International consensus on (ICON) pediatric asthma.

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.

A new symptom-based questionnaire for predicting the presence of asthma.

BACKGROUND: Early diagnosis and treatment of asthma is important for improving health and minimizing the social and economic burden of the disease. A simple questionnaire would provide a convenient and timesaving tool to help physicians diagnose asthma. OBJECTIVE: The senior author developed a simple, pre-interview screening questionnaire--the Asthma Screening Questionnaire (ASQ)--consisting of 6 questions. The present report provides performance evidence that the ASQ is a reliable instrument for diagnosing asthma in adults. METHODS: Participants were asthmatics or controls, aged 18 to 65 years. All participants completed the questionnaire (self-administered and physician-administered), and underwent spirometry and a methacholine challenge test (if there was no reversibility during initial spirometry). Sensitivity, specificity, and positive and negative predictive values were calculated for each question, and the total scores of asthmatics were compared with those of controls. The degree of agreement between the self-administered and the physician-administered questionnaire was calculated. RESULTS: The main symptoms discriminating asthmatics from controls were cough more than average (88% vs 0%), cough from chest (72% vs 0%), shortness of breath with exercise (84% vs 16%), and chest tightness when lying down (72% vs 4%). A cutoff point of total score > or = 4 was associated with the highest combination of sensitivity (96%) and specificity (100%). Substantial agreement was observed between the self-administered and the physician-administered questionnaire (kappa statistic, 0.56-1.00; P<.0001). CONCLUSIONS: The ASQ is a simple, inexpensive, and efficient pre-interview screening tool to diagnose asthma.

House dust mite, cat, and cockroach allergen concentrations in daycare centers in Tampa, Florida.

BACKGROUND: Allergen exposure in early childhood is a risk factor for sensitization and the development of asthma. Studies performed in Europe, New Zealand, and Singapore indicated the presence of indoor allergens in childcare centers and schools. However, the importance of indoor allergens in daycare centers in humid and warm regions of the world is not known. OBJECTIVE: To measure total mite counts, Der p 1, Der f 1, Fel d 1, and Per a 1 allergens in dust samples and mite allergen airborne concentrations in daycare centers in Tampa, Florida, United States. METHODS: Twenty daycare centers were surveyed for mite, cat, and cockroach allergens in Tampa, FL. One dust and two air samples (one during the day and one during the night) were collected in each center. Dust samples were extracted and analyzed for mite (Der p 1 and Der f 1), cat (Fel d 1), and cockroach (Per a 1) allergens. Mite airborne allergen concentrations were analyzed by RAST inhibition and expressed in standardized mite allergen units per m3 of air (AU/m3). RESULTS: Mites were identified in 15 samples, and concentrations ranged from 10 to 1,200 mites/g (298 +/- 355.2). The most prevalent mite species was Dermatophagoides pteronyssinus ( Der p 1). Der p 1 and/or Der f 1 were detected in 10 daycare centers. Der p 1 was detected in eight centers and ranged from I to 21.8 microg/g of dust (5.4 +/- 6.9); Der f 1 was detected in 3 centers and ranged from 0.2 to 2.1 microg/g of dust (1.3 +/- 0.9). Per a 1 and Fel d 1 were detected in all centers in small quantities; Per a 1 ranged from 8 to 1,806 ng/g (263.1 +/- 449.7) and Fel d 1 from 0.2 to 120 U/g of dust (16.6 +/- 31.7), respectively. Airborne mite allergen was detected in 18 centers and ranged from 0.01 to 2.7 AU/m3 during the day (0.2 +/- 0.6) and from 0.01 to 0.12 AU/m3 during the night (0.06 +/- 0.03), P = 0.001. CONCLUSIONS: Mite, cat, and cockroach allergens are present in daycare centers in Tampa, FL. Mite allergen concentrations exceeded levels that have been associated with sensitization and symptoms in allergic subjects in 40% of these centers.

Prevalence of upper respiratory symptoms in patients with symptomatic gastroesophageal reflux disease.

UNLABELLED: This study evaluated the prevalence of upper respiratory symptoms (URS) among patients with symptomatic gastroesophageal reflux disease (GERD). Seventy-four subjects with heartburn completed a URS questionnaire before dual-probe, 24-h esophageal pH monitoring. The URS questionnaire was also completed by 74 normal volunteers without previous or current symptoms of GERD. Esophageal pH monitoring results were classified as normal, distal, or proximal and distal gastroesophageal reflux using standardized criteria. Mean URS scores (+/- SD) were 8.31 +/- 3.98 in the 52 subjects with GERD and 4.57 +/- 3.57 in the 22 subjects with negative pH probe studies, p = 0.02. Subjects with negative pH probe studies and normal volunteers scored similarly on the URS questionnaire. Reflux episodes/24 h correlated with URS scores, r = 0.47, p = 0.0001. Seventy-five percent of subjects with upper reflux, 68% of subjects with lower reflux, 36% of subjects with normal esophageal pH studies, and 9% of normal volunteers reported laryngeal symptoms for at least 5 d/mo. Sixty-nine percent of subjects with upper reflux, 50% of subjects with lower reflux, 31% of subjects with normal pH studies, and 14% of normal volunteers reported nasal symptoms for at least 5 d/mo. URS are frequent among subjects with GERD. KEYWORDS: rhinitis; upper airway; gastroesophageal reflux

Recent findings in asthma likely to impact patient care.

The management of asthma is becoming increasingly complex as more pharmacologic agents become available and we gain increased understanding of the pathogenetic processes of asthma and the risks for potentially irreversible airway remodeling that might be increased by suboptimal management and interactions with concomitant disease states such as gastroesophageal reflux. Although physicians now have greater responsibility to make use of this increasing knowledge to provide more effective management for their asthma patients, they also have a greater opportunity to increase the overall quality of life of patients under their care.

Immunologic aspects of vasculitis and cardiovascular disease.

The immunologic cardiovascular diseases are a heterogeneous group of conditions. Many of these entities are associated with serious morbidity and mortality resulting from cardiac impairment, ischemic complications, or organ dysfunction, particularly of the kidneys, lung, and nervous system. The systemic nature of these conditions, coupled with vague symptoms and nonspecific initial physical findings, makes the differential diagnosis complicated. Research has identified specific mediators and primary origins in some conditions, with infections often being responsible. Immunosuppressive therapy, despite the potential complications, has improved the prognosis of some of the more serious immunologic cardiovascular diseases. Improvement in the treatment of immunologic cardiovascular diseases awaits identification of additional causes, improved definition of host factors that predispose an individual to develop these conditions, and better understanding of the immune dysregulation responsible for the progression of disease. The potential pathophysiologic role of immunologic mechanisms in common disorders such as congestive heart failure and atherosclerosis is intriguing and offers the possibility of novel therapies in these prevalent conditions.

Comparison of oral pulse methotrexate with placebo in the treatment of severe glucocorticosteroid-dependent asthma.

BACKGROUND: This study compared the efficacy of weekly oral administration of methotrexate and placebo in treatment of 24 subjects with chronic glucocorticosteroid-dependent asthma. METHODS: The 33-week randomized, double-blind, placebo-controlled crossover trial compared once weekly 15 mg doses of methotrexate with placebo. At the time of entry, the subjects' mean dosage of prednisone was 23.8 mg/day (range, 12.5 to 85 mg) and glucocorticosteroid therapy had been used continuously for a mean duration of 78 months (range, 5 to 360 months). RESULTS: Of the 21 subjects who completed the study, 13 tolerated lower daily prednisone doses during methotrexate treatment compared with placebo. When treated with methotrexate, subjects required 14.2% less prednisone than when treated with placebo (p = 0.0447), their subjective symptom scores improved 21.4% (p < 0.05), and mean forced expiratory volume in 1 second values tended to improve. Mean serum theophylline levels did not change significantly between the methotrexate and placebo arms of the study. Adverse effects were minimal, with nausea and headache occurring twice as often during methotrexate therapy compared with placebo. CONCLUSION: Short-term, low-dose, pulse therapy with orally administered methotrexate results in a decrease in the daily glucocorticosteroid requirement in a majority of subjects with severe asthma and is accompanied by improvement in subjective symptom scores without unacceptable side effects or deterioration of pulmonary function.

Alternative treatments for severe, chronic asthma.

The current focus of treatment for chronic asthma is anti-inflammatory pharmaceuticals and minimizing of environmental factors that contribute to airway inflammation. Despite the development of increasingly potent inhaled glucocorticoids, certain select asthmatic patients require chronic systemic glucocorticoids for management. Several nonglucocorticoid, anti-inflammatory agents have been shown or suggested to be beneficial in the treatment of chronic asthma. The major purpose of using these agents has been to maximize airway function and to minimize the use of systemic glucocorticoids, with their attendant side effects. Some of these alternative anti-inflammatory agents are reviewed in this paper, with emphasis on clinical experience in the treatment of asthma. Additional double-blind, placebo-controlled studies are necessary to define the role of these agents in the management of chronic asthma.

Immunologic aspects of cardiovascular disease.

The spectrum of vasculitis is diverse, and numerous entities do not fit the aforementioned broad categories. Examples of these include Buerger's disease; vaso-occlusive vasculitis of the lower extremities associated with cigarette smoking; Behçet's disease, which is prevalent in the Orient and Middle East and is characterized by recurrent aphthous stomatitis, genital ulcerations, uveitis, meningoencephalitis, and phlebitis; and isolated central nervous system vasculitis, a rare disease with a poor prognosis that primarily affects intracranial arteries without a systemic acute-phase response. Improvement in the classification and definitive therapy of vasculitis awaits identification of etiologic agents and definition of host factors and the immune response responsible for the pathology.

House dust mite allergy in Florida. Mite survey in households of mite-sensitive individuals in Tampa, Florida.

This study evaluated the prevalence of positive house dust mite skin tests in a population of atopic individuals and identified the mite species present in mattress and house dust samples in homes of the Tampa Bay area. Four hundred consecutive individuals were evaluated for respiratory complaints and skin tested with standardized extracts of Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df). Two hundred forty individuals (60%) had a positive skin test to the mite extracts. Dust samples were collected in 40 homes of mite-allergic individuals and analyzed by light microscopy. Mite species were found in 53 of the 60 dust samples (20 mattresses and 40 carpets). Mite numbers ranged from 110-6200 mites/g of mattress dust and from 120-5500 mites/g of carpet dust. Eleven different mite species were identified and Blomia tropicalis (Bt), not previously identified in the United States, was found in 30% of the samples. Dp and Df wee the predominant species. These observations suggest that house dust mite allergy is common in the Tampa Bay area and that the house dust mite fauna comprises several mite species besides Dp and Df. Prospective studies in progress are designed to confirm the role of different mite species in house dust mite allergy.

Serum IgE and human immunodeficiency virus (HIV) infection.

Human immunodeficiency virus infection is characterized by a progressive depletion of helper T-lymphocytes and, like allergic diseases, is associated with altered T cell regulation. Total serum IgE was measured in 67 infected male subjects, 27 uninfected heterosexual male subjects, and 18 uninfected homosexual male subjects. The mean IgE level (132 IU/ml) of infected subjects with a helper T-lymphocyte number less than or equal to 200/mm3 was significantly greater than mean IgE levels of the uninfected heterosexual (38 IU/ml) and homosexual (35 IU/ml) groups. IgE levels were inversely related to both helper T cell and suppressor/cytotoxic T cell numbers but not to IgG or IgA levels. The increase in IgE was not a reflection of an increased prevalence of atopic disease (allergic asthma, allergic rhinitis, or atopic dermatitis) in the infected subjects. The elevation of IgE may be related to a difference among the groups in T cell production of IgE regulatory lymphokines.