COmparisoN of TastES of Available NutriTional integrated or non-integrated formulas for infants older than 1 year of age with cow’s milk allergy: A multicenter, prospective, single blind, cross-sectional observational clinical study (CONTEST Study)

Palatability of the infant formulas lacking cow milk protein formulas is reported by parents to be an important drawback. The purpose of this study is to examine decisions made by mothers of infants having cow milk protein allergy, and physicians concerning the palatability of unflavored extensively hydrolyzed formulas and amino acid-based formulas. We conducted a multi-center, randomized, single-blinded, observational taste study involving 149 pediatri-cians from gastroenterology and allergy subspecialties at 14 tertiary healthcare units from different regions of Turkey and involving 94 mothers of infants with cow milk protein allergy. Blinding was performed for seven formulas available in the market, which were the most commonly prescribed for feeding: four AAFs (Neocate-Numil®, Aptamil Pregomin AS-Numil®, Alfamino-Nestle®, Comidagen-Mamma®), one AAF specifically designed to address the growing nutritional and lifestyle needs of children >1 year (Neocate Junior-Numil®), 2 eHFs (Bebelac Pepti Junior-Numil®, Similac Alimentum-Abott®). Considering all three formula characteris-tics, Neocate junior-Numil® ranked as the number 1 product among seven products by moth-ers (63.8%) and physicians (69.8%). The ratings of mothers were significantly higher than the physicians (8.1 points and 6.1 points, respectively; p < 0.001). No difference was found in terms of taste, smell, and appearance for Neocate junior-Numil® between the mothers’ and physicians’ ratings. Since caregivers have responsibility for careful selection of replacement products for infants with cow milk protein allergy, it is noteworthy that increased awareness and confidence in the palatability characteristics of these products should motivate mothers and physicians to comply with replacement treatment in the long term (AU)

Diagnosis and management of cow's milk protein allergy in Turkey: Region-specific recommendations by an expert-panel

Cow's milk protein allergy (CMPA) is the most common type of food-allergy in younger children. Prognosis is usually good, with most children developing tolerance before school age. Children may present with a wide spectrum of symptoms that range from mild to severe; skin reactions such as angioedema and urticaria and gastrointestinal symptoms are the most common presentations of CMPA. Approximately one-third of CMPA patients suffer from multiple food-allergies; severe conditions such as anaphylactic shock (9%), eosinophilic esophagitis (4.7%), and food-protein induced enterocolitis (1%) may also develop in some children. Timely and accurate diagnosis and management is essential for proper growth and development of children with CMPA. In this expert consensus report, we aimed to adapt current understandings in the CMPA field to the specific conditions in Turkey and health system to help physicians with their day-to-day decision making

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Diagnosis and management of cow's milk protein allergy in Turkey: Region-specific recommendations by an expert-panel.

Cow's milk protein allergy (CMPA) is the most common type of food-allergy in younger children. Prognosis is usually good, with most children developing tolerance before school age. Children may present with a wide spectrum of symptoms that range from mild to severe; skin reactions such as angioedema and urticaria and gastrointestinal symptoms are the most common presentations of CMPA. Approximately one-third of CMPA patients suffer from multiple food-allergies; severe conditions such as anaphylactic shock (9%), eosinophilic esophagitis (4.7%), and food-protein induced enterocolitis (1%) may also develop in some children. Timely and accurate diagnosis and management is essential for proper growth and development of children with CMPA. In this expert consensus report, we aimed to adapt current understandings in the CMPA field to the specific conditions in Turkey and health system to help physicians with their day-to-day decision making.

Can exhaled nitric oxide be a surrogate marker of bronchial hyperresponsiveness to adenosine 5'-monophosphate in steroid-naive asthmatic children?

BACKGROUND: The interrelation between airway inflammation, bronchial hyperresponsiveness (BHR) and atopy remains controversial. OBJECTIVE: The aim of this study was to document whether exhaled nitric oxide (eNO) may be used as a surrogate marker that predicts BHR to adenosine 5'-monophosphate (AMP) in steroid-naive school children with asthma. METHODS: This study was a retrospective analysis of steroid-naive school age children with atopic and non-atopic asthma. All patients whose eNO levels had been measured and who had been challenged with both methacholine (MCH) and AMP were included. Receiver operation characteristic analysis was performed, in both the atopic and the non-atopic groups, to evaluate the ability of eNO to detect the BHR to AMP. RESULTS: One hundred and sixteen patients, sixty-nine (59.5%) of whom had been atopic, were included in the analysis. In the atopic group, eNO values were significantly higher in patients with BHR to AMP compared to those without BHR to AMP (51.9 ± 16.9 p.p.b. vs. 33.7 ± 16.4 p.p.b.; P < 0.001), whereas in the non-atopic group, the differences were not statistically significant (29.7 ± 16.9 p.p.b. vs. 22.6 ± 8.1 p.p.b.; P = 0.152). In the atopic group, eNO levels (R(2) : 0.401; ß: 0.092; 95% CI: 1.19-14.42; OR: 7.12; P = 0.008) were found to be the only independent factor for BHR to AMP, whereas none of the parameters predicted BHR to AMP in the non-atopic group. The best cut-off value of eNO that significantly predicts BHR to AMP was 33.3 p.p.b. in the atopic group (P < 0.001), whereas a significant cut-off value for eNO that predicts BHR to AMP was not determined in the non-atopic group (P = 0.142). An eNO ≤ 17.4 p.p.b. has 100% negative predictive values and 100% sensitivity and 60.47% PPV for prediction of BHR to AMP in the atopic group. CONCLUSIONS: Exhaled NO may be used to predict BHR to AMP in atopic but not in non-atopic steroid-naïve asthmatic children.

When should we perform a repeat training on adrenaline auto-injector use for physician trainees?

BACKGROUND: Studies demonstrate that both doctors and patients may use adrenaline auto-injector improperly and the usage skills are improved by training. In this study, we aimed to determine the appropriate frequency of training to maintain skills for adrenaline auto-injector use. METHODS: We invited all interns of 2011-2012 training period. At baseline, all participants were given theoretical and practical training on adrenaline auto-injector use. The participants were randomly assigned into two groups. We asked those in group 1 to demonstrate the use of adrenaline auto-injector trainer in the third month and those in group 2 in the sixth month. RESULTS: One hundred and sixty interns were enrolled. Compared with the beginning score, demonstration of skills at all the steps and total scores did not change for the group tested in the third month (p = 0.265 and p = 0.888, respectively). However; for the group examined in the sixth month; the demonstration of skills for proper use of the auto-injector at all steps and the mean time to administer adrenaline decreased (p = 0.018 and p < 0.001, respectively). Besides, the group which was tested in the third month was better than the group which was tested in the sixth month in terms of demonstrating all steps (p = 0.014), the total score (p = 0.019), mean time of change to administer adrenaline (p < 0.001) and presumptive self-injection into thumb (p = 0.029). CONCLUSIONS: Auto-injector usage skills of physician trainees decrease after the sixth month and are better in those who had skill reinforcement at 3 months, suggesting continued education and skill reinforcement may be useful

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Desensitisation of the youngest patient with Pompe disease in response to alglucosidase alfa

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When should we perform a repeat training on adrenaline auto-injector use for physician trainees?

BACKGROUND: Studies demonstrate that both doctors and patients may use adrenaline auto-injector improperly and the usage skills are improved by training. In this study, we aimed to determine the appropriate frequency of training to maintain skills for adrenaline auto-injector use. METHODS: We invited all interns of 2011-2012 training period. At baseline, all participants were given theoretical and practical training on adrenaline auto-injector use. The participants were randomly assigned into two groups. We asked those in group 1 to demonstrate the use of adrenaline auto-injector trainer in the third month and those in group 2 in the sixth month. RESULTS: One hundred and sixty interns were enrolled. Compared with the beginning score, demonstration of skills at all the steps and total scores did not change for the group tested in the third month (p=0.265 and p=0.888, respectively). However; for the group examined in the sixth month; the demonstration of skills for proper use of the auto-injector at all steps and the mean time to administer adrenaline decreased (p=0.018 and p<0.001, respectively). Besides, the group which was tested in the third month was better than the group which was tested in the sixth month in terms of demonstrating all steps (p=0.014), the total score (p=0.019), mean time of change to administer adrenaline (p<0.001) and presumptive self-injection into thumb (p=0.029). CONCLUSIONS: Auto-injector usage skills of physician trainees decrease after the sixth month and are better in those who had skill reinforcement at 3 months, suggesting continued education and skill reinforcement may be useful.

Challenge-proven nonsteroidal anti-inflammatory drug hypersensitivity in children.

BACKGROUND: Few studies investigated hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) in children. The objective was to determine the frequency of true NSAID hypersensitivity (NSAID-H) and whether there were any parameters in the history of children that would predict NSAID-H. Secondly, an investigation was conducted into whether NSAID-hypersensitive children could tolerate safe alternatives. Differing from previous studies, the researchers followed the recent diagnostic algorithm proposed for acute reactions in NSAID-H. METHODS: Children with a history suggesting NSAID-H were evaluated by an allergist. The patients with a single NSAID in history were tested first with a skin prick test and if negative challenged with the culprit NSAID. The patients who had reactions with multiple NSAIDs were directly challenged with their culprit drugs. Safe alternatives in children with a confirmed NSAID-H were found by oral provocation tests (OPTs). RESULTS: Fifty-eight of 61 patients participated in the study. Thirty-eight patients (65.5%) described a reaction to a single NSAID and 20 mentioned reactions with ≥2 different NSAIDs. Single-drug-induced and cross-reactive NSAID-Hs were proven in 5 of 36 (14%) and 8 of 18 (44%) of patients, respectively. Acetaminophen and nimesulide were tolerated in 60% and 88.8% of the study patients as safe alternatives, respectively. Family history of NSAID-H was found as the only significant predictor of OPT (OR: 5.4; 95% CI: 1.02-28.6). CONCLUSION: Histories of both single and multiple NSAID-Hs are poor predictors of actual drug hypersensitivity. Therefore, diagnostic tests should be performed in all children if no contraindication exits. Family history of NSAID-H is the only significant parameter predicting OPT results.

Correlation of clinical score to pulmonary function and oxygen saturation in children with asthma attack.

BACKGROUND: The aim of this study is to demonstrate the importance of the relation between clinical score, pulse oximetry and spirometric tests in an asthma attack. METHODS: In this randomized, double blind, observational study, 110 children (age 2-15 years) with an asthma attack who were admitted to emergency room were evaluated. Patient history, physical examination, clinical score and oxygen saturation were recorded in all patients; however pulmonary function tests were obtained only in 54 children who were over 5 years of age. The clinical score was derived from respiratory rate, wheezing, dyspnea and retractions. RESULTS: Both oxygen saturation and spirometric tests were found to be significantly correlated with the clinical score in children. CONCLUSION: The clinical score could be used for assessing the severity of the asthma attack particularly in developing countries where laboratory facilities are not available or pulmonary function tests are not feasible.

Correlation of clinical score to pulmonary function and oxygen saturation in children with asthma attack / Correlación de la valoración clinica con la función pulmonar y la saruración de oxigeno en niños con crisis de asma

Background: The aim of this study is to demonstrate the importance of the relation between clinical score, pulse oximetry and spirometric tests in an asthma attack. Methods: In this randomized, double blind, observational study, 110 children (age 2-15 years) with an asthma attack who were admitted to emergency room were evaluated. Patient history, physical examination, clinical score and oxygen saturation were recorded in all patients; however pulmonary function tests were obtained only in 54 children who were over 5 years of age. The clinical score was derived from respiratory rate, wheezing, dyspnea and retractions. Results: Both oxygen saturation and spirometric tests were found to be significantly correlated with the clinical score in children. Conclusion: The clinical score could be used for assessing the severity of the asthma attack particularly in developing countries where laboratory facilities are not available or pulmonary function tests are not feasible

Antecedentes: la finalidad de este estudio es demostrar la importancia de la relación entre la valoración clínica, la pulso-oximetría y los tests espirométricos durante la crisis de asma. Métodos: en un estudio observacional, aleatorio, a doble ciego, se evaluaron 110 niños (entre2 y 15 años) atendidos en la unidad de urgencias por crisis de asma. En todos los pacientes se obtuvieron la historia clínica, examen físico, puntuación de los datos clínicos (score) y saturación de oxígeno; sin embargo, la función pulmonar sólo se efectuó en 54 niños con más de 5 años de edad. La puntuación clínica se basó en la frecuencia respiratoria, sibilancias, disnea y retracciones. Resultados: tanto la saturación de oxígeno como la espirometría estuvieron significativamente correlacionadas con la puntuación clínica. Conclusión: la puntuación clínica puede ser usada para valorar la gravedad de la crisis de asma, particularmente en países en desarrollo con problemas de disponibilidad de laboratorio o de los tests de función pulmonar

Rapidly progressive bronchiectasis complicating ulcerative colitis in a child.

Patients with ulcerative colitis may have a presentation dominated by extraintestinal manifestations. These manifestations, particularly bronchiectasis, are very rarely seen in pediatric patients. A 13-year-old boy with ulcerative colitis who was diagnosed by colonic mucosa biopsy is presented. He developed unexplained productive cough after the appearance of colonic disease. He was treated and followed up at his primary care hospital with the sole diagnosis of ulcerative colitis, with little attention given to the chest symptoms. The relation of the bronchial involvement to the ulcerative colitis was not established until two years after the onset of disease. Thoracal computed tomography (CT) examination after this period showed evidence of bronchiectasis and pulmonary involvement. Despite prophylactic inhaled corticosteroid treatment, no clinical or radiographic improvement was observed and widespread bronchial destruction developed very rapidly. More effective treatment with oral steroids was probably necessary in this patient, if the early chest symptoms were related to the ulcerative colitis.

Safety of inhaled corticosteroid therapy in young children with asthma.

BACKGROUND: Physicians have had some reluctance to use inhaled corticosteroids in very young children with asthma because of the possible risks of adverse systemic effects. OBJECTIVE: The purpose of this study was to evaluate the effects of fluticasone propionate on growth and adrenocortical function in young children with asthma. METHODS: We performed an open, prospective study for 24 weeks of 20 children with asthma, 2.5 to 5.0 years of age, who had received fluticasone by a large volume spacer at dosages ranging from 190.50 to 565.40 microg/m2 daily. Growth was evaluated by height standard deviation scores measured by a stadiometer. Adrenocortical function was evaluated twice in each child, before and after the study, by determining fasting serum cortisol concentrations at 8 AM and also at 30 and 60 minutes after adrenocorticotropic hormone stimulation. Posttreatment values of height standard deviation scores and fasting morning serum cortisol concentrations were compared with those of 18 age-matched children, who constituted the control group. RESULTS: The evaluation of mean +/- SEM (and range) of height standard deviation scores revealed a significant decrease from 0.44 +/- 0.27 (-1.46 to 2.22) to 0.28 +/- 0.26 (-1.51 to 2.07; P = 0.01) at week 18 and to 0.25 +/- 0.24 (-1.90 to 2.13; P = 0.04) at the week 24 in fluticasone-treated children. At the end of the treatment, however, height standard deviation scores of these children did not differ significantly (P = 0.35) from those of the control group. Delayed growth with medium-duration treatment was not associated with alterations in serum cortisol measurements, either at baseline or after stimulation. The mean fasting morning serum cortisol concentrations did not differ significantly between the fluticasone-treated patients and the control group. CONCLUSIONS: Some concern prevails about the safety of medium- or long-term treatment with regularly inhaled corticosteroids in young children with asthma. The prepubertal growth may be delayed, but the effect on ultimate height remains uncertain in such children. Growth should be regularly monitored in children who begin inhaled corticosteroid therapy for mild persistent asthma at an age <5 years old.

Prevalence of asthma-associated symptoms in Turkish children.

The aim of the first national cross-sectional survey was to determine the prevalence of asthma-like respiratory symptoms and the associated risk factors among children aged 0-17 via interview with the parents by primary care physicians. They were selected through stratified two-stage cluster probability sampling in urban and rural parts of randomly selected 27 of 81 administrative districts in Turkey. Data was collected for 46,813 children (23,512 males and 23,301 females) of whom 66 percent resided in urban areas. The prevalence of physician-diagnosed asthma was 0.7 percent. The lifetime and current (last 12 months) prevalences were 14.7 percent and 2.8 percent for asthma, and 15.1 percent and 3.4 percent for wheezing respectively. The presence of personal atopy and history of family atopy were the most significant risk factors for current prevalences of wheezing, and asthma [adjusted Odds ratios (OR) and 95% confidence intervals (CI) were 6.2 (CI=4.0-9.5) and 1.8 (CI=1.3-2.4) for wheezing, and 8.5 (CI=5.6-12.9) and 1.9 (CI=1.4-2.5) for asthma, respectively]. Though there were no significant differences among those residing in urban versus rural areas regarding the current prevalences of asthma and wheezing, those living in coastal areas had considerably higher current prevalences than those inland (OR=2.6, CI=1.9-3.5 for wheezing, and OR=2.3, CI=1.7-3.1 for asthma). Residence in northern Turkey appeared to be a significant risk factor for wheezing (OR=1.9, CI=1.4-2.5), and children resident in southern Turkey exhibited the highest risk for occurrence of asthma (OR=1.5, CI=1.1-2.0) compared with eastern Turkey. In conclusion, the respiratory symptoms associated with asthma were an important cause of morbidity in childhood in Turkey. The discrepancy between prevalence of physician-diagnosed asthma and lifetime and/or current asthma prevalence figures may reflect the reluctancy of both physicians and parents to diagnose this condition. Besides strongest associations with personal atopy and atopic heredity, there were significant differences in prevalence rates between children residing in different regions, supporting the role of environmental factors.

Prevalence of latex sensitivity in patients with malignancies.

UNLABELLED: An increased frequency of allergic reactions to latex have been reported in specific populations with chronic latex exposure (e. g., children with spina bifida, health-care workers, rubber and doll-manufacturing workers). However, latex sensitization occurs in adult patients with no known risk factors. This study investigated hypersensitivity to latex in patients with malignancies. MATERIAL AND METHODS: We studied 70 adult patients (40 females, 30 males) with a standard questionnaire, skin prick tests (SPTs) with latex, common aeroallergens and fruits to all of the subjects. In addition, specific IgE concentrations for all of these allergens were measured in serum with the Pharmacia UniCAP system. RESULTS: The prevalence of latex sensitization was found to be 11.4% (n = 8). Both SPTs and anti-latex IgE antibodies of these patients were positive in the sera. Latex sensitization was related to the personal history of allergic diseases (p = 0.02), the duration of disease (p = 0.01), and the number of invasive procedures (p = 0.04). DISCUSSION: This study shows that latex hypersensitivity is present in patients with malignancies. From our results latex sensitization must be kept in mind while dealing with this susceptible patient group.

Cardiac side effects of long-acting beta-2 agonist salmeterol in asthmatic children.

BACKGROUND: Salmeterol is a new long-acting beta 2 selective adrenoreceptor agonist. There are some reports about the cardiac side-effects of salmeterol in asthmatic adults. The aim of this study was to determine the cardiac side effects of salmeterol in children. METHODS: Seventeen children with moderate asthma (aged between 6 and 13 years, mean 8.76 years) received salmeterol with a spacer device (Volumatic 200 micrograms daily, b.i.d.) for 3 weeks. All the children were evaluated by 24 h ambulatory electrocardiography monitoring and echocardiography before, on the second and on the 21st day of treatment. RESULTS: In minimum heart rate measurements, there were significant differences between the baseline (mean +/- SD 54.29 +/- 7.13), second (59.24 +/- 6.86) and 21st day (60.65 +/- 8.23) results. Also, the mean heart rate before the treatment (89.59 +/- 6.78) was significantly different from that on the second (94.76 +/- 6.51) and 21st day (92.65 +/- 8.90) of treatment. Although all the values were within normal limits and there were no significant differences between the control group's values, a trend of increase in mean and the minimum heart rates was seen. There were no significant differences in blood pressure, serum K+, maximum heart rate, supraventricular and ventricular ectopic beats, ejection fraction, stroke volume, cardiac output and corrected QT interval at any time. No complaints of tremors or palpitations were reported. CONCLUSIONS: As no cardiac side effects were detected, it could be concluded that salmeterol is quite a safe drug for use in childhood asthma treatment.

The association of chronic urticaria and angioedema with autoimmune thyroiditis.

BACKGROUND: An increased frequency of autoimmune thyroiditis is seen in patients with chronic urticaria and angioedema (CUA) and it has been hypothesized that autoimmunity may be playing a role in the pathogenesis of CUA. The aim of this study was to learn the extent of autoimmune thyroid disease in a series of patients who presented with CUA. METHODS: Thyroid function tests and thyroid autoantibodies were measured by radioimmunoassay and immunoradiometric assay respectively in 94 CUA patients and 80 age- and sex-matched healthy volunteers. RESULTS: Eleven patients (11.7%) were found to have thyroglobulin antibodies (TGA) and nine patients (9.57%) thyroid microsomal (TMA) titers ranging from 150 to 1340.37 and from 165.73 to 8000 IU/mL respectively. Both antibodies were detected in three control cases (3.7%). The association was statistically significant (P < 0.01). Six of 11 patients had thyroid dysfunction and the other five cases were euthyroid. CONCLUSIONS: Our results justified the use of TMA and TGA for the early diagnosis of autoimmune thyroiditis in combination with CUA. The higher frequency of these antibodies in our patients, along with results from previously published data, suggest that this entity may reflect an autoimmune basis in some CUA patients. Thyroid function tests are not enough to rule out thyroid disease, and thyroid antibody tests should be carried out in all patients with CUA.