Spacer microbial contamination and asthma outcomes: case series.

OBJECTIVE: The primary method of drug delivery to treat asthma is through pressurized metered dose inhalers (pMDI). Asthma guidelines recommend that providers prescribe a spacer for all patients using pMDI. The objective of this study was to examine whether microbial contamination of spacer devices is associated with poor asthma outcomes. METHODS: This was a cross-sectional, single-center case series of seven pediatric patients with persistent asthma who had previously been prescribed a spacer. Spacers were swabbed with sterile cotton and samples assessed for bacterial/fungal growth. Parents completed a questionnaire including Asthma Control Test (ACT) and asthma control was assessed by an Allergist/Immunologist physician. RESULTS: Two (n = 2) children's parent-completed ACT score indicated poorly controlled asthma and three (n = 3) patients were noted to be poorly controlled by the physician. All but one caregiver reported cleaning the spacer with most reporting (n = 5) that they cleaned their child's spacer monthly and one (n = 1) reporting cleaning it every two weeks. One spacer had detected Candida albicans. There was not a statistically significant association between ACT score and microbial growth (p > 0.05). CONCLUSION: Most spacers in a pediatric sample were not contaminated, despite lack of consistent cleaning, as recommended by spacer manufacturers. Providers and pharmacists should discuss proper cleaning of spacers with caregivers of pediatric patients.

Eosinophilic esophagitis: comorbidities and atopic disease in Nevada.

Eosinophilic esophagitis (EoE) is a rare, immune-mediated illness. We aimed to examine the comorbidities and sensitization patterns associated with an EoE diagnosis in Nevada. The study goal was two-fold: to determine the most common EoE comorbidities and sequela in the state of Nevada using healthcare utilization records across all settings and to determine the most common food and aeroallergens in histologically positive EoE pediatric patients using clinical sensitization data. Esophageal obstruction/stricture was the most frequently reported diagnosis in adults with EoE (29.5%). Among pediatrics, the highest ranking comorbidities included asthma (13.4%); diseases of the stomach, duodenum, and intestine (7.26%); allergies (7.01%); and gastroesophageal reflux disease (GERD) (3.69%). Additionally, the top sensitizations reported in histologically positive EoE patients were largely pollen related (82.9%). Atopic disease and specifically food allergens are commonly reported as comorbid conditions with EoE in the literature. However, our clinical pediatric data set from this study revealed that aeroallergen sensitizations far exceeded that of food allergens (82.9% aero-positive vs. 17.1% dood positive). The high presence of esophageal stricture/obstruction in adults could be indicative of late diagnosis; in addition, the aeroallergen sensitization in children could suggest different clinical management techniques necessary may be needed for this disease. Education among healthcare providers regarding the presence of aeroallergen sensitization in this population may result in earlier diagnoses and help reduce morbidity and the cost from this disease.

Developing pictorial asthma action plans to promote self-management and health in rural youth with asthma: A qualitative study.

OBJECTIVE: Asthma action plans (AAPs) provide asthma management instructions to families; however, AAPs typically are written at a 7th-9th grade reading level, making them less useful in lower literacy families. There is a need to develop simpler AAP formats and content to optimize their utility across all families, including those who are rural and may be at a risk for literacy concerns. Because using pictures can simplify and enhance health education, our study's aim was to develop a pictorial AAP through a series of focus groups with key stakeholders - youth with asthma, caregivers, and physicians. METHODS: Fourteen caregiver/youth dyads and four physicians participated in separate focus groups where their preferences for pictorial AAP structure and content were obtained. Focus groups were audio recorded, transcribed, coded with ATLAS.ti, and analyzed for themes. RESULTS: Youth and their caregivers prefer that the AAPs include simple, cartoon-like pictures customized to the patient. Physicians emphasized AAP's capability to display pictures of controller medication given its importance in preventing asthma exacerbations. A stoplight format, currently used in most written AAPs, received positive reviews. Specific suggestions for pictures showing symptoms, medications, and how to take medication were suggested. Words and short phrases accompanying the pictures were thought to add clarity. CONCLUSIONS: Key stakeholders viewed pictorial AAPs as positive and potentially effective alternatives to standard written AAPs. It is expected that low literacy youth and caregivers would more easily understand a pictorial AAP presentation, which should facilitate better medication adherence and asthma outcomes in these children.

Asthma, allergy, and obesity: Examining the relationship among Nevada children.

OBJECTIVE: The majority of pediatric asthma is atopic, but whether pediatric obese asthma is atopic is indeterminate in the literature. In Nevada, children become sensitized to aeroallergens, a risk factor for asthma, at young ages. Additionally, Nevada children have high rates of obesity. Our objective is to determine whether elevated body mass index (BMI) is associated with asthma severity, allergen sensitization, and polysensitization. METHODS: Medical records from a pediatric allergy clinic provided BMI percentile, physician-diagnosed asthma severity, skin prick test data, and sociodemographics such as age, race, sex, and insurance status from asthmatic patients. Descriptive statistics and binary and multinomial logistic regression were conducted. RESULTS: In this population (N = 125) aged 1-16, 61% were male, 65% were white, and 74% had private health insurance. Sixty-five percent of children were under/healthy weight and 29% were overweight/obese. Asthma symptoms were moderate in 66% of the population, and severe in 18%. Nearly 85% of this population was atopic, and 82% were polysensitized. Sensitization and polysensitization occurred in all weight categories. Asthma severity and elevated BMI were not associated significantly. Overweight/obese children (≥85th percentile) had lower odds of allergen sensitization (adjusted odds ratio 0.26, 95% CI = 0.85-0.78, p = 0.016) and polysensitization (adjusted odds ratio 0.30, 95% CI = 0.11-0.85, p = 0.023) than healthy weight children (<85th percentile). CONCLUSION: Although overweight children did show allergen sensitization, those who were overweight had lower odds of allergen sensitization and lower odds of polysensitization, as compared to normal weight asthmatic children. Elevated BMI was not a significant predictor of asthma severity.

Parental perception of efficacy of antihistamines for pruritus in pediatric atopic dermatitis.

BACKGROUND: Clinicians have previously prescribed antihistamines for relief of atopic dermatitis (AD) associated pruritus. The use of antihistamines in AD has recently received less emphasis from newly published practice parameters that currently only recommend short-term, intermittent use of first-generation antihistamines to induce sleep in patients with AD. OBJECTIVE: Our study aimed to determine parents' perception of the usefulness of antihistamines in reducing their child's itch due to AD. METHODS: A 12-question survey was mailed to parents of patients who were attending a pediatric allergy clinic. Patients with physician-diagnosed AD who had a clinic visit in the past 3 years were included. Questions included the following: time since AD diagnosis, itching frequency, impact on sleep, frequency and relief provided from using antihistamines, and comparison of antihistamines to other antipruritus treatments. RESULTS: Sixty-three percent of parents surveyed responded that antihistamines were helpful in the management of their child's AD, and only 5% did not find any itch relief. The majority of the responders were parents of younger patients (ages, 2-10 years) with immunoglobulin E sensitization and AD for more than a year. Eighty-five parents (68.5%) reported no interruption of sleep due to itching, and, among them, an almost equal number were currently solely using either a first- or second-generation antihistamine. The more antihistamines were perceived as relieving itching, the more they were used (ρ = 0.209, p = 0.025) and provided more relief than other products (ρ = -0.336, p < 0.001). When compared, parents ranked antihistamines to be as helpful as topical corticosteroids. CONCLUSION: Parents of pediatric patients with AD found that antihistamines were an important part of AD management.

Efficacy of a parent-youth teamwork intervention to promote adherence in pediatric asthma.

OBJECTIVE: To determine whether a parent-youth teamwork intervention improved medication adherence and related outcomes among youth with asthma. METHODS: We used a randomized clinical trial with 48 youth (aged 9-15 years) assigned to 1 of 3 groups: Teamwork Intervention (TI), Asthma Education (AE), or Standard Care (SC). Treatment occurred across 2 months, with a 3-month follow-up assessment. Adherence to inhaled corticosteroids was assessed via the MDILog-II. Parent-adolescent conflict, asthma functional severity, and spirometry assessments were obtained pre-treatment, post-treatment, and on follow-up. Mixed linear model analysis was used to evaluate group and time effects for outcome measures. RESULTS: TI group had significantly higher adherence and lower functional severity scores than AE or SC conditions, and lower parent-reported conflict and a trend for higher spirometry values compared with the SC group. CONCLUSIONS: Results suggest support for the efficacy of TI for improving medication adherence as youth acquire more responsibility for their asthma management.

Examination of cord blood at birth in women with SARS-CoV-2 exposure and/or vaccination during pregnancy and relationship to fetal complete blood count, cortisol, ferritin, vitamin D, and CRP.

Background: SARS-CoV-2 is known to manifest a robust innate immune response. However, little is known about inflammatory influences from maternal SARS-CoV-2 infection or maternal mRNA vaccination upon the fetus. In addition, it is unknown if Vitamin D deficiency influences fetal homeostasis or if an anti-inflammatory mechanism to the development of possible innate cytokines or acute phase reactants by the maternal/fetal dyad, in the form of cortisol elevations, occur. In addition, effects on Complete Blood Count (CBC) are not known. Objective: To evaluate the neonatal acute phase reactants and anti-inflammatory responses after maternal SARS-CoV-2 disease or mRNA vaccination. Methods: Samples and medical records reviews from mother/baby dyads (n = 97) were collected consecutively, and were categorized into 4 groups; no SARS-CoV-2 or vaccination exposure (Control), Vaccinated mothers, maternal SARS-CoV-2 disease positive/IgG titer positive fetal blood, and maternal SARS-CoV-2 positive/IgG titer negative fetal blood. SARS-CoV-2 IgG/IgM/IgA titers, CBC, CRP, ferritin, cortisol, and Vitamin D were obtained to examine the possible development of an innate immune response and possible anti-inflammatory response. Student's t-test, Wilcoxon rank-sum, and Chi-squared with Bonferroni corrections were used to compare groups. Multiple imputations were performed for missing data. Results: Cortisol was higher in babies of both mothers who were vaccinated (p = 0.001) and SARS-CoV-2 positive/IgG positive (p = 0.009) as compared to the control group suggesting an attempt to maintain homeostasis in these groups. Measurements of ferritin, CRP, and vitamin D did not reach statistical significance. CBC showed no variation, except for the mean platelet volume (MPV), which was elevated in babies whose mothers were vaccinated (p = 0.003) and SARS-CoV-2 positive/IgG positive (p = 0.007) as compared to the control group. Conclusion: Acute phase reactant elevations were not noted in our neonates. Vitamin D levels were unchanged from homeostatic levels. Cord blood at birth, showed Cortisol and MPV higher in vaccinated and SARS-CoV-2 IgG positive mother/baby dyads as compared to the Control group, indicating that possible anti-inflammatory response was generated. The implication of possible inflammatory events and subsequent cortisol and/or MPV elevation effects upon the fetus after SARS-CoV-2 disease or vaccination is unknown and merits further investigation.

Electronic monitoring and feedback to improve adherence in pediatric asthma.

OBJECTIVE: To evaluate the effectiveness of electronic monitoring and feedback to improve adherence in children taking daily asthma controller medications. METHOD: Five patients with asthma and considered nonadherent participated. Inhalers were electronically monitored with the MDILogII(TM) device, and feedback was given by medical staff. Using a nonconcurrent multiple-baseline design, patients and their parents received bimonthly feedback regarding medication use. Following treatment, feedback was withdrawn and effects of monitoring alone were observed. RESULTS: Three participants showed improvements in adherence following treatment, with more notable increases when baseline adherence was low. Improvements in the inhaler technique occurred for all patients. Some patients demonstrated improvements in lung functioning and functional severity. When feedback was withdrawn, adherence decreased for some participants, but technique improvements maintained. CONCLUSIONS: Results support the use of objective monitoring devices for assessing pediatric asthma patients' adherence and indicate that feedback from medical staff may improve and maintain medication adherence for some patients.

A description of eosinophilic esophagitis in the Southwestern state of Nevada.

OBJECTIVES: Eosinophilic esophagitis (EoE) is a rare immune-mediated esophageal disorder that has been documented worldwide. Prior to this study, eosinophilic esophagitis had not been described in the Southwestern state of Nevada. Records containing positive eosinophilic esophagitis diagnosis codes were extracted from a large hospital utilization database and yielded over 2,000 records over 5 years (2013-2017). METHODS: Descriptive statistics were used to identify the overall population demography. Logistic regression was used to determine the factors associated with an eosinophilic esophagitis event in Nevada. RESULTS: Males were 2.93 times more likely (95% CI: 2.53, 3.41; p < 0.001) to have had an eosinophilic esophagitis event when compared to females. Older age was also significant; for each additional year in age the odds of having an eosinophilic esophagitis visit increased by 30% (95% CI: 1.28, 1.31; p < 0.001). Finally, individuals living in the Northern region had 1.95 higher odds of an eosinophilic esophagitis event than their Southern counterparts (OR = 1.95, 95% CI: 1.68, 2.26; p < 0.001). CONCLUSIONS: The climate in Nevada makes this study novel, as the climate is unlike other studies reporting EoE disease prevalence. Previous atopic studies in Nevada report that warmer, drier weather leads to increased atopic illness and perennial pollen, which ultimately may be contributing to the higher than expected number of EoE records identified. Given the well-documented relationship between EoE and atopy, Nevada may be a susceptible region for this condition and an ideal location for future studies.

Factors and cost associated with atopic dermatitis in Nevada.

Objectives: Atopic dermatitis, or eczema, is an inflammatory illness that impacts individuals of all ages. The cost of treating AD and the impact on the quality of life have not been well documented in the state of Nevada. This study seeks to fill this gap by identifying factors that impact the cost of AD in the state utilizing clinical and patient demographics. Methods: ANOVA with Bonferroni adjustment was performed using a large hospital utilization database to examine the cost of AD in the state of Nevada across all hospital settings. Results: Several significant factors were associated with the overall cost of AD in Nevada, including hospital setting type (outpatient vs. inpatient), physician type, region, AD diagnosis level, and age (p < 0.05). Stratified analysis was performed by setting type. In the inpatient setting, region, diagnosis level, and records with age listed between 0 and 5 years remained significant (p < 0.05). In the outpatient setting, physician type, region, and African American race remained significant (p < 0.05). Conclusions: Data from this study indicate that the AD cost burden is dependent on both demographic and clinical factors in the state of Nevada. These differences suggest that patients with AD may encounter higher costs depending on age, race, and clinical factors.

Cost of chronic inflammatory disease: The impact of eosinophilic esophagitis in Nevada.

OBJECTIVES: The cost of treating the rare eosinophilic esophagitis (EoE) disease and its impact on patients' quality of life have not been well documented in the literature. This study seeks to fill this gap by comparing the cost of EoE with other well-known inflammatory diseases, including Crohn's disease (CD) and celiac disease (CeD). METHODS: A Mann-Whitney U test and multiple logistic regression were used to examine the cost of EoE in the state of Nevada across all hospital settings and its impact on quality of life compared with CD and CeD. RESULTS: Several factors were associated with the overall cost of EoE in Nevada, including patients' age, sex and region (P < 0.001). EoE was significantly more expensive to treat in the pediatric group ($4001 EoE; $985 CD; $856 CeD), among men ($2532 EoE; $1500 CD; $1724 CeD), among those residing in the southern region of Nevada ($4501 EoE; $2538 CD; $1888 CeD), and among patients seeking medical care from outpatient clinics ($3298 EoE; $741 CD; $1686 CeD) (P < 0.001). Age, sex, region and hospital setting were all associated with having a positive EoE record compared with CeD or CD (P < 0.001). CONCLUSIONS: Data from this study indicate that the EoE burden is significantly higher in cost for certain demographics and regions compared with CD and CeD in the state of Nevada, specifically among pediatric and male patients. These differences suggest that clinicians may encounter similar issues when treating EoE.

Effect of evaporative coolers on skin test reactivity to dust mites and molds in a desert environment.

Dust mites and molds are usually not found in arid environments and have a lower prevalence in desert areas. Evaporative (swamp) coolers increase indoor humidity significantly. The purpose of this study is to determine whether evaporative coolers affect the skin test rate to dust mites and molds in patients. Patients with asthma or allergic rhinitis who were undergoing skin testing for molds, indoor allergens, grasses, weeds, and trees were asked about presence of central, window, and evaporative cooler air conditioning in their home. All were tested using the prick technique with controls. One hundred ninety patients between 1 and 42 years (mean, 5.4 years) were evaluated. Fifty-nine (31%) had an evaporative cooler in their home. Twenty-five (42%) of those with evaporative coolers had a positive skin test to at least one mold compared with 26 (19%) without coolers (chi-square, 10.5; p = 0.001). Twenty (34%) of those with evaporative coolers had a positive skin test to dust mites compared with 23 (17.5%) without coolers (chi-square, 6.2; p = 0.013). Children < or = 6 years of age had the greatest skin test prevalence (chi-square, 4.3; p = 0.03). In the desert, children in homes using evaporative coolers are significantly more likely to have positive skin tests to molds or mites. This appears to be because of humidity caused by these devices. Patients with asthma in homes with evaporative coolers should be counseled about the risk for mold and dust-mite allergy. Humidity monitoring, cooler maintenance, and filter changes should be discussed.

Otitis media as a presenting complaint in childhood immunodeficiency diseases.

Otitis media is one of the most common childhood infections and may result from a variety of underlying problems. Suspicion of immunodeficiency should increase when ear infections are frequent; suppurative; unresponsive to antibiotics; caused by unusual organisms; or seen in the context of other frequent infections, severe eczema, or failure to thrive. Humoral immune deficiencies, particularly with an inability to make antibody to encapsulated organisms, are the immunodeficiencies most likely to cause increased otitis media. Immune system evaluation should concentrate on humoral immunodeficiency disorders, but the presenting history and physical findings also should be considered when designing the work-up. Treating the underlying immune deficiency is usually necessary to adequately control the ear infections.

Clinical and molecular analysis of patients with defects in micro heavy chain gene.

Autosomal recessive disorders of B cell development are rare and heterogeneous. To determine the proportion of affected patients who have defects in the micro heavy chain (IGHM) gene, we used single-stranded conformational polymorphism analysis to screen genomic DNA from 40 unrelated patients with early onset infections, profound hypogammaglobulinemia, and absent B cells. All of the patients were genotypically normal in BTK, the gene that underlies X-linked agammaglobulinemia. Eight different mutations in the micro heavy chain were identified in 19 members of 12 unrelated families. Four of the mutations were large deletions that removed more than 40 kb of DNA in the IGHM locus. In six of the 12 families, the affected patients had an identical single base pair substitution, a G-->A, at the -1 position of the alternative splice site. Immunoglobulin haplotype analysis showed that this mutation occurred on at least three different haplotypes, indicating that this is a hot spot for mutations. Compared with patients with mutations in Btk, patients with defects in the micro heavy chain had an earlier onset of disease and more complications. Our study indicates that at least 20-30% of patients with autosomal recessive defects in B cell development have mutations in the micro heavy chain.

Bullous Skin Manifestations of Mycoplasma pneumoniae Infection: A Case Series.

Bullous skin lesions are uncommon in children. While it is well known that Mycoplasma infections are associated with papular skin manifestations, bullous skin lesions are not commonly reported. Mycoplasma pneumoniae is a very common bacterial pathogen causing respiratory tract infection in children and adults. We report 2 children with serology-confirmed Mycoplasma infection who were hospitalized for blistering skin lesions. Both of our patients responded well to corticosteroids and one of them required intravenous immunoglobulin. The aim of this case report is to raise awareness that Mycoplasma pneumoniae infection can present with bullous skin lesions, and to briefly review the pathophysiology, diagnosis, and management of the skin manifestation of Mycoplasma infection.

Microbial rRNA sequencing analysis of evaporative cooler indoor environments located in the Great Basin Desert region of the United States.

Recent studies conducted in the Great Basin Desert region of the United States have shown that skin test reactivity to fungal and dust mite allergens are increased in children with asthma or allergy living in homes with evaporative coolers (EC). The objective of this study was to determine if the increased humidity previously reported in EC homes leads to varying microbial populations compared to homes with air conditioners (AC). Children with physician-diagnosed allergic rhinitis living in EC or AC environments were recruited into the study. Air samples were collected from the child's bedroom for genomic DNA extraction and metagenomic analysis of bacteria and fungi using the Illumina MiSeq sequencing platform. The analysis of bacterial populations revealed no major differences between EC and AC sampling environments. The fungal populations observed in EC homes differed from AC homes. The most prevalent species discovered in AC environments belonged to the genera Cryptococcus (20%) and Aspergillus (20%). In contrast, the most common fungi identified in EC homes belonged to the order Pleosporales and included Alternaria alternata (32%) and Phoma spp. (22%). The variations in fungal populations provide preliminary evidence of the microbial burden children may be exposed to within EC environments in this region.