," but the bottom line is it is a great climb up an amazing natural feature to the top of one of the most spectacular formations in Yosemite - second only to El Cap itself. Get to the SW shoulder of Half Dome by following the Muir Trail to the Mist Trail past Nevada Falls, then back on the Muir Trail. From the top of Nevada Falls, continue for 0.75 mile to an obvious climber's trail that heads off to the left, contouring around behind the back of Liberty Cap to Half Dome. You'll pass a swampy area (Lost Lake), and then wander up slabs to the south face of Half Dome, heading back left across ledges to the base of the route. The approach is six miles and takes 2.5 to 4 hours. P1: The route starts up a slab below a prominent upside-down L-shaped roof formation. A big tree is up in this roof area on the right. Climb up into the roof, then traverse out the left end and up onto a nice belay ledge. 5.7. P2: Continue up the left-facing corner system above and past a pair of bolts (optional belay), then wander right past another bolt to a bolted anchor. 5.7. P3: Climb up and left past a bolt and 5.7 friction to reach the dike itself. Skip another bolted belay, climbing up the dike past a bolt and easier climbing, and up to a bolted belay. P4, P5, P6: Follow the dike for three more long pitches, all about 5.4, all very run out, stopping at bolted anchors. The final anchor is at a point past a steep section on a small ledge. P7, P8: Lots of low angle climbing (easy 5th class) wander up the face with occasional gear placements. Once you feel comfortable unroping, do so, and continue scrambling up 1000' of calf-burning slabs to the summit. Descent is down the Half Dome Cables route. You can't miss it. For logistical reasons, it's better to not leave anything at the base.
6 draws/slings, three or four small-medium sized cams. That's it!
I like long days so this qualifies.. The approach is tough, but the climb is great fun. Once the roped climbing is over it's a calf buster to the top.
Take a small set of cams. From 1/2 to one inch. On the first pitch climb to the tree on the left, sling it, and make the easy friction moves into the roof where you can immediately set a bomber cam. On the third pitch, look up and about five feet left from the belay to see the traverse bolt.
The free guide at Supertopo.com was quite helpful. Brought a set of nuts, six cams from black alien up to 0.75 camalot C4, six trad draws, one double-length draw, and some random slings/biners - more than enough gear. A skinny 60m rope allowed us to skip a couple of the belays. 8 pitches / 12 hours car-to-car. Bring gloves for the stupid cables :)
Good cruiser stuff up a nobby dike. Besides the traverse above the roof early on, the descent is the headiest part. Going down the cables is quite exposed. And the freaked out asian lady screaming chinese profanities whilst not letting go of either cable, makes the route memorable.
An excellent free download of the topo for Snake Dike is available from supertopo.com, loaded with lots of info: www.supertopo.com/freetopos.html#snakedike
I used to do this climb every year. It is awesome! On one of the upper pitches there is a short section where the dike ends and there is a bolt in the smooth gap. I always thought this section was pretty tricky. You may not notice it leading (with the bolt), but it can be scary for soloists.
When descending the cables on a crowded day you may find it easier to clip into the cables with a binner attached to a sling then step outside of the cables. Use another sling and binner to clip past the poles so that you are always clipped in.
The crux of the route is the never ending slabs to the top. Bring enough water and don�t worry too much about the Runouts. A fall in some areas would be really bad but the climbing is extremely easy.
Question: Are there any potential scary pendulum falls for the second on this route? I.e. would it be a bad idea to take a 5.8- climber as your second? Thanks!
There is some traversing at the beginning of the second (5.5ish) and third pitches (one 5.7 move). A 5.7-5.8 climber should have no problem. Enjoy!
The approach is not that hard to find, and it only took us 3 hours on our first try. After getting soaked at Mist Falls, the trail winds up towards Liberty Cap. When the trail abruptly runs into Liberty Cap, it forks. The hiker's trail goes right, you go left. It's that simple. The hardest part is thrashing through the spring growth in the valley between Liberty Cap and Mt. Broderick, but the views and route pays you back in spades.
Just did Snake Dike last week, had the free Supertopo beta and the Mountain Project beta. Neither accurately represents the second and third pitch. Here is what you will encounter. As you take off on the traverse of second pitch you can get in a piece and than clip a bolt. You will than see a pair of anchors about 60 ft up. I suggest you clip them and bring up partner. This ends the second pitch (do not recommend going further for the following reason). P2 on Mountain Project says go past "pair of bolts" (anchor), move up and right to a "fixed pin to another pair of bolts". The "fixed pin" is actually a folded metal hanger with bad 1/4 inch pin. The "pair of bolts" is wrong...as you move past the old folded hanger you encounter only one SMC hanger on a 1/4 inch bolt that sticks out approximately 1/4in and has old webbing hanging off of it. Would not anchor myself on it and use this as protection for my leader. If the leader on the third pitch were to slip on the 50 ft traverse after clipping into this suspicious bolt it probably would not hold. So belay from the two anchors about 30 feet below on P2. start P3 from here, do not use the folded hanger, clip the crappy SMC hanger and 1/4inch pin and hope no one falls.
Laurel, I think you got confused by the Mountain Project beta. The pair of bolts mentioned by Mountain Project that you have to pass in P2 is the optional belay from the free Supertopo for P1. If you used that optional bolted belay on top of P1 then the next pair of bolts you will encounter is indeed the P2 belay. Concerning P3, I think you missed the traverse on the left and went off route on Snake Dance. To future Snake Dike climbers, if you can clip any quarter incher during the climb, check your topo, you are probably off route.
A good thing for this route is a LONG rope 60m or better. This really helps out on the upper part.
Did this a couple years ago with some friends, 2 parties of two. First leader took about 20 slings and maybe a couple of nuts and started blasting, his partner simulclimbed behind him unclipping the gear and leaving it in place. My partner was right on his heels clipping in the pre placed gear and I brought up the rear cleaning everything. From bottom to top I think it took us about 1 hr 15 minutes or right about there. Fantastic route!
me and my girlfriend tried snake dike... the hike there was longer and more strenuous than we had originally thought it would be. curns pointed the way, just hard to find them all the time. finally getting to the dike. ive never climbed on gannet or done a "friction" climb so maybe thats why it was so hard? ? ? ? i had brand new 5.10 prism they didn't seem to stick to the rock at all. it seemed no matter what i did, i would feel very unsure and would slip a few times on the smooth rock. which made the first 3 pitches VERY SCARY !!! my girlfriend also had 5.10 shoes but seemed to do a little better than me, but was pretty scared too.. we were unprepared for the Friction parts of this climb. and i consider myself a hard climber. i tried to find everything i could on snake dike before we left so i wouldn't have any surprises. she and i eventually felt like doing the rest of the climb could be left for another day a repelled off and went home. :(
We did this route on one 60m rope as a party of 3 on a hot 8/29. Approach beta was good and made it from Curry to the base of the route in 3 hours. Climbed the P1 left side variation, slung the tree and made the easy friction moves up to the left side of the roof where it's easy to get a bomber nut in. Ran up the flake to the small ledge on top and belayed the followers from the 2 bolt anchor. While the traverse off the P2 belay is a bit of an attention grabber, the moves are easy and you get a nice piece in before stepping over the bulge and clipping the next bolt. Moved up and left, stepping down into a small bucket after clipping the bolt before finishing the traverse moves to the dike and the 2 bolt anchor where we set up the 2nd belay. Simuled all the dike pitches stopping twice to get gear back (note, some of the knobs are easy to sling if you want extra security)and found the route finding pretty straight forward although there are definitely some trickier variations to be had if you want them. Walkoff is long but the hike down the cables and back to camp is way longer. All in all a super fun day and easy enough for a 5.8 leader with his or her head on straight. The toughest part of this route is not thinking about the runouts. All the bolts that need to be in good shape are in good shape. Bring lots of water.
Once You reach the dike, the rest of the pitches can be linked with a 60m rope.
Moonlight ascent in summer 2009. 2pm leave bay area 6pm start hike at curry village 10pm base of climb 2am top of half dome 5am back to curry village nap time breakfast 9am drive back to bay area 1pm back home ...something like that. not sure if the hike is worth the climb. also, although moonlight ascent was something to remember, we didn't feel the "exposure" because we couldn't see how high we were. still, moonlight ascent meant no crowd and perfect temp even during summer.
the beta available is pretty accurate and if you use your brain the climbing is logical and the protection reasonable. (the runouts are real but easy, as everyone notes, and the cruxes have pro.) we found the approach to be tricky. not being a yosemite local, i contemplated crossing dicey slabs way too many times. ("should this look like third class to me??") all we lost was time- so i will say this: when the supertopo approach beta says "pretty much walk straight towards the face of half dome", they are serious. this may also mean trending right and up. we followed broken ledges and corners up and right, with some bad bushwacking, until a ledge walk back to the left (and southwest) became obvious. a little friendliness goes a long way with the parties that will inevitably surround you.
I now know why some call this 'snake HIKE'. I used to think it was to denigrate the climb as hardly worthy of consideration as a climb because it is a moderate--thinking that hardass climbers were snobs. But no! It's because of the hike after you climb. My freakin' god! I've done the hike before but not with gear in my pack. All I'm sayin' is, if BASE was legal... All that said, I'd do it again tomorrow. A stellar climb and truly worthy of the five star rating. Oh, and the runouts? Yeah--a real attention getter but never felt dangerous. Made us careful on lead.
Did snake dike Saturday 5/12. Left curry village parking lot at 8:30am and got back to car at 11:00pm. Last chance for water was at Nevada Falls. Fill up and drink as much as you can there. The climber�s trail is not too hard to find and follow in daylight using supertopo description. Had to wait in line at the climb for about an hour since we left late. We topped out and descended cables with prusiks before dark. Hiked down to valley via headlamp. I am a solid 5.8 trad leader and this is the rack we brought: Three stoppers sizes 12, 8, and 5. Two ball nuts; purple and blue (lighter than cams in their range) Three wild country cams sizes 2.5, 1.5, and 1. 5 alpine slings 3 double length slings (used two as cordlettes at belay stations) 60m twin ropes to save weight and have the ability to rap if needed (a single 60m is what everyone else was using)
Not a single person on the route. The clear crux for me was the first pitch traverse. It's slick! I used 4 draws, 3 cams from .5-1", and a #11 stopper on the route.
Agree with Jim Dover's assessment BANG on when folk say bring plenty of water- but to qualify with numbers - and add some 1) Hike in - plan for 4 hours unless you already know the approach 2) Runout - depending on how you link the pitches and which anchors you use - 165ft pitch with one bolt? Make sure that your head is ready for this. 3) Hike Out (back to Curry Village) - Plan for 5 hours 4) Climb - 8 pitches of REAL climbing then 1000 ft 3rd class slab with 5th class consequences if you take a tumble - i don't know that you'd just land flat on your face if you slipped. factor this time into any itinerary that you have for the day. depending on how long you stay roped up - plan 1 - 2.5 hours 5) Plenty of water - we had 4 liters (2 each) and got to the top with half a liter left. Climbing in september had a hand pump water filter with us and refilled the camelbacks at the river in little Yosemite camp ground. 6) you have climbing gear - keep your harness on and clip into those cables on the descent (two slings and two biners) - those cables are the scariest thing that i've done. more so that 165ft with one bolt..
Climbed this yesterday. I thought the technical crux was on the first pitch and the psychological is the 1200 feet of unroped slab to top out. There are bear lockers at Little Yosemite Valley. If you get a permit you can hike 4 of the 6 mile approach the day before.
My favorite way to do Snake Dike: Gear lightest 60m Rope you can get your hands on, a 50m might even work and be lighter. 6 single length slings/trad draws 2 double length slings 4 locking D biners 2 Locking HMS type biners Red and brown tri-cam black metolious 4 cam green metolious 4 cam Harnesses or webbing for a swiss seat. Steri-pen I start the hike around 5am with 3 water bottles, but only 2 filled (for both of us) at the top of the second water fall (nevada falls?) drink up and leave with all 3 filled. Climb the route I love slinging horns/knobs on the way up to reduce the runout. Hike the slabs and eat lunch. Hoof it down to the stream and drink more water. Truck past the tourists and hopefully make it to curry village to eat dinner before the buffet closes. Last time I did it our time was around 12 hours car to car and we weren't really hurrying. I usually don't take a belay device and just use a munter; I've even done it with just a piece of webbing tied into a swiss seat, but I think it's probably worth carrying a harness. Go light, be calm and enjoy!
The Supertopo is great with one exception. There are two new bolts above the 2nd belay (start of P3) that are easy to see and have taken some people off route. The bolt shown on the topo that you want to use is actually quite difficult to see from the belay. Head left from the belay on to the slab watching above for the bolt.
Climbed this one Wed, 4/24/2013 and was treated to fantastic weather and nobody else on the summit! What an amazing day. A trip report: - We left our car at the Glacier Apron lot at 7:45 and hiked directly from there. The SuperTopo suggests taking the bus to the Happy Isles, but saving the .5 miles hiking didn't seem worth that effort. - In addition to the light rack recommended above, we brought a sandwich and two energy bars each, plus 2.5 liters of water per person on a moderate/warm April day. In retrospect, the food was more-or-less sufficient but the water was lean. You may want to bring purification tablets so you can use the stream/snowmelt (if available) for water refill sources as opposed to lugging more water weight. - Although the SuperTopo approach beta suggested taking the: Muir Trail > Mist Trail > Muir Trail we accidentally missed the Mist Trail turn-off and wound up hiking to Clark Point before heading a bit back down across the valley. In retrospect, this didn't add much time and allowed us to avoid the oft-slippery Mist Trail portion as we stayed on well-groomed dry switchbacks all the way to Clark Point. Not a bad alternative. - After getting to the shoulder of Liberty Cap, the beta is to basically hug that rock as you head left, keeping tabs on a faint trail. Soon you'll reach the gap between Liberty and Half Dome, where you'll turn right to traverse the gap before the terrain will turn more flat (a small stream will be on your left). The trail then becomes fainter again, and the terrain more wooded. At this point, we crossed the stream at an arbitrary point and found the start of the extensive cairns leading to the base. - The toughest part of the approach felt like the last bit of hiking straight up steep, loose faint switchbacks in the heat of the morning, then traversing the Half Dome base to the route start. Take your time in this section so you're not too burned out for the route itself. - It took us a while to ID the route start from the SuperTopo because the cairns actually pass the Snake Dike route and go a little further to the base of a different route (I believe this is the "SW Face" route). The key to finding Snake Dike is IDing the "three trees" in the topo that bracket the route from below. - Lead this route only if you feel super-solid leading 5.8. I think if you lead at a lower level, the extensive run-outs might feel pretty scary (though the climbing itself is very solid, especially after P2). - Once on top of Half Dome, don't miss the epic photos from the top. Recommendation is to (carefully) position one photographer on the "diving board" and the other(s) across the top for great views! - I highly recommend prusiking into the Half Dome cables on the descent, especially if the cables are down. That bit is pretty steep and you'll likely be pretty tired by that point, so better safe than sorry. - We went for the one-day approach and although it was an exhausting day (took us 11 hours, 55 minutes car-to-car with minimal rests), I think this is the best way to do it as long as it's not too hot out. We did see a couple parties during our decent hiking up to camp out at the base and do it in two days, but the prospect of carrying camping gear and more food/water up and down that approach did not sound fun. If you have any other questions about the route, it'll be fresh in my mind for a while, so feel free to email!
Don't be distracted by the shiny new bolts a few feet to the right of the dike on pitch 3. Those belong to Eye in the Sky. If you're climbing with an inexperienced second then double ropes help minimize the pendulum potential when following pitches 1 and 3. But they're sure heavy to carry all that way. Most of the belays are semi-hanging. Bring comfy shoes and avoid climbing as a party of three.
Easy fun climb! Until it started raining on us three pitches up. Super slick when wet but plenty of pro the whole way up! We simul climbed and were able to place pieces all the way to the top..the cable descent was the scariest part! The rock was we so we girthed some slings and took it slow. One biner and cable section at a time :)
Climbed it this May under the full moon- spectacular. We started at 8pm and were back at the car at 8am. Above the 4th pitch, we were able to turn off headlamps and just follow the dike glowing in the moonlight. This was a climb I will never forget, and it was so surreal being on the summit of Half Dome at 3am. To anyone wondering about climbing it in the dark, if you are a confident leader and don't mind runouts, this is a great climb to do at night. The only part I found difficult was the first pitch (finding the proper spots with higher friction), but nothing too bad.
Is trap pro recommended or necessary? I only have sport pro and cant afford trad pro. But i would hate to have that keep me from climbing this wall.
I couldn't find much of any beta on descending the cables route when the cables are down (Columbus Day thru the Friday before Memorial Day) so here it goes, hopefully this will help a few weary people out: (skip to the bullet points if you don't want to read my TR/rant) I always wanted my first time on top of Half Dome to be when no tourists were up there, I thought the solitude up there would just be fantastic... and I was right. This is the way to do it! We had the summit to ourselves and only one other party. Very surreal at sunset. Anyway, before we went for it, I asked around Yosemite (mountain shop and ranger station) and very quickly shopped the internet about the beta when the cables were down, and pretty much got nothing solid. In my mind for some reason, I was envisioning the cables being just one long continuous cable system, anchored only at the bottom and the top. In hindsight, this is quite a retarded assumption. Obviously one long continuous cable is not the case. There are giant intermediate eye bolts every so often, with smaller cables connecting these points to the main cable, as well as a few junctions of separate cables. Despite these facts, when I was asking how to descend these safely at the mountain shop and got, "uh, I mean people definitely do it..." and not much of any other relevant info, to which I probed, "...so do people just use a Prusik?" To which he said, "...ya." The ranger station was less help, providing the same, "people do it..." along with a disclaimer that the parks service didn't recommend it. I was taking my girlfriend up this route, and the cables, with the knowledge they would be down, scared the shit out of her. My only option was to find the absolute safest way down these things, or I would not be sending. I thought Prusik was my answer... When we arrived at the cables, due to the dome shape, I could only see about 30 feet of cable. So we set up Prusik's along with a PAS locked onto the cable, for some redundancy. We began the descent and quickly ran into a cable support described above, so we were forced to untie the prusik and retie it on the other side of the support. Then 20 feet later it happened again. And again.... I could see this was becoming a continuous theme, and finally decided this prusik system would literally take hours and could not continue. The giant eye-bolts were pretty frequent, and provided a perfect rap anchor. We had a single 60m, and only in one spot was it not long enough to rap to the next eye-bolt, to which we then employed the prusik system I originally devised and slid down to the next eye-bolt and continued our rap. If you had double ropes, you could very easily make it in 3-4 raps, with no prusik shenanigans. So, these are the scenarios I can see in order from quickest to slowest (and sketchiest to safest) for descending the cables when they are down for the season:
Very mellow. Did it last week and it was packed with people. Luck is the only way to beat crowds in the valley.


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HATFIELD, Pa.—As every American child knows, toys come from the North Pole or—more likely—China. But K'Nex Brands LP, a family-owned company in this Philadelphia suburb, is trying to prove they can still be made in America.
A K'Nex Robo Creature. K'NEX/Associated Press
Over the past few years, K'Nex has brought most of the production of its plastic building toys back to its factory in Hatfield from subcontractors in China. To make that possible, the company has redesigned some of the toys and even handed over to kids a bit of the assembly formerly performed by hand in China.
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"In the long term, it's much better for us to manufacture here," says Joel Glickman, chairman of K'Nex and its manufacturing affiliate, Rodon Group. The two companies have combined sales of more than $100 million, making them small players compared with American rivals Hasbro Inc. HAS -0.25% Hasbro Inc. U.S.: Nasdaq $51.48 -0.13 -0.25% Dec. 12, 2013 4:00 pm Volume (Delayed 15m) : 836,365 AFTER HOURS $51.48 0.00 0.00% Dec. 12, 2013 4:41 pm Volume (Delayed 15m): 101,714 P/E Ratio 23.40 Market Cap $6.70 Billion Dividend Yield 3.11% Rev. per Employee $741,688 10/21/13 Latest Toy Sales Show Girls Ju... 10/21/13 Hasbro Earnings: Overseas Sale... 10/21/13 The Good News for U.S. Toy Mak... More quote details and news » and Mattel Inc., MAT -0.26% Mattel Inc. U.S.: Nasdaq $45.31 -0.12 -0.26% Dec. 12, 2013 4:00 pm Volume (Delayed 15m) : 1.89M AFTER HOURS $45.29 -0.02 -0.04% Dec. 12, 2013 4:42 pm Volume (Delayed 15m): 9,419 P/E Ratio 18.72 Market Cap $15.38 Billion Dividend Yield 3.18% Rev. per Employee $236,699 11/07/13 Mattel Gives Barbie a Makeover... 11/07/13 Mattel Gives Barbie Doll a Mak... 10/21/13 Latest Toy Sales Show Girls Ju... More quote details and news » neither of which has announced plans to shift production to the U.S.
By moving production closer to U.S. retailers, K'Nex said it can react faster to the fickle shifts in toy demand and deliver hot-selling items to stores faster. It also has greater control over quality and materials, often a crucial safety issue for toys. And as wages and transport costs rise in China, the advantages of producing there for the U.S. market are waning.
But K'Nex has found it impossible so far to produce 100% U.S.-made toys, the firm's goal. The K'Nex experience shows both the attractions of "reshoring" production and the difficulties of making that happen in a country whose manufacturing infrastructure has atrophied.
Lining up suppliers has been a complicated chore in the U.S., where toy-making skills have faded. China, by contrast, has a vast, efficient network of suppliers and skilled labor. "In China, you can go over with just a drawing and say, 'I need a million of these,'" says Michael Araten, chief executive of K'nex. That helps account for a huge U.S. deficit in the toy trade. In 2012, U.S. imports of toys, games and sporting goods, mostly from China, totaled $33.5 billion, or about three times U.S. exports of such items.
A Baxter robot, performs simple packaging tasks. K'Nex hopes more-sophisticated robots will help it move more assembly back to the U.S. Scott Lewis for The Wall Street Journal
The roots of K'Nex go back to 1956, when Irving Glickman set up a small factory to make plastic items, such as protective caps for chair legs. In the early 1990s, his son, Joel, invented K'Nex toys to diversify the product line. By the late 1990s, K'Nex was following the fashion among U.S. companies of moving production to China. The affiliated Rodon company continued to make such items as plastic window parts and coffee filters, requiring little manual labor, at the Hatfield factory.
When the U.S. economy slumped in 2008, demand for products made by Rodon fell so sharply that the company couldn't keep all its workers busy. To avoid major layoffs, the Glickman family decided to begin moving production of the K'Nex toys back to Hatfield.
The Glickmans were confident that Rodon, whose slogan is "Cheaper Than China," could use its highly automated processes to mold plastic parts at a competitive cost. The challenge was that making K'Nex toys also involves manual labor, which is still much more costly in the U.S.
Toys had to be reimagined in some cases. K'Nex roller-coaster tracks were held together with metal pins, inserted by hand in China. The company redesigned the tracks so they could snap together. A tiny hubcap for K'Nex car wheels used to be attached by workers in a Chinese factory. Now it is included as a separate part in K'Nex kits, and children who get the toy have one more piece to snap into place.
Last year, K'Nex took over production and sales of Tinkertoys under license from Hasbro, which used to make them in China. Tinkertoys, a century-old product, were originally made of wood and later included both wood and plastic parts. To reduce costs and make U.S. production economical, K'nex last year switched to plastic for the remaining wooden spokes. K'nex adds that moms consider plastic easier to clean than wood.
Yellow roller-coaster track parts, right, were made in China; Rodon Group made the green ones in the U.S. Scott Lewis for The Wall Street Journal
K'nex also makes Lincoln Logs, likewise under license from Hasbro. It considered transforming them to plastic, but research showed the public wasn't ready for plastic log cabins. So K'nex continues to have the logs made in China, though Mr. Araten hopes to find a U.S. furniture company to produce the tiny logs in America.
K'Nex still imports small battery-powered motors for its toys from China because it hasn't found a competitive U.S. supplier. Also still imported from China is the head of an Angry Bird toy that requires a rubberized coating that would be expensive to replicate in the U.S.
To increase U.S. content, K'nex has had to make compromises. Joseph Smith, the chief development officer at K'nex, points to a little car with a shiny metallic finish that zips around on one of the company's roller coasters. The car's silvery finish is "a neat look," Mr. Smith says, but the process used to apply the coating is "expensive, it's dirty, and we can't do it here, so we design it out of the product." Instead of the shiny coating, K'nex may supply decals, to be applied by the cars' owners.
K'Nex is getting kudos for its made-in-U.S.A. efforts. President Obama paid a visit to the Hatfield plant in November. Total employment at K'Nex and Rodon has grown to about 200 people from 150 four years ago. Wages at the nonunion plant range from about $12 an hour for the least-skilled machine operators to more than twice that for some of the toy designers, machine menders and makers of molds for plastic parts.
K'Nex recently bought a $30,000 Baxter robot from Rethink Robotics Inc., Boston. For now, Baxter is performing simple packaging tasks. Eventually, Mr. Araten hopes that more sophisticated versions of the robot will help K'Nex move more assembly work back to the U.S.
Write to James R. Hagerty at firstname.lastname@example.com


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New owner of Dexter Crossing shopping center reveals redevelopment plans
Oxford Cos., the new owner of the Dexter Crossing shopping center on Dexter-Ann Arbor Road in Dexter, intends to redevelop the complex and construct an additional building on the site.
The Dexter Village Council on Monday approved an area plan for the property in a 6 to 1 vote, the Dexter Patch reports.
Photo from loopnet
Oxford purchased the complex in April via its investment arm. The Ann Arbor company has purchased several distressed properties this year, including downtown Ann Arbor's former Fifth Quarter building. Oxford then invests in site upgrades to its properties.
Plans for the Dexter Crossing shopping center call for the construction of a 15,500-square-foot single-story building with 30 additional parking spaces on the southeast corner of the complex, according to the Dexter Patch report.
The company also recently finalized deals with two new tenants for the existing center: Jet's Pizza and Jewelry Box Boutique.
The amended area plan that was approved Monday includes a possible drive-thru lane. Oxford Cos. President Jeff Hauptman said they are still considering the kinds of tenants they would want to open in the new building.
Read the full Dexter Patch report .
Lizzy Alfs is a business reporter for AnnArbor.com. Reach her at 734-623-2584 or email her at firstname.lastname@example.com. Follow her on Twitter at http://twitter.com/lizzyalfs.


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Thursday, December 05, 2013 - 32°F
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Grand Forks woman says locket with mother's remains stolen from car
Fayme Stringer Henry feels like she lost her mother all over again. Nearly a year to the day since Henry's mother died at 55 from cancer, she lost a tiny urn, in a sort of locket, stolen from her car outside her home in south Grand Forks late Tuesday or early Wednesday, Henry says.
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North Dakota Supreme Court considers medical abortion law
North Dakota's highest court heard arguments Wednesday on a state law that would limit the use of drugs in abortions, a law passed in 2011 and struck down by a Cass County judge this year as unconstitutional.
Devils Lake oil refinery far from certain
Devils Lake officials are emphasizing that any plans to build an oil refinery there are extremely preliminary. On Tuesday, WDAZ-TV reported that American Energy Holdings plans to build a $250 million refinery with a capacity of 20,000 barrels per day that would employ up to 100 people.
RELATED CONTENTGED changes bring sprint to finish, tougher tests coming
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RELATED CONTENTChanges to North Dakota's tougher DUI law already being suggested
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Wal-Mart to Donate 90 Million Lbs. of Fresh Food, Freezers Too.
Filed under: Big Givers
The company won't seek a tax deduction for the gift and intends to increase its annual giving to 3 billion pounds of food over the next few years.
Their donation this year is the equivalent of 70 million meals, at a time when food banks have reported a 20% increase in demand.
And Wal-Mart isn't just providing food. Because it's donated protein and produce, unlike the canned goods and bags of rice you expect at the local food bank, Wal-Mart has also donated $2.5 million to buy freezer trucks and help prepare for new food storage challenges.
It's a nice start to the season of giving.


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IAC CHENNAI Volunteer Meeting : 09th April 2012.
Agenda : May 1st event planning.
Human Chain Demanding action against 16 Corrupt ministers listed by Team Anna.
Decisions made:
1. Printing A5 color Pamphlets - 20000 nos.
2. Printing A3 and A4 Color Posters - 500 nos.
3. Placing 10 to 15 Banners around city 3 days before the event.
4. Sms package of 1 lakh numbers to be purchased for the Human Chain event.
5. Paper caps with event details will be made (5000 nos) and will be distributed outside chepauk stadium on 28th of April for the Chennai Super Kings match.
6. Press meet will be arranged 3 to 4 days before the event.
7. Paper advertisements will be given 2 days before the event. Volunteers are asked to approach various papers and magazines and TV to get the advertisement done at a cheaper or free of cost.
8. Volunteers are asked to approach the radio fms to give event messages 2 days prior to the event date.
9. Flash Mob is planned at various crowded places to spread the event message.
10. Volunteers are asked to approach various drama troops and ask them a slot during their dramas to spread the event message.
We will prepare a estimate for the above works and publish it. If anyone interested to contribute can take up a particular task and pay directly to them.
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- Minutes of meet :09th April 2012.
- This will be IAC chennai's new contact numbers from the next event.