Severe asthma in adult, inner-city predominantly African-American and latinx population: demographic, clinical and phenotypic characteristics.

INTRODUCTION: The burden of asthma morbidity with co-existing atopy among the racial/ethnic minorities in the socio-economically disadvantaged NYC borough of the Bronx is unusually high. The multidisciplinary Montefiore Asthma Center (MAC) provides guideline-based treatment to this high-risk population through the joint efforts of Allergists/Immunologists, Pulmonologists, and on-site health educators. METHODS: The objective of this prospective, observational study was to define the demographic and clinical characteristics of severe asthma, evaluate improvement in asthma severity and lung function through the course of treatment at the MAC, and describe the asthma phenotypes of the patients managed at the MAC. Adults with severe asthma receiving treatment at the MAC were followed from their first to their last visit at the MAC. Patient demographics, along with asthma severity and co-existing allergies, were assessed. Possible phenotypes were defined (based on presence or absence of atopy, age at asthma onset, and blood eosinophil counts). RESULTS: 227 patients were included in the final analysis, of which 55.5% were Hispanic and 33.9% identified as non-Hispanic Black. Ninety-one percent (91%) of our cohort was found to be atopic and allergic rhinoconjunctivitis (ARC) was the most commonly identified co-existing allergic condition (86.3%). Mean Asthma Control Test (ACT) scores improved from 11.1 (± 4.9) at the initial visit to 14.8 (± 6.1) at the last visit. The spirometric values did not improve despite treatment at MAC. CONCLUSION: A multidisciplinary severe asthma center is an ideal setting to phenotype patients and offer personalized guideline-based management and education to adults with severe asthma.

Ustekinumab associated chronic eosinophilic pneumonia.

INTRODUCTION: Ustekinumab-induced eosinophilic pneumonia is rare and to our knowledge, this is the fifth reported case of such an entity. CASE STUDY: A 60-year-old female was admitted with worsening shortness of breath and a nonproductive cough for 4 months. Her past medical history was significant for Crohn's disease and psoriatic arthritis that was previously managed with adalimumab and switched to ustekinumab 2 months before symptoms. Initial diagnostic workup showed 10% peripheral eosinophilia and a CT chest showed numerous 5 mm nodules scattered throughout the lungs along with some peripheral reticulations. Her BAL fluid analysis showed abnormally high eosinophil count (67%), greatly limiting her potential diagnoses to eosinophilic pneumonia, EGPA, and tropical pulmonary eosinophilia (TPE). AEP typically causes more severe disease with a rapid onset, and there was low suspicion for TPE based on history, leaving EGPA and CEP. Based on her negative autoimmune serology, a negative biopsy of the nasal mucosa (no vasculitis/granulomata or eosinophils), and negative infectious workup, the patient was diagnosed with CEP secondary to ustekinumab and the drug was stopped. She was started on high dose prednisone and after a prolonged taper over 5 months, her symptoms and nodules and reticulations on her CT scan resolved. DISCUSSION: This case exemplifies the importance of identifying drug-induced lung diseases which in many cases might not have a strong temporal association with the symptom onset. It also highlights that some drugs owing to their long elimination half-time can remain in the system for a prolonged period and continues to cause symptoms despite their cessation and require prolonged treatment and reassurance. CONCLUSION: The association of eosinophilic pneumonia with ustekinumab, a drug used in the treatment of psoriasis and other autoimmune diseases, is rare and there is a paucity of literature regarding this association.

Diagnosis and management of NSAID-Exacerbated Respiratory Disease (N-ERD)-a EAACI position paper.

NSAID-exacerbated respiratory disease (N-ERD) is a chronic eosinophilic, inflammatory disorder of the respiratory tract occurring in patients with asthma and/or chronic rhinosinusitis with nasal polyps (CRSwNP), symptoms of which are exacerbated by NSAIDs, including aspirin. Despite some progress in understanding of the pathophysiology of the syndrome, which affects 1/10 of patients with asthma and rhinosinusitis, it remains a diagnostic and therapeutic challenge. In order to provide evidence-based recommendations for the diagnosis and management of N-ERD, a panel of international experts was called by the EAACI Asthma Section. The document summarizes current knowledge on the pathophysiology and clinical presentation of N-ERD pointing at significant heterogeneity of this syndrome. Critically evaluating the usefulness of diagnostic tools available, the paper offers practical algorithm for the diagnosis of N-ERD. Recommendations for the most effective management of a patient with N-ERD stressing the potential high morbidity and severity of the underlying asthma and rhinosinusitis are discussed and proposed. Newly described sub-phenotypes and emerging sub-endotypes of N-ERD are potentially relevant for new and more specific (eg, biological) treatment modalities. Finally, the document defines major gaps in our knowledge on N-ERD and unmet needs, which should be addressed in the future.

The Southern Sweden Adolescent Allergy-Cohort: Prevalence of allergic diseases and cross-sectional associations with individual and social factors.

OBJECTIVES: Asthma and allergic diseases are the most frequent chronic diseases in childhood worldwide, and considered a burden for the affected children and their families. The diseases impose an economic burden on society if not diagnosed and treated properly and management of and these diseases are challenging for healthcare professionals. The aim of the present investigation was to assess the prevalence of allergic diseases in an unselected cohort of adolescents in southern Sweden. Additionally, associations with sociodemographic factors were investigated, as well as impact on daily life. METHODS: This cross-sectional study was based on a cohort of n = 1 530 school children, aged 13 to 14, from 13 municipalities in southern Sweden. Data were collected through web-based questionnaires. RESULTS: Of all children 32% reported at least one allergic disease. 67% reported one allergic disease and 33% reported more than one. No allergy-related disease were reported by 68%. Current asthma was reported by 9.8% and current rhino-conjunctivitis was reported by 13%. The prevalence of food hypersensitivity was 12% and the prevalence of eczema was 11%. One to three wheezing attacks were reported from 55% and 40% reported more than four attacks of wheezing in the preceding year. The self-reported allergic diseases were diagnosed by a doctor in; 36% (food hypersensitivity) to 69% (rhinoconjunctivitis) of the cases. CONCLUSIONS: A high number of affected children were identified. Some children being undiagnosed and some not receiving satisfactory treatment. These results suggest that additional studies to evaluate treatment procedures in order to improve healthcare for allergic children are warranted.

Combined measurements of fractional exhaled nitric oxide and nasal nitric oxide levels for assessing upper airway diseases in asthmatic patients.

BACKGROUND: Despite the close linkage between rhinitis, chronic rhinosinusitis (CRS) and asthma, relevant biomarkers of both upper and lower airway inflammation are rare. METHODS: Patients with asthma (without upper airway disease [UAD; n = 24], with rhinitis [n = 25], CRS [n = 24], and nasal polyps [n = 2]), isolated rhinitis (n = 13), isolated CRS (n = 13), and 10 healthy controls were prospectively recruited. Fractional exhaled nitric oxide (NO) levels at 50 mL/s (FeNO50), nasal NO levels, Lund-Macay-scores of sinus computed tomography and an asthma control questionnaire (ACQ) were evaluated. RESULTS: Asthma was associated with higher FeNO50 levels irrespective of the UAD category. FeNO50 levels were higher in asthmatics with CRS (median: 54.0 ppb) than those with rhinitis (35.2 ppb, p = 0.02) and those without UAD (34.3 ppb, p = 0.002). Nasal NO levels were higher in rhinitis patients than other UAD categories, irrespective of the asthma concomitance. Nasal NO levels were higher in asthmatics with rhinitis (112.8 ppb) than those without UAD (67.2 ppb, p = 0.001) and those with CRS (57.6 ppb, p < 0.0001). A receiver-operating-characteristic curve analysis for detecting comorbid allergic rhinitis (AR) in asthmatics showed a high area under the curve (0.87). Nasal NO levels were positively correlated with FeNO50 levels (ρ = 0.56, p = 0.003) in asthmatics with rhinitis. In contrast, they were negatively correlated with the Lund-Macay (ρ = -0.46, p = 0.03) and ACQ scores (ρ = -0.52, p = 0.009) in asthmatics with CRS. CONCLUSIONS: Higher nasal NO levels reflect the presence of AR, irrespective of asthma concomitance. Higher FeNO50 levels reflect the presence of CRS and asthma. These NO measurements are useful for assessing comorbid UAD in asthmatics.

Geographic variation in inhaled corticosteroid use for children with persistent asthma in Medicaid.

OBJECTIVE: Geographic variation in the rates of inhaled corticosteroid (ICS) use for children with persistent asthma in Medicaid has been reported, but the source of this variation is unknown. The objective of this study was to quantify the geographic variation in ICS use for children with persistent asthma in Medicaid that remains after adjusting for the characteristics of children in an area. METHODS: Data from the 2005-2007 Medicaid Analytic eXtract files were used. Frequent fills of short-acting beta2-agonist (SABA) were used to identify children 5-18 years of age with persistent asthma across the United States. A child was considered to have used an ICS if the child initially filled an ICS following frequent SABA use. Areas were determined using published methods, and the unadjusted ICS rate and the area treatment ratio for ICS, which adjusted for demographic and clinical characteristics, were calculated for each area. RESULTS: Of 15,917 children, 13% used an ICS. The median unadjusted ICS rate for all areas was 10% but ranged from 0% to 64%. ICS use was less than expected for more than half of the areas based on the characteristics of the children in the area, but use was nearly five times what was expected in some areas. Areas with higher than expected ICS use were found contiguous to areas with lower than expected use. CONCLUSIONS: Geographic variation in ICS not attributable to the demographic and clinical characteristics of the children in an area exists and could prove useful in the struggle to reduce asthma exacerbation rates.

Atopy as a risk factor for the development of asthma in young recruits.

OBJECTIVE: Asthma is one of the most common chronic diseases globally. Atopy, and especially allergic rhinitis (AR), was found as an important risk factor for asthma. The purpose of this study was to examine the association between different atopic parameters and military professions to the incidence of asthma. METHODS: In a retrospective study, we included 128 591 Israel Defense Forces soldiers drafted between the mid-nineties to the early-2000s. We examined the incidence rates of asthma in relation to atopic background and to military profession. RESULTS: The relative risk (RR) for the development of asthma in persons with a history of AR and the RR for asthma in atopics vs. nonatopics was 1.86 (95% CI: 1.57-2.21) and 1.73 (95% CI: 1.47-2.04), respectively. The RR for the development of asthma in persons with a history of AR was higher in Combat Units (CU) and Administrative and Driving units (ADU) (RR = 2.80; 95% CI: 2.09-3.76 and RR = 1.58; 95% CI: 1.19-2.12, respectively) than in Maintenance Units (MU) (RR = 1.27; 95% CI: 0.93-1.74). When comparing the risk for asthma amongst persons with AR, we found it lower in MU compared to ADU (RR = 0.65; 95% CI: 0.43-0.97). In atopics vs. non-atopics, the risk for asthma was higher in ADU as compared to other occupations. CONCLUSIONS: Atopy, particularly AR, is a risk factor for the development of new-onset asthma in young adults. Atopy has the highest significant effect in CU where the physical demands are higher.

Respiratory allergy to airborne fungi in São Luís--MA: clinical aspects and levels of IgE in a structured asthma program.

INTRODUCTION: Respiratory allergies are becoming increasingly frequent, especially based on studies of asthma and rhinitis. It is estimated that 20-30% of the world's population is affected. Allergic reactions are caused by the production of IgE antibodies specific to inhaled allergens, such as fungi in the air. This study aimed to analyze the level of specific IgE against airborne fungi in patients with a clinical diagnosis of asthma and rhinitis/sinusitis. METHODS: In total, 158 patients enrolled in the Program of Support for Asthmatic Patient, and 20 controls were studied. Clinical data from the period of 2007-2008 were surveyed using a protocol form. ELISAs were performed to quantify the levels of total and specific IgE. RESULTS: Of the 158 patients diagnosed with asthma, 71 had rhinitis and 32 had sinusitis. There was a predominance of females and residents of urban areas. The main symptoms reported were dyspnea, cough, wheezing and nasal obstruction. There was a statistically significant relationship between dyspnea and seropositivity for Fusarium (p = 0.01) and Penicillium (p = 0.005) and between cough and seropositivity for Aspergillus (p = 0.007). CONCLUSIONS: Anti-Penicillium (79.7%) and anti-Fusarium IgE (77.8%) were found to have the highest prevalence of seropositivity in individuals with asthma and rhinitis/sinusitis. Sensitivity to fungi was higher in symptomatic individuals. The identification of environmental fungi is essential for the diagnosis of respiratory allergy.

[Sinonasal mucormycosis revealed by a necrotic velar ulceration]. / Mucormycose rhinosinusienne révélée par une ulcération nécrotique vélopalatine.

INTRODUCTION: Mucormycosis is a deep mycosis which has been spreading out in recent years. It is still poorly understood and poorly described in sub-Saharan Africa. The authors report a case of sinonasal localization, of fatal evolution and late diagnosis in a young child. OBSERVATION: It is about a 13-year-old child suffering from chronic rhinosinus syndrome for two years. He was observed in stomatology for a necrotic velar ulceration that have occurred for three months. The clinical, radiological and histological explorations were in favor of a sinonasal mucormycosis. The administration of amphotericin B and the surgical treatment did not slow down the fatal evolution. CONCLUSION: Mucormycosis should not be dealt with any diagnostic error and no therapeutic improvisation. It has to be thought about when dealing with a rhinosinusal syndrome with cleft ulceration.

Different Surgical Treatment of Chronic Rhinitis-sinusitis the Impact on Maxillary Sinus Mucociliary Transport Function / 现代生物医学进展

Objective:To compare the effects of different surgical treatment of chronic rhinitis-sinusitis difference,and its impact on transport function of maxillary sinus mucociliary,provide a clinical-surgical sinusitis preferably reference about the treatment of chronic nasal formulation for.Methods:From 2013.9-2014.12,otorhinolaryngology clinic in our hospital,160 cases were diagnosed as chronic nose-as research subjects were randomly divided into four groups of patients with sinusitis were treated from 1 to 4,60 cases in each group;treatment groupl receiving the maxillary sinus ostium augmentation,treatment group 2 received fenestration,treatment group 3 through tears crypt before maxillary sinus surgery,treatment 4 group receiving the maxillary sinus balloon dilatation;after covering the nasal mucosa observed and compared four groups of patients about edema,vesicle formation,bone exposure,scarring,etc.,as well as internal maxillary sinus secretions traits,volume situation,and compared patients after four groups line maxillary sinus cavity and perioral saccharin test biopsy cases three months and six months.Results:The four groups were made after surgery better clinical efficacy,and group efficacy 4 with the other three groups,the effect is most significant (all P ＜0.05),the difference was statistically significant,and after three months and six months,group 4 compared with other surgical group,the Lund-Kernedy score were also lower,MMT time were also lower,the difference was more significant (all P ＜0.05);in the maxillary sinus biopsy aspects:the number of postoperative inflammatory cells and dendritic cells and glandular cell morphology and submucosal edema improved submucosal structures also in the group of four most significant (P＜0.05).Conclusion:Maxillary sinus balloon dilatation treatment chronic nasal sinusitis curative effect is higher,which can effectively improve the cell and submucosal gland cell morphology and sinus mucosa edema,sinus unobstructed drainage effect,and high safety.

Clinical analysis of fluticasone propionate nasal combined with cetirizine in the treatment of allergic rhinitis-sinusitis caused adult subacute cough of 56 cases / 中国医师进修杂志

Objective To research the therapeutic effect of fluticasone propionate nasal combined with cetirizine in the treatment of allergic rhinitis-sinusitis caused adult subacute cough.Methods Allergic rhinitis-sinusitis caused adult subacute cough of 56 patients were randomly divided into study group and control group with 28 cases each group by random digits table method.They were treated with cough expectorant drugs commonly brown mixture,the study group was additionally given fluticasone propionate nasal combined with cetirizine.The therapeutic effect and adverse reactions were compared.Results The total effective rate of study group was 82.1％ (23/28),which was superior to control group 53.6％ (15/28),there which was statistical difference (P ＜ 0.01).Conclusion Fluticasone propionate nasal combined with cetirizine in treatment of allergic rhinitis-sinusitis caused adult subacute cough effect is good,and is worthy of clinical promotion.