Risk Factors for Exacerbations in School-Age Children with Asthma.

INTRODUCTION: Awareness of risk factors for asthma exacerbation can reduce the morbidity and mortality of the disease. The current study aimed to investigate the risk factors associated with current asthma exacerbations in school-age children. METHODS: This study enrolled children who were admitted to a tertiary outpatient paediatric allergy and asthma department and were diagnosed with asthma. Patients and their caregivers underwent an interviewer-administered questionnaire, which obtained information regarding the demographic features and parameters to determine environmental exposures along with previous disease history. Laboratory examinations, including complete blood count with differential, total IgE levels, skin prick tests, and pulmonary function tests, were also performed. RESULTS: A total of 431 children (288 male, 66.8%) with a median age (interquartile range) of 8.1 (6.3-11.2) years were included, among whom 265 (61.5%) had aeroallergen sensitization. Asthma was controlled, partially controlled, and uncontrolled in 154 (35.7%), 53 (12.3%), and 143 (33.2%) patients, respectively. A total of 81 patients (18.8%) experienced asthma exacerbation. Multivariate logistic regression analysis revealed that a history of asthma exacerbation within the last year (odds ratio [confidence interval]) (20.73 [9.95-43.20]; p < 0.001), a shorter asthma duration (<2.5 years) (2.58 [1.44-4.61]; p = 0.001), and a lack of regular controller therapy (4.12 [1.54-10.98]; p = 0.005) were associated with current asthma exacerbation. DISCUSSION/CONCLUSION: Awareness of risk factors for asthma exacerbation may help physicians treat school-age children with asthma by providing prompt and rational interventions in order to prevent asthma exacerbations.

Predictors of Airway Hyperresponsiveness in Symptomatic Children with Normal Spirometry and Suspicious of Possible Asthma.

BACKGROUND: Asthma diagnosis may be challenging particularly in patients with mild symptoms without an obstructive pattern in spirometry. Detection of airway hyperresponsiveness (AHR) by a positive methacholine challenge (MCC) is still an important diagnostic tool to confirm the presence of asthma with reasonable certainty. However, it is time consuming and could be exhausting for patients. We aimed to identify the predictive factors for AHR in children with respiratory symptoms without obstructive pattern in spirometry. METHODS: Data from children who had undergone MCC were analyzed retrospectively. The demographic features of patients along with laboratory results were collected. RESULTS: A total of 123 children with a median age of 10.5 years were enrolled. AHR was detected in 81 children (65.8%). The age of the children with AHR was significantly younger. The prevalences of aeroallergen sensitization, nocturnal cough, wheezing, and a baseline forced expiratory flow at 75% of vital capacity (FEF75) <65% were significantly more frequent in children with AHR. Multivariate logistic regression analysis revealed age, ever wheezing, nocturnal cough, tree pollen allergy, and FEF75 <65% as independent predictors of AHR. A weighted clinical risk score was developed (range, 0-75 points). At a cutoff point of 35, the presence of AHR is predicted with a specificity of 90.5% and a positive predictive value of 91.5%. CONCLUSION: In children suspected of having asthma, but without an obstructive pattern in the spirometry, combining independent predictors, which can be easily obtained in clinical practice, might be used to identify children with AHR.

Complications following metal bar removal after Nuss repair are rare in a duocentric retrospective evaluation.

PURPOSE: Minimally invasive pectus excavatum repair has gained widespread acceptance and its results and complications are well-described. However, there is a substantial debate on the risks and frequencies of complications following metal bar removal. We, therefore, aimed to analyse all complications that occurred during and after metal bar removal at our two paediatric surgical centres. METHODS: Bar removal surgeries were identified via procedural codes and electronic records were reviewed using a pre-specified data extraction chart. Both intra- and postoperative complications were included and the latter scored according to Clavien-Dindo. We analysed the influence of the pre-specified potential predictors age, sex, and the number of implanted metal bars on the occurrence of complications using logistic regression. RESULTS: We included 279 patients with a median age of 19 years (interquartile range 17-20 years). 15 patients experienced 17 complications. Of 11 postoperative complications, only an enlarging pleural effusion required a chest drain in local anaesthesia, resulting in a Claven-Dindo grade IIIa, whereas the remainder were classified as grade I. Neither age (adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.84-1.13, P = 0.73), nor sex (aOR 0.88, 95% CI 0.19-4.07, P = 0.87) or the number of bars (aOR 0.64, 95% CI 0.15-2.71, P = 0.547) did influence the occurrence of complications. CONCLUSION: Complications following metal bar removal were scarce in our duocentric retrospective series and usually of minor relevance. However, to address the perceived paucity of data on the frequency and severity of complications following metal bar removal, further studies, including large database research is necessary.

Perinatal risk factors for asthma in children with allergic rhinitis and grass pollen sensitization.

BACKGROUND: Results of epidemiologic studies have determined several risk factors for asthma in school-age children. OBJECTIVE: To examine whether parental and perinatal risk factors, along with infantile feeding patterns, were associated with asthma in children with grass pollen allergy and allergic rhinitis. METHODS: We retrospectively analyzed the data of our cohort, which consisted of children with allergic rhinitis. Only children with grass pollen sensitization were enrolled. A detailed questionnaire regarding demographic features and perinatal events was given to the parents. RESULTS: A total of 293 children (200 boys [68.3%]; with median age, 10.2 years [interquartile range {IQR}, 7.4-13.0 years]) were included. A total of 109 children (37.2%) had accompanying asthma. The median age of onset of rhinitis symptoms was earlier (5.3 years [IQR, 4.0-8.0 years] versus 7.0 years [IQR, 5.0-10.0 years]; p = 0.001), histories of prematurity (16.7 versus 6.5%; p = 0.006), preeclampsia (5.5 versus 0%; p = 0.001), neonatal intensive care unit admission (15.1 versus 6.0%; p = 0.01), phototherapy (17.9 versus 7.1%; p = 0.004), early formula feeding (58.7 versus 41.2%; p = 0.006), and parental asthma (25.0 versus 11.4%; p = 0.002) were more frequent in children with asthma. Multivariate logistic regression analysis revealed prematurity (odds ratio [OR] 2.78 [95% confidence interval [CI],1.24-6.24]; p = 0.013), history of formula feeding (OR 1.81 [95% CI, 1.09-3.01]; p = 0.022), and parental asthma (OR 2.37 [95% CI, 1.22-4.63]; p = 0.011) were associated with asthma in school-age children with grass pollen-induced allergic rhinitis. CONCLUSION: Close monitoring of patients with these risk factors may help with an earlier diagnosis of asthma and prompt initiation of therapeutic interventions in children with allergic rhinitis and who were sensitized to grass pollen.

Serum basal tryptase levels in healthy children: correlation between age and gender.

Tryptase is used as a marker in many clinical conditions such as mast cell activation and systemic anaphylaxis. Normal levels of the serum basal tryptase (sBT) are determined in adulthood; however, data about nonallergic healthy children is limited. This study was designed to determine the normal sBT levels in healthy children. Total sBT levels were measured in 113 sera from healthy nonallergic children, for routine follow-up or diagnosis of illnesses that are not known to induce changes in serum tryptase levels. One hundred thirteen children aged 0.16-9.91 years (male/female subjects, 68/45 [60%/40%]) with a median (interquartile) age of 3.36 years (1.94-5.68 years) were evaluated. The sBT level was determined to be 3.30 ng/mL (2.38-4.36) median (interquartile) for the whole group. There was a tendency of higher sBT levels for boys than girls (3.49 [2.56-4.64 ng/mL] and 2.91 ng/mL [2.16-4.16 ng/mL], respectively); however, these findings were not significant (p = 0.12). The analysis of the whole group revealed that sBT levels were inversely related with age (r = -0.259; p = 0.006); and the decrease of sBT with age was more prominent in girls (r = -0.282; p = 0.02) than in boys. The highest sBT levels were found in the 0- to 1-year age group (all, 4.67 ng/mL [4.04-6.39 ng/mL]; boys, 5.34 ng/mL [4.04-6.39 ng/mL]; girls, 4.48 ng/mL [3.23-16.26 ng/mL]). The sBT levels in healthy children are similar to those in adults except in infancy. Interestingly, sBT levels tend to decrease slightly with age. Although they did not reach significance, sBT levels were found to be higher in boys compared with the girls.

Clinical features of children with venom allergy and risk factors for severe systemic reactions.

BACKGROUND: Severe systemic reactions (SRs) to insect venom are rare in childhood and there are few data on this study population. The aim of our study is to analyze the clinical features and to document the risk factors for severe SRs in children with insect venom allergy. METHODS: Children with SRs after Hymenoptera sting were analyzed. The diagnosis was based on medical history, skin tests and/or specific IgE testing. RESULTS: Seventy-six children were included [57 boys (75%), mean age 9.8 ± 3.4 years]. The mean age of children at the time of SR was 8.3 ± 3.4 years. Reactions were accounted for Vespula (wasp) venom in 58 (76%) and Apis mellifera (bee) venom in 18 (24%) patients. Twenty-six percent of patients had aeroallergen sensitization and 33% had atopic disease, whereas 66% had experienced previous stings. The upper limb was the most frequent area of sting (43%), and the cutaneous system (99%) was the most frequent involved system. SRs occurred in 59% of patients. Multivariate logistic regression analysis revealed eosinophilia (>5%) [odds ratio (OR) 12.6; confidence interval (CI) 1.5-109.7; p = 0.022], female sex (OR 6.4; CI 1.5-26.9; p = 0.011) and accompanying atopic disease (OR 3.4; CI 1.2-12.3; p = 0.016) as significant risk factors for severe SRs. Ninety-seven percent of patients were admitted to the emergency department; however, epinephrine was used in only 46% of patients. CONCLUSIONS: There was a high frequency of hypersensitivity to wasp venom among the study population, and severe reactions were related to mild eosinophilia, female sex and concomitant atopic diseases. A better understanding of the risk factors may lead to effective utilization of health care sources in the future.

Factors that predict the clinical reactivity and tolerance in children with cow's milk allergy.

BACKGROUND: Specific IgE (sIgE) may be used for the diagnosis of cow's milk allergy (CMA) and as a guide to perform food challenge tests in patients with CMA. The effect of genetic variants on the prognosis of food allergy is largely unknown. OBJECTIVE: To examine the performance of sIgE analysis and the utility of the genetic variants of CD14, STAT6, IL13, IL10, SPINK5, and TSLP in predicting the clinical course in children with CMA. METHODS: Serum sIgE levels of 94 children who underwent open food challenges and 54 children with anaphylaxis due to cow's milk (CM) were retrospectively analyzed between January 2002 and May 2009. The genetic polymorphisms were determined in 72 children. RESULTS: A total of 148 children were followed up for a median of 3.5 years, and 42 of the 94 challenge results were positive. The probability curves with 95% decision points were 2.8 kU/L for younger than 1 year, 11.1 for younger than 2 years, 11.7 for younger than 4 years, and 13.7 for younger than 6 years. Sixty-six children outgrew CMA during follow-up. Children with initial an CM sIgE level less than 6 kU/L outgrew CMA earlier than children with an initial CM sIgE level of 6 kU/L or higher (P < .001). The age of tolerance development for CM was significantly higher in children with the GG genotype at rs324015 of the STAT6 gene compared with those with the AA+AG genotype (2 years [range, 1.5-3.9 years] vs 1.2 years [range, 1.0-2.2 years]) (P = .02). CONCLUSION: The decision points of sIgE obtained in different age groups may help to determine the likelihood of clinical reactivity more precisely. The results suggest that sIgE levels and STAT6 gene variants may be important determinants to predict longer persistence of CMA.

Validation of the Turkish version of "Test for Respiratory and Asthma Control in Kids (TRACK)" questionnaire.

BACKGROUND: Test for Respiratory and Asthma Control in Kids (TRACK) questionnaire is the first to measure both the risk and impairment domains of the current guidelines in preschool children. We aimed to measure the reliability, validity and responsiveness of the Turkish version of the TRACK. METHODS: A total of 268 children (69.8% boys) were included in the study. Caregivers responded to three individual TRACK questionnaires, at each clinical visit (baseline, 1st month, and 3rd month). At each visit, physicians determined the control level and the treatment strategy based on the GINA guideline recommendations. RESULTS: The internal consistency reliability of the Turkish version of the TRACK questionnaire was found to be 0.74, 0.74, and 0.76 at each of the three visits, respectively (reliability statistics, Cronbach's alpha). There was a significant difference between the mean TRACK scores of the patients in different asthma control status categories (p < 0.001). The test-retest reliability in stable patients was 0.90. The optimal cut-off scores according to the Youden index were 80 and 60 points for uncontrolled and very poorly controlled children, respectively. CONCLUSION: The Turkish version of the TRACK is an accurate and reliable tool for evaluating asthma control status among preschool Turkish children. Its widespread use may help physicians correctly assess control levels among children and may improve the quality of life for both patients and their caregivers.

Anaphylactic reaction to polyethylene-glycol conjugated-asparaginase: premedication and desensitization may not be sufficient.

In hypersensitive reactions to native L-asparaginase, either premedication and desensitization or substitution with polyethylene glycol conjugated asparaginase (PEG-ASP) is preferred. Anaphylaxis with PEG-ASP is rare. An 8-year-old girl and a 2.5-year-old boy, both diagnosed as having acute lymphoblastic leukemia, presented with native L-asparaginase hypersensitivity and substitution with PEG-ASP was preferred. They received a premedication (methylprednisolone, hydroxyzine and ranitidine) followed by desensitization with PEG-ASP infusion. Both patients developed anaphylaxis with peg-asparaginase. These are the first reported cases of anaphylactic reaction to PEG-ASP, despite the application of both premedication and desensitization. Anaphylaxis with PEG-ASP is very rare and premedication and desensitization protocols may not prevent these hypersensitive reactions.

[Influencing factors on operating times for metal bar removal after Nuss repair]. / Einflussfaktoren der Schnitt-Naht-Zeiten der Metallentfernung nach Nuss-Operation.

BACKGROUND: Metal bar removal after the Nuss repair procedure is prone to be cancelled in cases of operating time shortages due it being suitable to be postponed without harming patients. Consequently, planning operation times as exactly as possible could be one solution. OBJECTIVE: Statistical modelling of operation times of metal bar removal after Nuss repair using the prespecified independent predictors of age, sex, intraoperative complications, and number of implanted metal bars. MATERIAL AND METHODS: We included all patients whose operation notes included an operation time, which was modelled via linear regression and subject to internal validation via bootstrap. Exploratory analyses also consisted of the surgeon's experience, the number of stabilizers, the body mass index, and preceding re-do surgery for bar dislocation. RESULTS: We included 265 patients (14% ♀) with a median age of 19 years (interquartile range 17-20 years), of whom 81% had 1 and 17% had 2 metal bars removed. The prespecified regression model was statistically significant (likelihood ratio 56; df = 5; P < 0.001) and had a bias corrected R2 of 0.148. Patient age influenced operation times by 2.1min per year of life (95% confidence interval 1.3-2.9min; P < 0.001) and 16min per explanted metal bar (95% confidence interval: 10-22min; P < 0.001). CONCLUSION: The patient-specific factors of age and the number of explanted metal bars influenced the operation times and can be included into scheduling operation times.

Different Patterns of Foods Triggering FPIES in Germany.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food allergy mainly affecting infants and young children. Allergic FPIES reactions differ from IgE-mediated food allergies, for example, regarding elicitors and clinical course. OBJECTIVE: The aim of our study was to describe causative agents and development of tolerance in German children with FPIES. METHODS: We conducted a retrospective survey on children with FPIES from 14 centers in Germany assessing a 6-year period. RESULTS: We analyzed 142 patients with 190 FPIES reactions, 130 of which met acute FPIES criteria and 60 were defined as chronic FPIES. The most frequent eliciting food for acute FPIES was cow's milk, followed by fish, vegetables (eg, potato, pumpkin), meats (eg, beef), and grains. A total of 119 children reacted to 1 food only, 16 children to 2 or 3 foods, and 7 children to ≥4 foods. In chronic FPIES, all but 4 exclusively breastfed infants reacted to cow's milk feeding. IgE sensitization to the triggering food was found in 21 of 152 (14%) cases. Two children developed additional IgE-mediated symptoms upon a food challenge. Time to proof of tolerance was shortest in cow's milk-induced FPIES, and it was shorter in chronic than in acute FPIES. CONCLUSION: In our national survey, we identified triggers for acute FPIES that partially differ from those reported internationally. Mainly foods introduced early in infant nutrition triggered acute reactions. Time to proven tolerance was shown to be contingent on FPIES symptomatology and on the triggering food. These data should be considered regarding nutritional advice for infants with FPIES.

Chronic urticaria: etiology and natural course in children.

BACKGROUND: Chronic spontaneous urticaria (CSU) in childhood is infrequent, and information about the disease in children is limited. We attempted to investigate its etiologic factors, natural course, and predictors of prognosis. METHODS: All children aged ≤ 18 years followed for CSU during an 8-year period were analyzed retrospectively, and the final outcomes were queried via a telephone interview. RESULTS: One hundred patients (male/female ratio 1.27) with a median age of 9.2 years (range 0.7-17.2) at symptoms onset were evaluated. The median follow-up was 2.5 years (range 0.2-18.1). An autologous serum skin test was positive in 46.7% of the subjects (n = 45), with a female predominance (71.4%) (p = 0.023). In 13.8% of the children, ANA titers were over 1/100. Food allergy (n = 1), thyroid autoantibodies (n = 3), possible collagen disease (n = 1), and drug usage (deferoxamine) (n = 1) were found to be associated factors. Infections could not be confirmed as the cause of CSU. Recovery was seen in 16.5, 38.8, and 50.0% of the children after 12, 36, and 60 months, respectively. Though in multivariate analysis none of the factors, including age, gender, autologous serum skin test positivity, the presence of angioedema, or other allergic diseases, appeared to predict the prognosis, in univariate analysis being female and being older than 10 years of age predicted an unfavorable prognosis. CONCLUSION: The etiology of CSU in children is mainly related to an autoreactive background, as in adults. CSU has a favorable prognosis, and resolution is seen in half of the children within 5 years. Girls older than 10 years may have an unfavorable prognosis.

Phenotypes of IgE-mediated food allergy in Turkish children.

Data on food allergy-related comorbid diseases and the knowledge on factors associating specific food types with specific allergic outcomes are limited. The aim of this study was to determine the clinical spectrum of IgE-dependent food allergy and the specific food-related phenotypes in a group of children with IgE-mediated food allergy. Children diagnosed with IgE-mediated food allergy were included in a cross-sectional study. IgE-mediated food allergy was diagnosed in the presence of specific IgE or skin-prick test and a consistent and clear-cut history of food-related symptoms or positive open provocation test. Egg (57.8%), cow's milk (55.9%), hazelnut (21.9%), peanut (11.7%), walnut (7.6%), lentil (7.0%), wheat (5.7%), and beef (5.7%) were the most common food allergies in children with food allergy. The respiratory symptoms and pollen sensitization were more frequent in children with isolated tree nuts-peanut allergy compared with those with egg or milk allergy (p < 0.001); whereas atopic dermatitis was more frequent in children with isolated egg allergy compared with those with isolated cow's milk and tree nuts-peanut allergy (p < 0.001). Children with food allergy were 3.1 (p = 0.003) and 2.3 (p = 0.003) times more likely to have asthma in the presence of allergic rhinitis and tree nuts-peanut allergy, respectively. Interestingly, children with atopic dermatitis were 0.5 (p = 0.005) times less likely to have asthma. Asthma (odds ratio [OR], 2.3; p = 0.002) and having multiple food allergies (OR, 5.4; p < 0.001) were significant risk factors for anaphylaxis. The phenotypes of IgE-mediated food allergy are highly heterogeneous and some clinical phenotypes may be associated with the specific type of food and the number of food allergies.

Pollen counts and their relationship to meteorological factors in Ankara, Turkey during 2005-2008.

Pollen plays an important role in the development and exacerbation of allergic diseases. We aimed to investigate the days with highest counts of the most allergenic pollens and to identify the meteorological factors affecting pollen counts in the atmosphere of Ankara, Turkey. Airborne pollen measurements were carried out from 2005 to 2008 with a Burkard volumetric 7-day spore trap. Microscope counts were converted into atmospheric concentrations and expressed as pollen grains/m(3). Meteorological parameters were obtained from the State Meteorological Service. All statistical analyses were done with pollen counts obtained from March to October for each year. The percentages of tree, grass and weed pollens were 72.1% (n = 24,923), 12.8% (n = 4,433) and 15.1% (n = 5,219), respectively. The Pinaceae family from tree taxa (39% to 57%) and the Chenopodiaceae/Amaranthaceae family from weed taxa, contributed the highest percentage of pollen (25% to 43%), while from the grass taxa, only the Poaceae family was detected from 2005 to 2008. Poaceae and Chenopodiaceae/Amaranthaceae families, which are the most allergenic pollens, were found in high numbers from May to August in Ankara. In multiple logistic regression analysis, wind speed (OR = 1.18, CI95% = 1.02-1.36, P = 0.023) for tree pollen, daily mean temperature (OR = 1.10, CI95% = 1.04-1.17, P = 0.001) and sunshine hours (OR = 1.15, CI95% = 1.01-1.30, P = 0.033) for grass pollen, and sunshine hours (OR = 3.79, CI95% = 1.03-13.92, P = 0.044) for weed pollen were found as significant risk factors for high pollen count. The pollen calendar and its association with meteorological factors depend mainly on daily temperature, sunshine hours and wind speed, which may help draw the attention of physicians and allergic patients to days with high pollen counts.

Subglottic cysts in a patient with recurrent stridor and respiratory distress.

Subglottic cysts are rare causes of stridor in infancy and should be suspected in the case of intubation. A 15-month-old male presented with recurrent stridor and respiratory distress. Prematurity and intubation were present in his history. Two subglottic cysts below the glottis were diagnosed. The cysts were ruptured by flexible bronchoscopy. The child's stridor and other symptoms disappeared thereafter. Early diagnosis of subglottic cysts is important since the obstruction can be relieved by rupturing the cysts with bronchoscope, whereas development of a fibrotic stenosis may require a tracheotomy, with its attending morbidity.

Cor a 14, Hazelnut-Specific IgE, and SPT as a Reliable Tool in Hazelnut Allergy Diagnosis in Eastern Mediterranean Children.

BACKGROUND: Improving the diagnostic efficacy of laboratory tests might reduce the need for oral food challenges and facilitate our daily practice. OBJECTIVE: We aimed to determine cutoff values and probability curves, as well as to investigate the role of component-resolved diagnosis in predicting clinical reactivity in children with hazelnut allergy and to evaluate the association with pollen sensitivity. METHODS: A total of 56 children with hazelnut allergy who underwent double-blind placebo-controlled food challenge and 8 children who experienced anaphylaxis after accidental hazelnut intake were included. Serum IgE levels to hazelnut extract, Cor a 1, Cor a 8, Cor a 9, Cor a 14, and Bet v 1 were measured with the ImmunoCAP system. Skin prick tests (SPT) with hazelnut, other implicated foods, and aeroallergens were performed. RESULTS: The optimal cutoff levels for hazelnut sIgE and SPT wheal diameter that predicted clinical reactivity with the highest sensitivity and specificity were 3.15 kU/L and 7.5 mm, respectively. Among the components, only Cor a 14 discriminated between reactive and nonreactive children. The area under curve (AUC) at the optimal cutoff point of 0.63 kU/L for Cor a 14 (0.936) was higher than the AUC of hazelnut sIgE (0.818) and SPT wheal diameter (0.803). For the first time, a 95% probability for clinical reactivity was estimated for SPT wheal diameter, IgE to hazelnut extract, and to Cor a 14 at 12 mm, 10.2 kU/L, and 1.0 kU/L, respectively. CONCLUSION: Cor a 14 was found to be a useful and reliable tool for predicting clinical reactivity in children with hazelnut allergy in the Eastern Mediterranean area.

Recombinant activated factor VII for severe gastrointestinal bleeding after chemotherapy in an infant with acute megakaryoblastic leukemia.

Recombinant activated factor VII (rFVIIa) is a major alternative for management of hemophiliac patients with inhibitors. Additionally, it has been used off-label for the treatment of massive life-threatening hemorrhage associated with various bleeding situations. Herein, we describe a 16-month-old boy with acute megakaryoblastic leukemia and severe intractable gastrointestinal bleeding controlled by rFVIIa. rFVIIa should be considered as a novel treatment alternative in severe bleeding conditions including leukemias that may have hemostatic defects and platelet dysfunction.