Sarcoidosis in the Middle East.

Sarcoidosis, a systemic granulomatous disease of unknown cause, has been described worldwide and in all populations with notable differences in clinical characteristics, organ involvement, disease severity, and prognosis among different ethnic and racial groups. While the exact prevalence of sarcoidosis in the Middle East is unknown, studies from various countries in the region have reported the clinical characteristics of affected patients, along with a few anecdotal reports. A search of the MEDLINE and Google Scholar databases was conducted for relevant English-language articles using the terms "sarcoidosis" and "Middle East" or "sarcoidosis" and "Arabs." Subsequently, the names of individual countries were used as search terms, replacing "Middle East." Overall, the clinical picture of patients with sarcoidosis in the Middle East is similar to that reported elsewhere; for example, the disease was more frequent among females and respiratory complaints were the predominant symptoms. Within the region, most patients from Oman were older and female, with arthralgia, hypercalcemia, and eye involvement being more common. Constitutional symptoms were frequent, especially among patients from Iran. Cough was more common among patients from Kuwait and Iran, while dyspnea was the predominant symptom for Saudi patients. Erythema nodosum was more common in the Turkish population. Clustering was seen in patients with Stage I and II of the disease in all countries except Oman. Apart from those in Iran, the prognosis of most patients from the Middle East was excellent.

Clinical features of Sarcoidosis in Oman: A report from the Middle East region.

BACKGROUND: Though clinical features of sarcoidosis follow a similar pattern, some heterogeneity is seen in different ethnic and racial groups. OBJECTIVES: To describe for the first time the clinical characteristics of sarcoidosis patients in the Sultanate of Oman. METHODS: The data on all cases of sarcoidosis followed up in the two tertiary hospitals in Oman were retrieved retrospectively. RESULTS: Of the 92 patients, for representing the ethnic data only Omani patients (n=83) were included. The mean age was 52.90±12.35 years. Majority were females (72.3%, n=60). Cough (n=44, 53.0%), dyspnea (n=39, 47%), arthralgia (n=26, 31.3%) and fatigue (30.1%) were the major symptoms. Arthralgia was reported by 41.7% of the females and 4.3% of the males (p= 0.001). Uveitis was present in 16 (19.3%), erythema nodosum in 8 (9.6%) and hypercalcemia in 13 (15.7%). The radiological stage at presentation was stage 0, 18.7%; I, 28%; II, 17.3%; III, 24% and IV, 12%. Majority (61.4%) of the patients had tissue diagnosis; intra-thoracic site 70.6%. Pulmonary function showed abnormal diffusion in 75%. Sixty eight received treatment, 81.9% took prednisolone. Based on radiograph good outcome (Resolving) was noted in 20.9%, intermediate (Stable) in 73.1% and poor (Progressive) in 6%. Lung function wise, resolving, stable and progressive disease was seen in 31.4%, 40.0% and 28.6% respectively. CONCLUSION: The clinical picture of the patients with sarcoidosis from Oman was similar to that reported from the rest of the world. Region wise, our patients were older and arthralgia and hypercalcemia were more common. The management of sarcoidosis needs a more organized approach in the country with clear guidelines on monitoring and treatment.

Asthma control: importance of compliance and inhaler technique assessments.

OBJECTIVES: The available assessment tools to determine asthma control do not include components assessing factors that may directly affect control. Our aim was to evaluate the relationship between patient compliance, inhaler technique and the level of asthma control. METHODS: Scores from the Asthma Control Test, individual inhaler device checklists and a novel questionnaire on the patient's medication regimen were used to measure control, inhaler technique and compliance, respectively, in patients with asthma attending Sultan Qaboos University Hospital, Muscat, Oman during a 3-month period. RESULTS: All of the 218 patients were receiving inhaled steroids, either in combination with long-acting beta agonists (86.2%) or alone. Asthma control was good in 92 (42.2%) patients; with 38 males (50%) and 54 females (38%), respectively (p = 0.059). Compliance and inhaler technique were poor in 40.8% (89) and 18.3% (40) of the patients. 60% (36) of the patients with good and 59.4% (41) with partial compliance had good control while 83.1% (74) with poor compliance had poor control (p < 0.001). Of the 92 patients with good control, 86 (93.5%) exhibited good inhaler techniques. In contrast, 85% (34) of the patients with poor inhaler techniques demonstrated poor control (odds ratio [OR] = 5.3; 95% confidence interval [CI]: 2.05-14.8; p < 0.001). A total of 93.3% (56) with good and 89.9% (62) with partial compliance demonstrated good inhaler techniques (p < 0.001). In patients with good control, 35 (38%) exhibited both good inhaler techniques and compliance and 38 (41.3%) had a good technique and partial compliance. CONCLUSION: Patients with good inhaler techniques and compliance have better control of their asthma. Asthma control will remain suboptimal unless the reasons for this lack of control are identified, assessed and eliminated. We recommend that inhaler technique assessment and measurements of patient compliance with their prescribed treatments should be considered for inclusion in the current assessment tools.

Severe Pulmonary Involvement in Leptospirosis: Alternate antibiotics and systemic steroids.

Pulmonary complications in leptospirosis, though common, are often unrecognized in a non-endemic area. We report here a patient with leptospirosis and severe pulmonary involvement who was treated with meropenem (1 g every 8 hours), moxifloxacin (400 mg once daily), and high doses of corticosteroids. Systemic steroids were continued for 3 months because of persistent pulmonary lesions.

Documentation of the management of asthma exacerbation in adults by primary health care physicians in a teaching hospital in oman.

OBJECTIVES: Asthma exacerbation is a major cause of morbidity and it is usually an indication of poor control. Appropriate management and documentation of the clinical assessment of an exacerbation, its severity, contributing factors and treatment are all essential components of asthma control. The aim of this study was to assess the documentation of the management of asthma exacerbations by primary care physicians (PCPs). METHODS: A retrospective analysis was carried out on patient records from 1 May 2008 to 31 April 2009. We included all acute exacerbation episodes in asthmatic patients aged ≥ 14, who received nebulized bronchodilators in the two family medicine clinics attached to Sultan Qaboos University Hospital (SQUH), Oman. A special form was designed to collect PCP's documented management. RESULTS: A total of 67 patients with 100 episodes were treated by 42 PCPs. Documentation of clinical assessment was low for previous admissions (2%), rescue nebulization (25%), duration of symptoms (57%), trigger factors (19%), compliance (9%), clinical signs (48%), peak flow rate (3%), and inhaler technique (5%). The diagnosis of asthma exacerbation was documented in 77% of the episodes. Documentation of therapy was also low (3% for oxygen therapy and 24% for systemic steroids). Documentation of post-nebulization assessment, follow-up appointment, and referral to asthma clinic were found in 37%, 23% and 11% of cases respectively. No documented evidence was found for referral to chest specialist or spirometry. CONCLUSION: Our study indicates major deficiencies in the documentation of asthma exacerbation management among PCPs. Further research is needed to identify the causes of those deficiencies. Following the standardised management protocol can be helpful.

Home exposure to Arabian incense (bakhour) and asthma symptoms in children: a community survey in two regions in Oman.

BACKGROUND: Incense burning has been reported to adversely affect respiratory health. The aim of this study was to explore whether exposure to bakhour contributes to the prevalence of asthma and/or triggers its symptoms in Omani children by comparing two Omani regions with different prevalence of asthma. METHODS: A randomly selected sample of 10 years old schoolchildren were surveyed using an Arabic version of ISAAC Phase II questionnaires with the addition of questions concerning the use and effect of Arabian incense on asthma symptoms. Current asthma was defined as positive response to wheeze in the past 12 months or positive response to "ever had asthma" together with a positive response to exercise wheeze or night cough in the past 12 months. Simple and multivariable logistic regression analyses were performed to estimate the effect of bakhour exposure and other variables on current asthma diagnosis and parents' response to the question: "Does exposure to bakhour affect your child breathing?" RESULTS: Of the 2441 surveyed children, 15.4% had current asthma. Bakhour use more than twice a week was three times more likely to affect child breathing compared to no bakhour use (adjusted OR 3.01; 95% CI 2.23-4.08) and this effect was 2.55 times higher in asthmatics (adjusted OR 2.55; 95% CI 1.97-3.31) compared to non-asthmatics. In addition, bakhour caused worsening of wheeze in 38% of the asthmatics, making it the fourth most common trigger factor after dust (49.2%), weather (47.6%) and respiratory tract infections (42.2%). However, there was no significant association between bakhour use and the prevalence of current asthma (adjusted OR 0.87; 95% CI 0.63-1.20). CONCLUSION: Arabian incense burning is a common trigger of wheezing among asthmatic children in Oman. However, it is not associated with the prevalence asthma.

Normal spirometric reference values for Omani adults.

International guidelines recommend the use of population-specific reference values to eliminate the well-recognized influence of ethnic variation on lung function. This study was designed to derive spirometric prediction equations for healthy Omani adults. Forced vital capacity (FVC), forced expiratory volume in one second (FEV(1)), peak expiratory flow rate (PEFR), and forced expiratory flow at 25% to 75% of FVC (FEF(25-75%)) were measured in 419 "healthy" nonsmoking Omani adults (256 men, 163 women), aged 18-65 years. Multiple linear regression analysis was performed for each spirometric parameter against age, height, and weight for men and women separately, and prediction equations for all the above parameters were derived and compared with values derived using equations published from other populations. All measured spirometric parameters increased with height and decreased with age, and they were all significantly higher in men. In contrast, FEV(1)/FVC% values decreased with height and increased with age and were higher in women. The predicted normal values of FVC and FEV(1) for our subjects using the derived equations were lower by 7-17% compared with respective Caucasian values, with smaller difference in the predicted values of PEFR, FEV(1)/FVC%, and FEF(25-75%). This report presents previously unavailable spirometric reference equations for the Omani adults. Our findings highlight the need to use reference values based on updated data derived from relevant populations.

Management and control of asthma in patients attending a specialist centre in oman.

OBJECTIVES: The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control. METHODS: All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol. RESULTS: Of the 207 patients, (mean age 40.64 ±14.8), 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E (IgE) was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists (LABA), antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority (40.1%) was receiving medium dose inhaled steroids. Although asthma was controlled in 162 (78.3%), during the previous month 66 (31.9%) patients had visited the emergency department and 31 (15.0%) patients were hospitalised at least once during the previous year. Only 63 (30.4%) patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 (25.6%) patients. CONCLUSION: Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored.

An audit of the sleep medicine service in Oman.

OBJECTIVE: To audit the sleep service at Sultan Qaboos University Hospital (SQUH), Muscat, Oman, and to explore deficiencies to introduce new measures of improvement. METHODS: Polysomnography (PSG) reports and SQUH medical records of all patients who underwent sleep studies from January 1995 to December 2006 in the sleep laboratory at SQUH were reviewed and analyzed. RESULTS: Out of a total of 1042 sleep studies conducted in the specified period, 768 PSG recordings were valid for analysis. The audit showed that the Otolaryngology Department was the main referring specialty for PSG (43%). Snoring was the main symptom for 33% of the subjects referred, but suspicion of obstructive sleep apnea was the main reason for referral (38%). Three quarters of the patients were males who were also younger, and with lower body mass index compared to females (p=0.0001 for all). Despite large number of patients with an apnea-hypopnea index of >15 (n=261), only 94 (36%) patients received continuous positive airway pressure titrations and treatment. CONCLUSION: The sleep medicine service in SQUH provided the basic service, and raised the awareness of the importance of this specialty. However, substantial effort is required to bring it to international standards.

Trends in asthma prevalence and severity in Omani schoolchildren: comparison between ISAAC phases I and III.

BACKGROUND AND OBJECTIVE: This study evaluated changes in the prevalence of asthma symptoms and asthma severity in Omani school children over time. METHODS: Two cross-sectional surveys, in 1995 and 2001, were conducted as part of the International Study of Asthma and Allergies in Children on Omani schoolchildren in two different age groups (6-7 and 13-14 years). RESULTS: There were 7067 children surveyed in 1995 (3893 in the younger and 3174 in the older group) and 7879 in 2001 (4126 in the younger and 3753 in the older group). Over the 6 years there was a significant increase in the prevalence of current wheeze 'any wheeze during the past 12 months' (from 7.1% to 8.4%; P = 0.035) in the younger group with no significant change in asthma diagnosis (10.5% vs 10.6%) or any other asthma symptoms. In the older group, all asthma symptoms remained unchanged except speech-limiting wheeze which declined from 4.0% to 2.8% (P = 0.007). In both surveys, more than 60% of current wheezers reported severe asthma symptoms, while only 60% of these reported a diagnosis of asthma. CONCLUSION: The prevalence of both asthma and severe asthma remains high among Omani children. There is significant 'under-diagnosis' and/or 'under-treatment' of asthmatic children which requires urgent evaluation and intervention.

Tuberculosis suspicion and knowledge among private and public general practitioners: Questionnaire Based Study in Oman.

BACKGROUND: Early detection of smear positive TB cases by smear microscopy requires high level of suspicion of TB among primary care physicians. The objective of this study is to measure TB suspicion and knowledge among private and public sector general practitioners using clinical vignette-based survey and structured questionnaire. METHODS: Two questionnaires were distributed to both private and public GPs in Muscat Governorate. One questionnaire assessed demographic information of the respondent and had 10 short clinical vignettes of TB and non-TB cases. The second questionnaire had questions on knowledge of TB, its diagnosis, treatment, follow up and contact screening based on Ministry of Health policy. TB suspicion score and TB Knowledge score were computed and analyzed. RESULTS: A total of 257 GPs participated in the study of which 154 were private GPs. There was a significant difference between private and public GPs in terms of age, sex, duration of practice and nationality. Among all GPs, 37.7% considered TB as one of the three most likely diagnoses in all 5 TB clinical vignettes. Private GPs had statistically significantly lower TB suspicion and TB knowledge scores than public GPs. CONCLUSION: In Oman, GPs appear to have low suspicion and poor knowledge of TB, particularly private GPs. To strengthen TB control program, there is a need to train GPs on TB identification and adopt a Private Public Mix (PPM) strategy for TB control.

Regional Variation in the Prevalence of Asthma Symptoms among Omani School Children: Comparisons from Two Nationwide Cross-sectional Surveys Six Years Apart.

OBJECTIVES: The International Study of Asthma and Allergies in Children (ISAAC) highlighted the presence of wide variations in asthma prevalence between and within countries. The aim of this study was to determine the changes in the prevalence of asthma and its symptoms across the different regions of Oman. METHODS: Two cross-sectional surveys were conducted as part of ISAAC phases I (1995) and III (2001) in two age groups (6-7 and 13-14 years) from nation-wide samples of Omani school children, with 7,067 participants in 1995 (3,893 young and 3,174 older group) and 7,879 participants in 2001 (4,126 young and 3,753 older group). RESULTS: Over the period of six years, the Sharqiya (Eastern) region continued to have the highest prevalence of self-reported asthma diagnosis and all asthma symptoms in both age groups, with a significant increase in the prevalence of wheeze in the past 12 months (from 8.7% to 13.8%; p=0.002) and asthma diagnosis (from 13.8% to 17.8 %; p=0.046) in the young group, and a significant increase in night cough (from 21.6% to 27.8%; p=0.039) in the older group. All other regions had lower prevalence rates in 1995 in both age groups, and showed either no significant change or a decline in one or two of the self-reported asthma symptoms. The prevalence of asthma diagnosis among wheezy children remained unchanged across all regions. In addition, asthma under-diagnosis remains a problem with only 60% of children with severe wheeze reporting asthma diagnosis in both surveys. CONCLUSION: The geographic variation in the prevalence of self-reported of asthma symptoms among Omani school children persists with further increase in the Sharqiya region. The findings also suggest under-diagnosis and/or poor recognition of asthma which had not improved over time.

The pattern of sensitisation to inhalant allergens in omani patients with asthma, allergic rhinitis and rhinoconjunctivitis.

OBJECTIVE: Identification of relevant allergens that are prevalent in each environment which may have diagnostic and therapeutic implications in allergic diseases. This study aimed to identify the pattern of sensitisation to inhalant allergens in Omani patients with asthma, allergic rhinitis and rhinoconjunctivitis. METHODS: The study was carried out during three consecutive years (2004-2006) at the allergy skin test laboratory of Sultan Qaboos University Hospital, Oman. Records of patients who had undergone an allergy skin prick test with a referring diagnosis of asthma, allergic rhinitis or rhinoconjunctivitis were reviewed. Two panels were used during the 3 years period. The frequencies of positive skin tests were analysed. RESULTS: 689 patients were tested, 384 for the first panel and 305 for the second panel. In the first panel, the commonest positive allergens were: house dust mites (37.8%), hay dust (35.4%), feathers (33.3%), sheep wool (26.6%), mixed threshing dust (25.8%), cat fur (24.2%), cockroach (22.7%), straw dust (22.7%), horse hair (17.4%), maize (16.1%), grasses (11.5%), cotton flock (10.7%), trees (10.4%), cow hair (7.8%), Alternaria alternata (3.6%), Aspergillus Niger (3.4%), and Aspergillus fumigatus (1.3%). In the second panel, the commonest positive allergens were also house dust mites: Dermatophagoides pteronyssinus (50.8%), Dermatophagoides farinae (47.9%); Mesquite (Prosopis glandulosa) (35.7%), Russian thistle (Salsola kali) (34.4%), cockroach (32.1%), Bermuda grass (Cynodon dactylon) (19.7%), grass mix-five standard (18.0%), wheat cultivate (14.1%), cats (13.8%), Penicillium notatum (4.3%), Alternaria tenius (3.9%), Aspergillus Niger (3.3%), feather mix (3.0%), dog (2.6%), horse hair and dander (2.6%), and Aspergillus fumigatus (1.6%). CONCLUSION: The pattern of sensitisation to environmental allergens in Oman seems to be similar to other reports from the Arabian Peninsula. Methods to identify and characterise environment specific allergens like a pollen survey may help in the management of patients with allergic asthma, allergic rhinitis and rhinoconjunctivitis.

Compliance of physicians with documentation of an asthma management protocol.

BACKGROUND: Studies continue to show poor physician compliance with asthma management guidelines in clinical practice. However, standardized protocols specifically designed to be practical and user-friendly improve patient outcomes. OBJECTIVE: To determine the degree of physicians' compliance with the documentation of an asthma management protocol in a university hospital. METHODS: A simple asthma management protocol was designed and applied in our pulmonary clinic and primary care clinic for asthma. The protocol was based on the 1998 Manual for the Management of Asthma, from the Oman Ministry of Health, which follows internationally recognized guidelines. The protocol consisted of 4 sections: clinical history, peak expiratory flow (PEF) data, medication section, and simplified asthma management guidelines. RESULTS: All 30 physicians scheduled to conduct asthma clinics in the pulmonary clinic (14 physicians) and the primary care clinic (16 physicians) agreed to use the protocol. A total of 282 protocol forms were collected: 130 forms from 6 senior physicians and 152 from 24 junior physicians. Documentation of the entire clinical history was 65%, with the senior physicians scoring significantly higher documentation-completion rates (82%) for all components of the history than the junior physicians (50%). Documentation of all PEF data was poor (26%), despite high documentation of the PEF value itself (95%). There were significant differences in documentation of percent-of-predicted PEF between junior physicians in primary care clinic (70%) and other physicians (19%). Documentation of the entire medication section was only 34%. Although documentation of prescribed medicines was high (92%), compliance (48%) and inhaler technique (49%) documentation was low, with similar patterns demonstrated by all physicians. Documentation of the entire protocol by all physicians was low (9%), with junior physicians in the primary care clinic completing 28% of their forms. CONCLUSIONS: Our protocol enabled us to identify opportunities for improvement in documentation of asthma management in both the pulmonary and primary care clinics. The findings highlight the need for regular asthma education programs for all physicians, with a focus on documentation of performance skills such as monitoring of PEF and inhaler technique.

Normal spirometric reference values for Omani children and adolescents.

OBJECTIVES: Normal lung function has been shown to be population specific. The aim of this study was to derive normal reference spirometric values for Omani children and adolescents. METHODOLOGY: Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)), peak expiratory flow and forced mid-expiratory flow were measured in 837 healthy Omani school children aged 6-19 years. Multiple linear regression analysis was performed for each spirometric parameter against age, height and weight for boys and girls separately. RESULTS: All measured spirometric parameters increased with age and height and were significantly higher in boys than girls. Height explained the maximum variance for all parameters. After accounting for height in the prediction equations, the contribution of age and weight was minimal. The expiratory ratio (FEV(1)%FVC) was independent of age and height and its mean values (+/- standard deviation) were slightly higher in girls (91.1 +/- 6.1%) than boys (86.5 +/- 7.1%; P < 0.001). The predicted normal values of the subjects using the derived equations were between 5 and 10% lower than the respective values for subjects in Caucasian sample groups. CONCLUSION: The developed prediction equations can be used in clinical practice in Oman and can be considered for use in neighbouring Arab countries.

A relatively high prevalence and severity of asthma, allergic rhinitis and atopic eczema in schoolchildren in the Sultanate of Oman.

OBJECTIVES: Although asthma, allergic rhinitis and eczema are among the most common chronic diseases in children worldwide, there is very limited information about the burden of these conditions in Oman. The aim of this study was to determine the prevalence and severity of symptoms of asthma, allergic rhinitis and eczema in Omani schoolchildren using the International Study of Asthma and Allergies in Childhood (ISAAC) Phase I questionnaire. METHODS: An Arabic version of the ISAAC Phase I questionnaire was completed by parents of 3893 children aged 6-7 years and self-completed by 3174 children aged 13-14 years, randomly selected from a nationwide sample of public schools. RESULTS: The prevalence rates of reported diagnoses of asthma, allergic rhinitis and eczema were higher in older children (20.7%, 10.5% and 14.4% compared with 10.5%, 7.4% and 7.5%, respectively, in young children). In young children, 277 were current wheezers and of these 40.8% had sleep-disturbing wheeze at least once a week and 45.1% had speech-limiting wheeze during the past year. Similarly, 283 older children were current wheezers, and of these 30.0% had sleep-disturbing wheeze at least once a week and 37.5% had speech-limiting wheeze during the past year. Exercise-induced wheeze was higher in older children (19.2% vs 6.9%; P < 0.001). Allergic rhinitis and eczema were also associated with significant sleep disturbance and limitation of activity in both age groups. CONCLUSION: Allergic conditions in Omani schoolchildren are common and associated with significant morbidity. Further research is required to identify the local risk factors for allergy to allow better understanding and management of these conditions.

Atopy in Omani patients with asthma.

OBJECTIVES: To determine the range of serum IgE in healthy subjects and in asthmatic patients in Oman and to assess the degree of atopy in the asthmatic patients. METHOD: Serum IgE and in vivo (the skin prick test) and in vitro (the ImmunoCAP test) allergen-specific IgE levels were measured in 44 patients with asthma. Control groups were 19 healthy subjects and 27 asymptomatic allergic subjects. RESULTS: The normal range for serum IgE in the Omani population was established at ≥ 101 IU/ml. The geometric mean (and 95% confidence interval) for asthmatic patients was 468 IU/ml (323-676). Positive results for allergen-specific IgE, defined as responses to ≥ 1 allergen mix in the ImmunoCAP and to ≥ 3 allergens in the skin prick test, occurred in 26/35 (74%) and in 34/44(77%) asthmatic patients respectively. Six out of 38 patients with serum IgE ≥ 101 IU/ml and 2/6 with levels <101 IU/ml gave negative and positive results respectively in the skin prick test. Overall, the degree of reactivity in the skin prick test correlated with the level of total serum IgE (r= 0.54, p<0.001). A similar correlation could not be established with ImmunoCAP reactivity, but sIgE levels ≥ 101 IU/ml were supported by a high frequency of positive ImmunoCAP responses for the majority of allergen mixes. CONCLUSIONS: Total serum IgE levels should be routinely monitored in asthmatic subjects as this may give an indication of atopy where skin prick testing is not indicated. Since in a minority of patients serum IgE levels and skin prick results do not predict in the same direction, all laboratory data should be interpreted in context of clinical history.