Asthma deaths outside the hospital in an urban community from 2004 to 2008.

BACKGROUND: Several studies have been performed reviewing medical examiner's autopsy reports of asthma deaths. None, to our knowledge, have focused on the characteristics of asthma deaths in the urban community alone. OBJECTIVE: To characterize factors related to asthma deaths occurring outside the hospital setting in an urban community. METHODS: We reviewed the medical records of 22 patients who died outside the hospital of asthma and underwent autopsy performed by the Milwaukee County medical examiner from 2004 to 2008. RESULTS: The mean age of the patients was 32 years (range, 12-71 years), 11 patients were male, and 14 patients (64%) were African American. Seventeen patients (77%) died during the night or shortly on awakening. Twelve patients (55%) died in June, July, or August. A history of illicit drug, alcohol, or tobacco use was discovered in 13 patients (59%). Toxicologic test results for drugs of abuse were positive in 4 patients (18%). Twenty patients were using or overusing a short-acting ß-agonist, 1 patient was taking omalizumab, and none were taking long-acting ß-agonists alone. Two patients were taking no medications. Asthma severity and medication adherence were not consistently reported. Lung pathologic testing revealed eosinophils in 18 patients and a lack of neutrophils in every case. CONCLUSION: In this small and limited series of asthma deaths occurring in an urban setting outside the hospital, individuals were more likely to be African Americans, with deaths occurring more frequently at night, during the summer months, and in those with substance abuse and not taking anti-inflammatory asthma medications.

Oxaliplatin hypersensitivity: case report and successful repeat desensitization.

INTRODUCTION: Oxaliplatin is a third generation organoplatinum complex used as an antineoplastic agent in combination with fluorouracil and leucovorin for colorectal carcinoma. Hypersensitivity reactions are commonly observed to oxaliplatin, with an incidence of 12% to 16%. Desensitization protocols for oxaliplatin with premedication using steroids or antihistamines have been previously reported. We present a patient who underwent successful repeat desensitization without premedication. CASE SUMMARY: A 43-year-old Asian male with metastatic rectal adenocarcinoma was started on chemotherapy with oxaliplatin and leucovorin followed by fluorouracil. Three hours after the first infusion of oxaliplatin, he developed generalized urticaria, which resolved with Benadryl. Similar symptoms developed after the second cycle. A desensitization protocol, without premedication, was developed for the third oxaliplatin cycle starting at 1:10,000 of the therapeutic dose followed by doubling doses thereafter until a cumulative goal dose of 175 mg was administered. Fluorouracil and leucovorin were then infused at the usual rates. Skin prick testing, before the procedure, using 5 mg/mL oxaliplatin was negative. Intracutaneous testing using dilutions of 1:1000, 1:100, and 1:10 were also negative. The patient was observed for 2 hours after the procedure without evidence of a hypersensitivity reaction. Two weeks later, the same protocol was successfully implemented for completion of his fourth cycle of chemotherapy and continued biweekly for a total of 11 cycles. Follow-up revealed tumor remission. CONCLUSION: A desensitization protocol without premedication may be considered in those patients with a history of oxaliplatin hypersensitivity reactions with avoidance of the cumulative exposure to pretreatment medications.

Allergic bronchopulmonary aspergillosis and cystic fibrosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a disease affecting patients with asthma as well as those with cystic fibrosis. The clinical picture of ABPA is characterized by symptoms of wheezing, pulmonary infiltrates, bronchiectasis, and in later stages, pulmonary fibrosis. Since patients with cystic fibrosis may have several of these clinical features as part of their disease process, it is important to distinguish the overlap of this entity so that therapy may be instituted in a timely manner. This paper will discuss the clinical diagnosis, immuno-pathology and treatment of ABPA as it affects patients with cystic fibrosis.

Infliximab retreatment in adults and children with Crohn's disease: risk factors for the development of delayed severe systemic reaction.

OBJECTIVES: Although effective in the treatment of refractory Crohn's disease, episodic retreatment with the antitumor necrosis factor a chimeric monoclonal antibody infliximab (Remicade, Centocor, Malvern, PA) can be associated with severe acute and delayed systemic reactions. METHODS: We analyzed episodic infliximab retreatment over 30 months in 86 adult and pediatric patients receiving 304 infusions to determine factors associated with the development of severe systemic reaction. RESULTS: Overall, 14% of patients experienced severe systemic reactions with episodic infliximab retreatment. There was a significant difference in the rates of severe systemic reaction observed in adults (11/52 [21%]) and pediatric patients (1/34 [3%]) (p < 0.02). Delayed systemic reactions, characterized by arthralgia, fever, and myalgia requiring corticosteroid treatment, were found exclusively in adults (age > 17 yr) and occurred in eight patients treated for luminal Crohn's disease. Acute systemic reactions, characterized by hypotension, mucosal irritability, and laryngospasm requiring epinephrine, diphenhydramine, and/or methylprednisolone treatment, occurred sporadically in three adults and one child, treated for both luminal and fistulizing disease. Second infliximab infusions were associated with two thirds of severe systemic reactions, and a distant second infusion (> or = 20 wk from first infusion) was poorly tolerated relative to earlier retreatment (p < 0.001). Concomitant medications were similar in adults and children. CONCLUSIONS: Episodic infliximab retreatment--specifically, a distant second infusion--is associated with high rates of severe systemic reaction in adults, but not children. We recommend multiple early infusions of infliximab if retreatment is anticipated in adult patients to avoid the development of delayed severe systemic reactions.