Showing papers in "Annals of Allergy Asthma & Immunology in 1995"

Risk of administering cephalosporin antibiotics to patients with histories of penicillin allergy.

Abstract: Objectives: The purpose of tits review was to analyze available relevant data regarding the safety of administering cephalosporins to penicillin-allergic patients, including the significance of penicillin skin test reactions and any difference related to first, second, or third generation cephalosporins. Background: Penicillin and cephalosporins both contain a beta-lactam ring. This structural similarity has led to considerable confusion about the cross-allergenicity of these drugs and the risk of allergic reactions from cephalosporins in penicillin-allergic patients. Methods: Published reports and post-marketing data from pharmaceutical corporations provided the basis for this analysis. Results: The overall incidence of adverse reactions from cephalosporins ranges from 1% to 10%, with rare anaphylaxis (<0.02%). In patients with histories of penicillin allergy the incidence of cephalosporin reactions is minimally, if at all increased. Post-marketing studies of second and third generation cephalosporins showed no increase in allergic reactions in patients with penicillin allergy histories. Penicillin skin tests do not predict the likelihood of allergic reactions to cephalosporins in patients with histories of perucillin allergy. One reaction occurred in 98 patients (1%) with positive penicillin skin tests and six reactions occurred in 310 patients (2%) with negative tests. Conclusions: These data indicate that it is safe to administer cephalosporin antibiotics to penicillin-allergic patients and penicillin skin tests do not identify potential reactors

Salmeterol xinafoate in children on high dose inhaled steroids.

Abstract: BACKGROUND Current UK and international guidelines on asthma management recommend that, in pediatric patients still symptomatic on treatment with high-dose inhaled corticosteroids, consideration should be given to the introduction of regular twice daily long-acting beta 2-agonists. OBJECTIVE The purpose of this study was to assess the efficacy and safety of inhaled salmeterol xinafoate 50 micrograms bid via the Diskhaler when added to the existing treatment of children with moderate to severe asthma. METHODS A 12-week multicenter, double-blind, placebo-controlled, parallel group study was conducted at 78 hospital centers throughout the United Kingdom, involving 210 asthmatic children aged between 4 and 16 years of age. Morning peak expiratory flow (PEF), evening PEF, night-time and daytime symptoms and relief medication usage were recorded daily by the patient or parent over a 12-week treatment period. RESULTS Compared with placebo, the addition of salmeterol xinafoate to existing high dose inhaled corticosteroid treatment significantly improved mean morning PEF expressed as percent predicted (PEF-PP) during the first 4 weeks of treatment (median increase 6.5 percentage points P < .001). This effect persisted throughout the 12-week treatment period (P < .05). Both groups demonstrated an overall improvement in mean morning PEF-PP, 7.5 percentage points for salmeterol xinafoate and 4 percentage points for placebo. The mean evening PEF-PP followed a similar although less pronounced trend which was significant only during the first 4 weeks of treatment (P = .014). Daytime relief medication and recorded symptoms were reduced significantly in both groups. There was a greater improvement in the number of symptom-free days during the first 4 weeks (P < .01) and the last 4 weeks (P < .05) of treatment for salmeterol xinafoate. The overall incidence and nature of minor adverse events was similar in both groups. CONCLUSIONS This study demonstrates that the addition of salmeterol xinafoate to inhaled corticosteroid therapy in symptomatic asthmatic children significantly improves morning PEF-PP, and reduces their symptoms and use of relief medication.

Maternal-fetal transfer of immunoglobulins.

Abstract: Objective The goal of this review is to summarize the current knowledge about the transfer of immunoglobulins from the mother to the fetus. Data obtained experimentally and clinically will be discussed, and intervention trials and options will be examined. Data source References are limited to the English language and to human data. Sources include computerized databases and bibliographies of recent articles and books. Results Electronmicroscopic studies have unveiled the passage route of IgG through the placenta. The placental in vitro perfusion system has become a valuable experimental model, with a crucial role in the preclinical evaluation of trials to manipulate the maternal-fetal passage of immunoglobulins. Conclusions Immunoglobulins are transferred through the placenta in an active, selective and affinity-restricted process, which is Fc-gamma receptor mediated and intracellular. Much work is still required to improve our ability to control the rate and the efficiency of this process, but the results of pioneering attempts have been encouraging.

Oral allergy syndrome successfully treated with pollen immunotherapy.

Abstract: Background : Some patients with allergic rhinitis have oral allergic reactions to fresh fruits and vegetables. This phenomenon has been termed oral allergy syndrome and is proposed to be due to cross-reacting allergens in the foods and pollens. Methods : We report a patient with allergic rhinitis and oral allergy syndrome treated with pollen immunotherapy. Prior to immunotherapy, eating any fresh fruit or vegetable caused immediate itching and swelling of his tongue and throat. Prick skin test titration with pollens and foods was performed before and after 13 months of immunotherapy. Specific IgE immunoassay was performed with the same extracts on serum obtained before and after 7 and 13 months of immunotherapy. IgE immunoblots were performed on the same extracts separated by polyacrylamide gel electrophoresis using sera from the same time periods. Results : After 1 year on immunotherapy, the patient's allergic rhinitis symptoms resolved, and he was able to eat fresh fruits and vegetables without reaction. Skin testing and specific IgE immunoassay demonstrated a marked reduction in sensitivity to not only the pollens but the foods as well. Immunoblots revealed that the intensity of IgE binding to most components of the extracts, some common to pollens and foods, declined during immunotherapy. Conclusions : These results support the notion that oral allergy syndrome is due to cross-reacting allergens in foods and pollens and may be amenable to treatment with pollen immunotherapy.

Food Anaphylaxis Following Ingestion of Carmine

Abstract: Background : The risk of sensitization to reactive dyes is well established The clinical situation is caused most often by synthetic azo dyes and triphenylmethane derivatives but natural dyes such as carmine extracted from dried female insects, Coccus cacti (cochineal), have been incriminated Objective : Study of a case of anaphylaxis after ingestion of yogurt to establish the responsibility of carmine Method : Case report of a patient who received skin prick test and leukocyte histamine release test with carmine and yogurt Conclusions : This case provided evidence of an IgE-dependent mechanism and draws attention to the triggering dose of carmine (1 mg) although the acceptable daily intake is up to 50 mg per kg of body weight

Spectrum of presentation of paradoxical vocal cord motion in ambulatory patients.

Abstract: Background: Paradoxical vocal cord motion (PVCM) frequently masquerades as asthma. Atypical presentations of asthma or situations in which asthma does not respond to traditional therapies mandate the consideration of PVCM in the differential diagnosis. Objective: Evaluate the demographics and spectrum of presentation of PVCM in an ambulatory outpatient population. Methods: Retrospective survey of medical records of 164 consecutive patients (86 males, 78 females) who underwent fiberoptic rhinolaryngoscopy over a 3-year period. Results: Twenty patients (16 females, 4 males) with PVCM diagnosed by direct visualization were identified. Mean age at diagnosis was 33 years (range, 14-58 years). Asthma was the most common presenting diagnosis (15/20, 75%), while the remaining 25% had other unusual presentations including two patients (10%) with PVCM masquerading as anaphylaxis. When PVCM masqueraded as asthma, 44% of those patients were inappropriately treated with oral steroids. Nine patients (45%) had a readily identifiable psychologic trigger of their PVCM. Conclusions: Our data confirm previous observations indicating that PVCM is most common in young females and is often associated with psychologic problems. PVCM frequently masquerades as asthma, resulting in overtreatment with corticosteroids. PVCM may also masquerade as stridor, resulting in mimicry of anaphylaxis in the appropriate clinical setting. Thus, PVCM should be considered in any patient presenting with atypical upper and lower respiratory tract symptoms

Mosquito bite anaphylaxis: immunotherapy with whole body extracts.

Abstract: Background Adverse reactions to mosquito bites have been recognized for some time. These usually consist of large local swellings and redness, generalized urticaria, angioedema and less easily definable responses such as nausea, dizziness, headaches, and lethargy. Methods We report two patients who experienced systemic anaphylaxis from mosquito bites. Both were skin tested and given immunotherapy using whole body mosquito extracts. Results Skin testing using whole body mosquito extracts was positive to Aedes aegypti at 1/1,000 weight/volume (wt/vol) in one patient and to Aedes aegypti at 1/100,000 wt/vol, and Culex pipiens at 1/10,000 wt/vol in the other. Skin testing of ten volunteers without a history of adverse reactions to mosquito bites was negative. Immunotherapy using these extracts resulted in resolution of adverse reactions to mosquito bites in one patient and a decrease in reactions in the other. Conclusions Immunotherapy with whole body mosquito extracts is a viable treatment option that can play a role in patients with mosquito bite-induced anaphylaxis. It may also result in severe side effects and one must determine the benefit versus risks for each individual patient.

Inhalation challenge effects of perfume scent strips in patients with asthma.

Abstract: Background : Perfume- and cologne-scented advertisement strips are widely used. There are, however, very few data on the adverse effects of perfume inhalation in asthmatic subjects. Objectives : This study was undertaken to determine whether perfume inhalation from magazine scent strips could exacerbate asthma. Methods : Twenty-nine asthmatic adults and 13 normal subjects were included in the study. Histories were obtained and physical examinations performed. Asthma severity was determined by clinical criteria of the National Heart, Lung, and Blood Institute (NHLBI). Skin prick tests with common inhalant allergens and with the perfume under investigation were also performed. Four bronchial inhalation challenges were performed on each subject using commercial perfume scented strips, filter paper impregnated with perfume identical to that of the commercial strips, 70% isopropyl alcohol, and normal saline, respectively. Symptoms and signs were recorded before and after challenges. Pulmonary function studies were performed before and at 10, 20, and 30 minutes after challenges. Results : Inhalational challenges using perfume produced significant declines in FEV 1 in asthmatic patients when compared with control subjects. No significant change in FEV 1 was noted after saline (placebo) challenge in asthmatic patients. The percent decline in FEV 1 was significantly greater after challenge in severely asthmatic patients as compared with those with mild asthma. Chest tightness and wheezing occurred in 20.7% of asthmatic patients after perfume challenges. Asthmatic exacerbations after perfume challenge occurred in 36%, 17%, and 8% of patients with severe, moderate, and mild asthma, respectively. Patients with atopic asthma had greater decreases in FEV 1 after perfume challenge when compared with patients with nonallergic asthma. Conclusions : Perfume-scented strips in magazines can cause exacerbations of symptoms and airway obstruction in asthmatic patients. Severe and atopic asthma increases risk of adverse respiratory reactions to perfumes.

Anaphylaxis induced by the carboxymethylcellulose component of injectable triamcinolone acetonide suspension (Kenalog).

Abstract: Background Allergic reactions to various corticosteroids are rare but have been reported previously. Objective We wished to determine the etiology of an anaphylactic reaction in a patient who had received intracutaneous Kenalog (triamcinolone acetonide). Methods Skin testing and serologic testing for allergen-specific IgE antibodies was performed for triamcinolone acetonide, its individual components, and three other corticosteroid preparations in both the patient and six other nonallergic persons. Results The patient had positive skin tests to only the carboxymethylcellulose component of triamcinolone acetonide. He had negative skin test reactions to three other steroid preparations which did not contain carboxymethylcellulose. Specific IgE antibodies to carboxymethylcellulose were also elevated by immunoassay and immunoblotting. Control patients had negative skin tests to triamcinolone acetonide, its components, and three other corticosteroid preparations, and their sera lacked significant specific IgE antibodies to these materials. Conclusions Our results indicate that the triamcinolone acetonide component responsible for the patient's reaction was the suspending agent carboxymethylcellulose. We urge physicians to consider component testing when patients experience allergic-type reactions to drugs.

Compliance with an allergen immunotherapy regime.

Abstract: Background: Compliance with an allergy immunotherapy regimen is obviously the difference between a potentially successful or unsuccessful outcome. Objective: The purpose of this study was to assess retrospectively compliance of patients receiving immunotherapy in a private allergy practice. Methods: The study evaluated retrospectively patient compliance with prescribed allergy injections for a private practice in Atlanta, Georgia. Patients who ordered allergy extract material for their injection immunotherapy program during an 18-month period served as the index population for this study. For the purposes of this study, noncompliance was defined as stopping the allergy injection program without the approval of the prescribing physician. Part of this investigation was to determine whether there were compliance differences between those who received their allergy injections within the confines of the clinic and those who received their injections at outside physician offices. A 12-month period of review was considered adequate to monitor compliance because of the 12-month expiration date placed on the allergy extracts. Results: There was a noncompliance rate of 10.77% for those who received their injections within the clinic. This contrasted with the noncompliance rate in the remote population of 34.82%. The difference between these two groups was statistically significant (P<.01). There were no statistical differences with respect to sex or diagnostic category. Significant differences were found between age groups in those receiving injections within or outside the clinic. Conclusions: There is a much higher rate of noncompliance in those who receive their injections in facilities outside the allergist's office. This suggests that to ensure better compliance either individuals should either be encouraged to receive their injections at the allergist's office, or better communications should be established between the referring allergist and the nonallergy physicians who are administering the injections

Allergic rhinitis and olfactory loss.

Abstract: Background : Allergic rhinitis is associated with reports of olfactory loss, but there are few formal investigations Patients with diminished smell function frequently have nasal polyps or sinusitis, making it difficult to separate the impact of allergic rhinitis from the effects of these other problems Objective : The goals of this descriptive study were to establish the prevalence of positive skin tests in patients reporting rhinitis and olfactory deficiency, and to assess olfactory function and the results of skin testing in a patient group with chronic rhinitis but without concomitant sinusitis or nasal polyps Methods : Sixty-two patients reporting olfactory loss and chronic rhinitis were examined by history, physical examination, olfactory testing, skin testing with perennial and seasonal allergens, endoscopic rhinoscopy, and CT scan of the paranasal sinuses Results : Seventy-one percent of all the subjects had at least one positive skin test, 69% to a perennial allergen, and 58% to mite Eighty-two percent of the 28 subjects with chronic rhinitis but no evidence of polyps or sinusitis had positive tests The mean olfactory score for this rhinitis group was 435, consistent with moderate hyposmia The mean olfactory score of 34 subjects with polyps and/or chronic sinusitis was 061, consistent with anosmia, and significantly lower (P <001) Sixty-two percent of this group had positive skin tests Conclusion : These subjects who experienced olfactory loss and rhinitis appeared to have a high prevalence of allergic rhinitis as suggested by the number of positive skin tests Olfactory loss was observed in patients without polyps or sinusitis, which suggests that allergic processes may have affected olfactory function

Chronic sulfasalazine therapy in the treatment of delayed pressure urticaria and angioedema

Abstract: Background Delayed pressure urticaria/angioedema can be profoundly disabling with painful and prolonged swelling of feet and hands as well as systemic symptoms of malaise and flu-like illness. Occupations requiring prolonged standing and forceful use of hands may be seriously compromised by this condition. The severe forms of the disease are usually unresponsive to antihistamines and nonsteroidal anti-inflammatory drugs, and patients frequently require corticosteroids for control of symptoms. Objective It was the purpose of this report to evaluate the clinical utility of sulfasalazine for two patients with refractory delayed pressure urticaria. Methods Sulfasalazine, starting at 500 mg/day (with weekly incremental dosing to a total of 4 g), was administered to two patients with disabling pressure urticaria and angioedema (symptomatic daily with normal activities) who had failed all other reported therapeutic options except corticosteroids. Results Patient A required daily prednisone in excess of 30 mg (for more than 6 months) to control his painful angioedema sufficiently in order to continue working as a colorectal surgeon. Patient B also experienced daily symptoms for more than 1 year. Both patients tolerated sulfasalazine to a dose of 4 g/day without adverse reactions and achieved complete resolution of symptoms. Patient A continued to be well controlled 1 year after starting but must maintain a dose of 2 g or greater per day. Patient B reported excellent control 6 months after starting but was subsequently lost to follow-up. Conclusion Sulfasalazine, in doses used for inflammatory bowel disease, appears to be an effective alternative therapy for delayed pressure urticaria and angioedema in patients poorly controlled by traditional treatment and may act as a corticosteroid-sparing agent.

Latex allergy in housekeeping personnel.

Abstract: Background : Latex allergy has been well described in healthcare workers and children with spina bifida. Cost effective measures to avoid latex allergic reactions are possible in these recognized risk groups. Objective : To study the prevalence of latex allergy among hospital housekeepers regularly exposed to latex gloves. Methods : Fifty members of the housekeeping staff at a Toronto teaching hospital were screened by questionnaire for latex allergy. Patients with possible atopy or symptoms suggestive of latex allergy (20) were skin tested with latex (Bencard Laboratories) eight common allergens and histamine control. Results : Four of 20 tested had a positive latex prick skin test representing an 8% prevalence overall within this group, and a 20% prevalence among atopic housekeepers. Based on an expected 1% prevalence in the general population, this was statistically significant (P < .005). Latex-positive patients had extensive exposure to high protein-unlined latex gloves. Positive patients had a similar yet completely unique immunoblot pattern of IgE binding. All four positive patients had unrecognized latex allergic symptoms (hand dermatitis, rhinoconjunctivitis). One house-keeper experienced itchiness of her face, angioedema, and lightheadedness immediately after inflating a latex balloon. Conclusions : The 8% prevalence of a positive latex skin test in regularly exposed hospital housekeepers is similar to that observed among healthcare workers suggesting this is a new risk group.

Characterization of daytime sleepiness and psychomotor performance following H1 receptor antagonists.

Abstract: Background : While first generation H 1 -receptor antagonists are widely used, there are relatively few data describing their comparative effects on subjective daytime sleepiness and psychomotor performance. Objective : To compare the effects of first generation H 1 receptor antagonists on subjective daytime sleepiness and psychomotor performance. Methods : We conducted two single-dose, cross-over studies. In the first, we validated our methodology in 18 healthy subjects by examining the response to diphenhydramine (50 mg), terfenadine (60 mg), and placebo. In the second trial, we evaluated the relative effects following diphenhydramine (50 mg), diphenhydramine (25 mg), chlorpheniramine (4 mg), and placebo. Psychomotor tests included choice reaction time, hand steadiness, and a test that divided attention between tracking and reaction time. Introspective drowsiness was measured using a visual analog scale and the Stanford Sleepiness Scale. Assessments were made prior to dosing and at one, three, and five hours after dosing ; a 7-hour post-drug assessment was included in the second trial. Results : In the first trial, 50 mg diphenhydramine produced significant impairment relative to placebo in both subjective and objective assessments (P < .05). Responses following terfenadine did not differ from placebo. In the second study, all three regimens produced subjective and objective soporific effects to a significantly greater degree than placebo. For example, significant introspective sleepiness was noted three hours following all three regimens (P < .05) and slower choice reaction times were noted one and three hours after dosing (P < .05). The general rank order of effects was diphenhydramine (50 mg), followed by diphenhydramine (25 mg), followed by chlorpheniramine (4 mg). Significant differences among the three regimens were, for the most part, confined to greater soporific effects from diphenhydramine relative to chlorpheniramine (P < .05). Conclusions : Taken together, our observations confirm that subjective and objective measures of sleepiness and psychomotor performance occur following single doses of diphenhydramine and chlorpheniramine, but not terfenadine. Differences in soporific effects do exist among regimens of first-generation compounds.

Allergic gastroenteropathy in children.

Abstract: Objective: To review the pathogenesis, symptoms, and treatment of gastrointestinal disorders linked to immunopathologic reactions associated with the ingestion of food antigens in infancy and childhood. Data Sources: A computerized MEDLINE search was performed for the following topics: allergic colitis, allergic proctitis, eosinophilic gastroenteritis, eosinophilic colitis, cow milk intolerance, protein losing enteropathy, and malabsorption. This search was restricted to the English language and human subjects. Articles published between 1960 and 1993 were included as references. The textbooks which were used as references include: (1) Walker WA, et al, eds. Pediatric gastrointestinal disease; pathophysiology, diagnosis, management, Philadelphia: BC Decker, 1991; (2) Wyllie R, et al, eds. Pediatric gastrointestinal disease; pathophysiology, diagnosis, management, Philadelphia: WB Saunders, 1993; (3) Targan SR, et al, eds. Immunology & immunopathology of liver and gastrointestinal tract. Igaku-Shoin, 1991; (4) Goldman H, et al, eds. Pathology of the gastrointestinal tract. Philadelphia: WB Saunders, 1992. Conclusion: The symptoms of allergic gastroenteropathy may be those of classic allergic reactions or present as symptom complexes that may include diarrhea, malabsorption, and protein-losing enteropathy. The immunopathogenesis of allergic gastroenteropathy is complex and is still not clearly understood. As our understanding of the gastrointestinal mucosal system evolves, we should be able to manage and care for the infants and children who suffer from this group of disorders better

Selective deficiency in pneumococcal antibody response in children with recurrent infections

Abstract: Background : Impaired ability to respond to polysaccharide capsular antigens of Streptococcus pneumoniae may be associated with an IgG subclass deficiency and recurrent respiratory infections. Objective : To identify children over three years of age with recurrent otitis media, sinusitis, or pneumonia who had low or absent pneumococcal antibody titers as their sole manifestation of immune deficiency and to determine their response to the 23-valent pneumococcal vaccine. Results : Of 100 children with low pneumococcal antibody titers, 87 generated a protective antibody response to the pneumococcal vaccine (>300 ng/mL to the majority of the antigen serotypes), while 13 responded poorly or not at all. Repeated vaccination of nonresponders failed to produce a normal response. Conclusion : We have identified two clinically distinct subpopulations of children with recurrent respiratory infections characterized by their responsiveness to pneumococcal antigens : one group did not respond to pneumococcal vaccination, whereas the other group responded both clinically and serologically. The nonresponding 6.5% subpopulation has an apparent isolated defect in anti-pneumococcal antibody production associated with recurrent respiratory infections despite normal IgG2 subclass levels.

Bronchial hyperreactivity revisited.

Abstract: Objective : The purpose of this article is to review bronchial reactivity : how it is detected, what are the clinical and pathologic correlates and what treatment modulates it. Is it a good diagnostic test for a disease such as asthma ? Is it a reasonable parameter to follow in assessing disease severity and response to treatment ? Data Sources : Recent studies on human subjects in the English language medical literature involving bronchial hyperreactivity. In particular all studies were sought that correlated indices of inflammation obtained either by bronchoalveolar lavage or biopsy with degree of bronchial hyperresponsiveness. Pertinent studies reviewing disease association with presence of bronchial hyperreactivity were sought. All studies of treatment with inhaled corticosteroids were reviewed and those in which the subjects could be classified as having either mild or moderately severe asthma on the basis of the clinical information given were used to provide data on correlation of bronchial reactivity and disease severity. Results : The relationship of bronchial reactivity and any disease state is not straightforward. It is not clear what causes hyperreactivity of the airways but there must be other factors besides inflammation as bronchial hyperreactivity can occur without microscopic evidence of inflammation. Hyperresponsiveness does not appear to be as sensitive or specific for the diagnosis of asthma as previously thought, or as closely related to the severity of asthma. Effects of treatment appear to be somewhat independent of their impact on bronchial responsiveness. Conclusions : Airway hyperresponsiveness can be found in many circumstances. Its relationship to symptom production and clinical course in any disease is not clear. Further studies are needed to elucidate the relationship between airways hyperreactivity, asthma, and other lung diseases and the factors that lead to increased bronchial reactivity.

Intravenous immunoglobulins in the therapy of autoimmune and systemic inflammatory disorders.

Abstract: Objective: The focus of this review is to summarize the mechanism and the adverse side-effects of Intravenous Immunoglobulin (IVIg) therapy, and to highlight the current cumulative experience of its use in the treatment and management of autoimmune and systemic inflammatory diseases. Data sources: Detailed search of the literature was done. Studies involving only humans were considered for clinical evaluation. Animal studies were used only for understanding mechanisms of action. The NIH Consensus Conference of May 1990 and the Australian Society for Blood Transfusion of July 1993 were used for guidelines. Study Selection: Material was taken only from peer reviewed journals. Results: It appears that IVIg may act by more than one mechanism of action. It is unclear whether the mechanism is different in different diseases and whether more than one mechanism may apply to any disease or clinical state. The incidence and gravity of serious side effects appears low. It is the mainstay of treatment of immune thrombocytopenia purpura and Kawasaki disease. Conclusion: IVIg is a safe and effective therapeutic modality that can be added to the repertoire of various agents used to treat autoimmune and systemic inflammatory diseases. Long-term prospective studies are needed to define indications, dose-schedules, duration of therapy, and influence on the clinical courses of chronic diseases better

US asthma mortality: 1941 to 1989.

Abstract: Background: Asthma mortality in the United States has nearly doubled in the past 10 years. An examination of long-term trends in United States asthma mortality places the current mortality rates in a historical perspective, identifies high-risk groups for interventions, and may provide clues to the etiology of asthma mortality. Methods: Asthma deaths for the population aged 5 to 34 years were abstracted from United States vital statistics reports for the period 1941 through 1989. Race-specific and sex-specific mortality rates were age-adjusted to the 1989 estimate of the US population. Results: Among the population aged 5 to 34 years, three distinct periods of asthma mortality were observed: 1941 to 1964, 1965 to 1977, and 1978 to 1989. From 1941 through 1964, nonwhites exhibited a gradual increase in asthma mortality rates; in contrast, whites showed no change in mortality rates. From 1965 through 1977, a marked decline in mortality rates was observed among both nonwhites and whites. From 1978 through 1989, asthma mortality increased with a near doubling in the mortality rates in both nonwhites and whites. Overall, non-whites had mortality rates 4 times those of whites, with nonwhite males aged 15 to 34 at the greatest risk of death due to asthma. Age and sex differences in asthma mortality are also apparent. The population aged 15 to 34 years generally had mortality rates greater than the population aged less than 15 years. For the population aged 5 to 14 years, regardless of calendar year, females had lower mortality rates than males. Among the population aged 15 to 34 years, females experienced twice the mortality rates of males prior to 1965; however, by the 1980s this relationship no longer existed. Conclusions: The asthma mortality rate for nonwhites was 4-fold higher than for whites, although the reported prevalence of asthma is less than 2-fold greater. The population aged 15 to 34 years had higher mortality rates than the population aged 5 to 14 years despite exhibiting a lower prevalence of asthma. There are also gender differences in asthma mortality. These differences may be attributable to differences in asthma severity, or differences in disease management or reflect actual differences in mortality. These findings suggest that the search for clues to understand the increase in asthma mortality from 1978 to 1989 should include an attempt to understand why asthma mortality declined in the preceding decade from 1967 to 1977 as these may not be completely unrelated trends

Immunoblot study of IgE binding allergens in celery roots.

Abstract: Objectives : The purpose of this study was to characterize the IgE binding components of celery root by immunoblot analysis and to investigate the cross-reactive nature of the allergens. Background : Sensitization to celery is very common in patients hypersensitive to mugwort pollen and birch pollen, and is due to cross-reactions of allergen-specific IgE antibodies. Recently, the pan-allergen profilin has been identified as an important cross-reactive allergen in celery, birch pollen and mugwort pollen. Very few data, however, on additional celery allergens are available. Methods : Sera of 38 patients with an isolated or combined sensitization to birch pollen, mugwort pollen, and celery were investigated by immunoblot and immunoblot inhibition techniques using celery extract and purified Bet v I, the major allergen from birch pollen. The selection of sera was based on serologic sensitization, independent of clinical manifestations. Celery profilin was affinity isolated and analyzed by immunoblotting with patients' sera as well as with rabbit polyclonal antiserum raised against celery profilin. Results : Only weak IgE binding occurred on celery immunoblots in the patient groups with a negative RAST to celery. Sera of 6/8 patients with a birch pollen/celery sensitization recognized a 16-kDa celery allergen that cross-reacted with Bet v I in immunoblot inhibition experiments. In the mugwort pollen/celery and birch pollen/mugwort pollen/celery patient groups, the sera of 6/16 patients contained IgE that bound to a 15 to 16-kDa double band identified as celery profilin. Furthermore, three sera of the birch pollen/mugwort pollen/celery group appeared to contain IgE antibodies against carbohydrate determinants. Conclusions : The 16-kDa Bet v I-related celery protein appears to be an important allergen for patients sensitized to birch pollen and celery. In contrast IgE binding to celery profilin appears to be more important in patients with an additional sensitization to mugwort pollen.

Asthma and related atopic disorders in outpatients attending an urban HIV clinic

Abstract: BACKGROUND: Drug hypersensitivity and pruritic cutaneous disorders are common in human immunodeficiency virus (HIV)-infected patients. Systematic cross-sectional studies, detailing the pattern of atopic disease, however, have not been performed in patients with HIV infection. OBJECTIVE: To analyze the relationships between atopic disease and factors relating to lifestyle, environment, gender, genetics, and HIV disease-associated immune cell depletion. METHODS: CD4 cell counts and interview data were recorded in a survey of 136 adult patients attending a community hospital-based HIV outpatient clinic. The reported presence of various atopic and related conditions (including asthma, hay fever, otitis, sinusitis, and dermatitis) were analyzed for prevalence and associations with CD4 cell depletion, family atopy, and other factors using logistic regression. RESULTS: Seventeen percent and 15% of patients claimed to have asthma and hay fever, respectively. Eleven percent claimed chronic nasal symptoms without known hay fever. A recent CD4 count > or = 200 cells/dL was significantly associated with current asthma (P = .01) and this association remained after adjusting for other significant factors. The mean recent log CD4 count for patients with current asthma was significantly higher than other patients (5.63 +/- .73 versus 4.92 +/- 1.38, P = .001). There was no association between rhinitis and CD4 cell depletion. Histories of recent sinusitis (24%) and ear infections (16%) were common, and were significantly associated with current hay fever +/- chronic nasal symptoms (P < .05). Chronic pruritic rashes or eczema were reported in 29% and were more frequent in those with CD4 counts < 200/dL. Family histories of either asthma or hay fever were significantly associated with several condition including hay fever +/- chronic nasal symptoms, otitis, drug allergy, chronic pruritic rashes or eczema, and asthma. CONCLUSIONS: Although atopic disorders in the setting of HIV infection appear to have some clinical associations similar to that reported for the general population, asthma appears to have a predilection towards less severe CD4 cell depletion. The potential role of chronic rhinitis +/- family atopy as risk factors for sinusitis and otitis may be important because treatment of selected individuals with rhinitis may potentially decrease some paranasal disease-related morbidity in HIV infection.

Very low frequency of latex and fruit allergy in patients with spina bifida from Venezuela: influence of socioeconomic factors.

Abstract: Background : The prevalence of latex allergy appears to be substantially higher in certain high risk groups, particularly in children with spina bifida. The source of this increase is presently unknown and may be due either to increased infantile exposure or to an intrinsic predilection for atopy in this condition. Objective : We attempted to ascertain the prevalence of latex and tropical fruit allergy in children of lower socioeconomic strata with spina bifida from Caracas, Venezuela, who have limited operative and other medical exposure to latex. Methods : Ninety-three unselected patients with spina bifida from clinic and hospital populations were prick tested with commercial (Stallergenes-Pasteur) latex extract and crude glove (Baxter-Triflex, 1/5 wt/vol) latex extract as well as with standardized mite and cockroach, 1/10 wt/vol, extracts (Hollister-Stier). An array of tropical fruits were also included in the battery of skin test materials, using the prick by prick method. Careful family and personal history for allergy as well as any reactions to rubber products were noted, placing emphasis on intraoperative anaphylaxis, number of operations and use of bladder catheters. Results : Only four patients of the 93 skin tested (4.3%) were positive to latex. Atopy was not a predisposing factor for latex allergy and neither was the number of surgical interventions. No fruit allergy was found in this population and three of the four skin test-positive patients had facial angioedema when exposed to balloons. Conclusions : The very low incidence of latex allergy found in our patients with spina bifida could very well be due to a low level of rubber exposure as best exemplified in the use of nonlatex bladder catheters, frequently washed and resterilized surgeon's gloves, and low number of operations per patient. The fact that atopy was no more prevalent in children with spina bifida than in the general population in Venezuela strongly supports exposure level as the major factor determining latex sensitization.

Continuous versus frequent intermittent nebulization of albuterol in acute asthma : a randomized, prospective study

Abstract: Background : In acute severe asthma the optimal dose, frequency, duration and method of administration of beta-2 agonists is unknown. No study to date has evaluated the efficacy of high dose beta-2 agonists beyond the initial two hours. Objective : (1) To determine whether high-dose continuous nebulization of albuterol (7.5 mg/h) is as safe and as efficacious as high-dose intermittent nebulization of albuterol (2.5 mg every 20 minutes) for four hours. (2) To evaluate whether there is a continual improvement using high dose therapy beyond two hours. Methods : We devised a simple means of continuous nebulization calibrated to deliver 7.5 mg albuterol per hour. Twenty-two nonsmoking, patients with acute, severe asthma who presented to the emergency department with less than 60% predicted normal PEFR were randomized to either the continuous or intermittent group. All patients received intravenously 125 mg methyl prednisolone on initiation of the study. No theophylline was administered. Spirometry and vital signs were measured at baseline and every 30 minutes thereafter. Electrocardiograms were obtained on all patients and all patients had continuous cardiac monitoring. Results : Both groups doubled their baseline spirometric values over the four-hour period (P <.0001). The FEV 1 did not differ significantly between regimens at any time interval. Improvement from 120 minutes to 240 minutes was statistically significant (P <.0001). There was no significant difference in vital signs at the end of the study compared with baseline in either group, nor between the two groups at any time interval. Conclusion : High-dose continuous nebulization of albuterol is as safe and as efficacious as intermittent nebulization of albuterol in the early treatment of asthma in an emergency department. To our knowledge, this is the first study showing continued significant improvement beyond the initial two hours of therapy using high dose nebulized beta-2 agonists.

Clinical management strategies to maintain drug compliance in asthmatic children.

Abstract: Objective: Noncompliance with asthma medication is a common cause of treatment failure and may lead to unnecessary hospitalization and emergency care. This publication reviews factors associated with compliance with treatment regimens in general as well as with recommended asthma medications. General strategies (educational, organization, and behavioral) are reviewed with emphasis in behavioral strategies. These include reminders, tailoring, and contracting. Study selection: A case report follows regarding a 9-year-old boy with severe asthma who was treated in a short-term inpatient asthma rehabilitation center and followed for 3 years as an outpatient. Specific clinical management strategies and techniques to maintain theophylline compliance are presented. Conclusion: A systematic approach emphasizing the use of behavioral strategies and drug monitoring can be helpful in promoting compliance with a therapeutic regimen. This may lead to a reduction in pulmonary morbidity and medical costs

Leukotriene inhibitors and antagonists in asthma.

Abstract: Objective : This article reviews the literature on the effects of leukotrienes in asthma. In particular, the ability of recently developed receptor antagonists and synthesis inhibitors to attenuate the asthma-causing effects of leukotrienes is examined. Design : Published literature on the role of leukotrienes in asthma was reviewed. Reports of research on agents that inhibit the synthesis of leukotrienes or block leukotriene receptors were also studied. Results : Leukotrienes are endogenous molecules formed by the breakdown of a membrane constituent, arachidonic acid, via the 5-lipoxygenase enzyme pathway. This pathway ultimately produces several species of leukotrienes with various biologic activities, including generalized inflammatory effects associated with asthma: increased vascular permeability, enhanced mucous production, and decreased mucociliary transport. Particularly important in asthma, leukotriene receptors on the airways mediate a potent bronchoconstriction. Two general types of drugs have been developed with the goal of attenuating the leukotrienes' effects in inflammation and asthma : the leukotriene receptor blockers and the leukotriene synthesis inhibitors (eg, 5-lipoxygenase inhibitors). Conclusions : The antileukotriene drugs attenuated the responses to inhaled leukotrienes and allergen challenges. These agents produced beneficial effects in cold-, exercise-, and aspirin-induced asthma, as well as clinical asthma. Many of these medications appear to be effective in the treatment of asthma ; however, further clinical research is needed to determine which patients would benefit most from their use.

Measurement of mosquito Aedes vexans salivary gland-specific IgE and IgG antibodies and the distribution of these antibodies in human sera.

Abstract: Background Lack of sensitive, reproducible, and specific immunoassays has hampered the evaluation and immunotherapy of mosquito allergy. Objective We wanted to develop ELISAs for measurement of mosquito-specific IgE and IgG using salivary glands from the mosquito Aedes vexans. Methods Microplates coated with the salivary gland antigen were sequentially incubated with serum samples or reference serum, goat antibody to human IgE or IgG, and enzyme-conjugated rabbit anti-goat IgG. Results The specificity of the assays was demonstrated by the successful inhibition of the ELISA reactions with the mosquito antigens. Reproducible results were obtained; mean coefficients of variation between assays were 0.200 +/- 0.002 for the IgE measurement and 0.114 +/- 0.001 for the IgG measurement. The sensitivity of each assay was 0.39 U/mL. Using these assays, sera from 50 subjects with skin reactions to mosquito bites ranging from negative to strongly positive were analyzed for mosquito-specific IgE and IgG. The mean mosquito-specific IgE and IgG were significantly higher in subjects with skin reactions to mosquito bites than in those without skin reactions (P .05). Also, there was a significant correlation between mosquito-specific IgE and IgG levels (r = .77, P Conclusions Specific, reproducible, and sensitive ELISAs have been developed for measurement of antibodies to Aedes vexans. Mosquito-specific IgE and IgG may involved in the development of sensitivity to mosquito bites.

Specific IgE to Japanese cypress (Chamaecyparis obtusa) in patients with nasal allergy

Abstract: Background Japanese cedar (Cryptomeria japonica) is the most important pollen causing pollinois during spring. During recent years some patients' nasal symptoms have been getting worse after the Japanese cedar pollen season. Japanese cypress (Chamaecyparis obtusa) pollen is also observed in this period. The purpose of the study was to investigate the effect of Japanese cypress pollen and cross-allergenicity between Japanese cypress and Japanese cedar in patients with allergic rhinitis. Methods A total of 267 patients were enrolled in the study. IgE antibodies to both tree pollens were measured by the CAP RAST method. The results of the CAP RAST test were compared with those of skin tests. In order to compare cross-allergenicity between these two pollens, CAP RAST inhibition assay was carried out. Results The positive frequencies of Japanese cypress and Japanese cedar in 267 patients were 50.1% and 74.7%, respectively. A significant correlation (r = .765) was observed between the two tree pollens. There was good concordance (75%) between RAST and skin tests to Japanese cypress. The results of RAST inhibition assay indicated cross-allergenicity between these two pollens and species-specific allergens. Conclusion Measurement of IgE antibody to Japanese cypress is useful for the diagnosis of pollinois during the spring.

Spontaneous variations in congestion of the nasal mucosa.

Abstract: Background Nasal patency shows spontaneous variations but is also influenced by exercise and allergic conditions. These variations have not been described in detail with regard to allergy. Objectives The purpose of this study was to examine whether these variations are different in nonallergic subjects and in subjects with nasal allergy to pollen out of the pollen season. Methods We examined 12 of each type of subject in the winter on two days for seven hours in a climatic chamber with constant temperature and relative humidity, one day for examination of spontaneous variations and one day for examination of exercise response. Every 15 minutes the volume of the nasal cavities, minimum cross-sectional areas, and areas at fixed distances from the nostril were measured by acoustic rhinometry. Symptoms were scored by a questionnaire. Results There were more pronounced spontaneous variations expressed as the coefficient of variation of nasal volume in allergic than in nonallergic subjects (14% against 9%, P = .004). A nasal cycle was observed in four of the nonallergic subjects and three of the allergic subjects. In the postexercise period, the spontaneous variations in the nonallergic subjects were increased but decreased in the allergic subjects. Exercise increased nasal patency more in the allergic subjects but only significantly for the cross-sectional area at 3.3 cm (105% compared with 43% in the nonallergic subjects, P = .05). In contrast, pharmacologic decongestion in the allergic subjects showed a tendency to be more pronounced for the nasal cavity volume (55% increase versus 42%, P = .08). There was no difference between the groups in nasal symptom scores. Conclusion Allergic subjects out of the pollen season have more congested and more sensitive nasal mucosa than nonallergic subjects.

Cross-reactivity of alternate plant sources of latex in subjects with systemic IgE-mediated sensitivity to Hevea brasiliensis latex

Abstract: Background Previous studies have suggested that there is cross-reactivity in subjects sensitive to natural rubber proteins with other plant proteins such as banana, chestnut, and avocado. There are numerous other plants known to produce rubber including Parthenium argentatum and Ficus elastica. It is not known whether patients with IgE-mediated systemic reactions caused by the common source of natural rubber Hevea brasiliensis are also sensitive to the rubber-containing material from these other plant sources of latex. It is also not certain how much the allergenicity of latex made from Hevea brasiliensis can be reduced by extracting proteins from the sap since some proteins are tightly associated with the cis-1,4-polyisoprene. Objective In this study we investigated whether there would be cross-reactivity to other natural sources of latex in these patients. Methods Seven patients with histories of systemic type I hypersensitivity to latex products had strongly positive skin tests to Hevea brasiliensis latex from two different sources. These subjects were tested by the prick method for sensitivity to three other natural sources of latex. These included latex-containing material from Parthenium-argentatum and Ficus elastica as well as washed and centrifuged rubber particles from Hevea brasiliensis sap. Results All subjects had negative skin tests to all dilutions of the rubber samples from these other natural sources of latex. Conclusion These results suggest several potential sources of natural hypoallergenic latex that might be tolerated by latex-sensitive individuals.