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1.  Secondhand tobacco smoke exposure in low-income children and its association with asthma 
Allergy and Asthma Proceedings  2014;35(6):462-466.
Secondhand tobacco smoke (SHS) is a common indoor environmental exposure that is particularly prevalent in low-income families. It has been found to be associated with asthma in some studies; however, across all relevant studies, results have been conflicting. This study aimed to determine the prevalence of SHS exposure in the home environment in a low-income, minority population and to determine the association of exposure with childhood asthma, wheeze, and oral corticosteroids use. This retrospective study analyzed self-reported data collected as part of the Kansas City Safe and Healthy Homes Partnership to determine prevalence of SHS exposure. A logistic regression model was then used to assess the association between exposure and asthma, oral steroid use, and wheeze. Overall, 40% of children lived with at least one smoker and 15% of children lived with at least one smoker who smoked inside the house. No significant association was found between asthma or oral corticosteroid use and SHS exposure. Children who lived with a smoker had a 1.54 increased odds of wheeze in the past year. A large percentage of low-income children in the Kansas City area continue to suffer the adverse effects of SHS. These data support the need for innovative public policy to protect children from such exposure in their home environment.
doi:10.2500/aap.2014.35.3788
PMCID: PMC4210654  PMID: 25584913
Asthma; disadvantaged background; environmental health; environmental tobacco smoke; epidemiology; oral corticosteroids; pediatrics; secondhand smoke; secondhand smoke exposure prevalence; tobacco smoke; wheeze
2.  Homes of low-income minority families with asthmatic children have increased condition issues 
Allergy and Asthma Proceedings  2014;35(6):467-474.
The home is increasingly associated with asthma. It acts both as a reservoir of asthma triggers and as a refuge from seasonal outdoor allergen exposure. Racial/ethnic minority families with low incomes tend to reside in neighborhoods with low housing quality. These families also have higher rates of asthma. This study explores the hypothesis that black and Latino urban households with asthmatic children experienced more home mechanical, structural condition–related areas of concern than white households with asthmatic children. Participant families (n = 140) took part in the Kansas City Safe and Healthy Homes Program, had at least one asthmatic child, and met income qualifications of no more than 80% of local median income; many were below 50%. Families self-identified their race. Homes were assessed by environmental health professionals using a standard set of criteria and a specific set of on-site and laboratory sampling and analyses. Homes were given a score for areas of concern between 0 (best) and 53 (worst). The study population self-identified as black (46%), non-Latino white (26%), Latino (14.3%), and other (12.9%). Mean number of areas of concern were 18.7 in Latino homes, 17.8 in black homes, 13.3 in other homes, and 13.2 in white homes. Latino and black homes had significantly more areas of concern. White families were also more likely to be in the upper portion of the income. In this set of 140 low-income homes with an asthmatic child, households of minority individuals had more areas of condition concerns and generally lower income than other families.
doi:10.2500/aap.2014.35.3792
PMCID: PMC4210655  PMID: 25584914
Air quality; allergens; asthma triggers; children; environment; Healthy Homes Program; housing quality; low-income; minority; urban
3.  Prevalence and characteristics of reported penicillin allergy in an urban outpatient adult population 
Allergy and Asthma Proceedings  2014;35(6):489-494.
Penicillin allergy remains the most common drug allergy, with a reported prevalence of 10% in the United States. Epidemiology of penicillin allergy in outpatient populations is relatively scarce. This study sought to determine the prevalence and characteristics of reported penicillin allergy in an urban outpatient population and to identify trends in clinical evaluation and management from a tertiary center serving a large inner-city population. A retrospective review of electronic medical records was performed of adult patients seen in the Internal Medicine Associates Clinic of Mount Sinai Hospital between January 31, 2012, and July 31, 2012. Medical records were selected based on the documentation of penicillin in patient's allergy section. Of the 11,761 patients seen in the clinic, 1348 patients (11.5%) reported a history of penicillin allergy. The most common allergic reactions were rash (37%), unknown/undocumented (20.2%), hives (18.9%), swelling/angioedema (11.8%), and anaphylaxis (6.8%). There was an increased prevalence of penicillin allergy in female patients compared with male patients (odds ratio [OR] = 1.82; 95% CI = 1.60, 2.08; p < 0.0001), and there were significantly fewer Asians with penicillin allergy compared with Caucasians (OR = 0.51; 95% CI = 0.32, 0.83; p = 0.007). However, only 78 (6%) of the patients reporting penicillin allergy had a referral to an allergy specialist. Overall, improved referral to an allergist will help to identify patients who have penicillin allergy requiring avoidance.
doi:10.2500/aap.2014.35.3791
PMCID: PMC4210656  PMID: 25584917
Adverse drug reactions; anaphylaxis; drug allergy; electronic medical record; epidemiology; outpatient; penicillin
4.  Fifty-five-year-old man with chronic yeast infections 
Allergy and Asthma Proceedings  2014;35(5):415-422.
As immunologists, we are frequently asked to evaluate patients with recurrent infections. These infections can provide us with clues regarding what pathways might be aberrant in a given patient, e.g., specific pyogenic bacteria with Toll-like receptor problems, atypical mycobacteria with interferon gamma receptor autoantibodies, and Candida/staphylococcal infections with cellular immune abnormalities. We present a 55-year-old man who presented to our immunology clinic with onychodystrophy of the toenails and fingernails and recurrent oral–esophageal candidiasis. The differential diagnosis for recurrent yeast infections is complex and includes usual suspects as well as some that are not as straightforward.
doi:10.2500/aap.2014.35.3776
PMCID: PMC4147028  PMID: 25295810
Antibody deficiency; autoantibodies; chronic mucocutaneous candidiasis; Good's syndrome; IL-12; interferon alpha; thymoma
5.  Emergency department visits for acute asthma by adults who ran out of their inhaled medications 
Allergy and Asthma Proceedings  2014;35(3):e42-e50.
This study was designed to determine the percentage of asthma-related emergency department (ED) visits made by patients who recently ran out of their inhaled short-acting beta-agonists or inhaled corticosteroids and to characterize this understudied patient population. A secondary analysis was performed of data from four ED-based multicenter studies of acute asthma during 1996–1998 (n = 64 EDs). In each study, consecutive adult patients, aged 18–54 years, with acute asthma underwent a structured interview that assessed running out of inhaled medications. The analytic cohort comprised 1095 adults. Overall, 324 patients (30%; 95% confidence interval [CI], 27–32%) ran out of either of their inhaled beta-agonists or inhaled corticosteroids during the week before their index ED visit; 311 (28%; 95% CI, 26–31%) ran out of inhaled beta-agonists per se. Among a subset of 518 patients on inhaled corticosteroids, 55 patients (11%; 95% CI, 8–14%) ran out of inhaled corticosteroids. In the multivariable model, predictors of running out of an asthma medication were male sex, non-Hispanic black race, Hispanic ethnicity, no insurance, lower household income, and use of EDs as the preferred source of asthma prescriptions (all p < 0.05). Among patients who ran out of medications, 49% (95% CI, 43–55%) ran out of inhaled beta-agonists and 72% (95% CI, 58–84%) ran out of inhaled corticosteroids, before onset of their acute asthma symptoms. In 1095 adult ED patients with acute asthma, we found that 30% ran out of their inhaled asthma medications before the ED visit. Asthma patients who ran out of medications had sociodemographic characteristics that may help with identification of preventable ED visits. Multifaceted strategies needed to ensure optimal use of inhaled medications are warranted.
doi:10.2500/aap.2014.35.3747
PMCID: PMC4012130  PMID: 24801458
Acute asthma; emergency department; ethnicity; inhaled bronchodilator; inhaled corticosteroids; multicenter study; nonadherence; race; socioeconomic status
6.  C-027 Inhibits IgE-mediated passive sensitization bronchoconstriction and acts as a histamine and serotonin antagonist in human airways 
Atopic asthma is poorly controlled by current therapies. Newer therapies and novel antihistamines are, therefore, required to treat patients whose atopic asthma is not controlled. For the first time, C-027 is shown to antagonize histamine, IgE-mediated and serotonin-induced contraction in human airways and vessels. Human precision-cut lung slices (PCLS, 250 µm thick), containing an airway or blood vessel, were pretreated with either C-027 (2 hours) or with vehicle alone and were contracted with histamine or serotonin. Known antihistamine was used as a comparator in antihistamine studies. Also, human airways were contracted via IgE passive sensitization in the presence or absence of C-027 or fexofenadine. Affinity of C-027 toward human G-protein coupled receptors was also determined, as well as the drug's biodistribution in murine model. C-027 was shown to have the highest affinity toward human histamine and serotonin receptors. Subsequently, C-027 was shown to antagonize histamine- and serotonin-induced airway and vascular smooth muscle contraction, respectively, and histamine-released bronchocontraction mediated by IgE passive sensitization in human small airways. C-027 also inhibited histamine-mediated single-cell calcium ion release. Low levels of C-027 were found in murine brain tissue. Collectively, these data suggest that C-027 markedly inhibits IgE-induced bronchoconstriction and antagonizes histamine and serotonin-contraction with little biodistribution in the brain. The compound may offer a future therapy for allergen-induced airway hyperresponsiveness in patients with asthma.
doi:10.2500/aap.2011.32.3460
PMCID: PMC3968313  PMID: 22195688
Airway smooth muscle; allergy; antagonist; anti-histamine; anti-serotonic; asthma; IgE mediated; novel compound; PCLS; reverse agonist
7.  Assessment of humoral and cell-mediated immune response to measles–mumps–rubella vaccine viruses among patients with asthma 
Little is known about the influence of asthma status on humoral and cell-mediated immune responses to measles–mumps–rubella (MMR) vaccine viruses. We compared the virus-specific IgG levels and lymphoproliferative response of peripheral blood mononuclear cells to MMR vaccine viruses between asthmatic and nonasthmatic patients. The study subjects included 342 healthy children aged 12–18 years who had received two doses of the MMR vaccine. We ascertained asthma status by applying predetermined criteria. Of the 342 subjects, 230 were available for this study of whom 25 were definite asthmatic patients (10.9%) and the rest of subjects were nonasthmatic patients. The mean of the log-transformed lymphoproliferative responses between definite asthma and nonasthma who had a family history of asthma were for measles, 0.92 ± 0.31 versus 1.54 ± 0.17 (p = 0.125); for mumps, 0.98 ± 0.64 versus 2.20 ± 0.21 (p = 0.035); and for rubella, 0.12 ± 0.37 versus 0.97 ± 0.16 (p = 0.008), respectively, adjusting for the duration between the first MMR vaccination and determination of the immune responses. There were no such differences among children without a family history of asthma. MMR virus–specific IgG levels were not different between study subjects with or without asthma. The study findings suggest asthmatic patients may have a suboptimal cell-mediated immune response to MMR vaccine viruses and a family history of asthma modifies this effect.
doi:10.2500/aap.2010.31.3399
PMCID: PMC3941466  PMID: 21708062
8.  Impact of delay in asthma diagnosis on health care service use 
Delays in diagnosing asthma in children are common and are known to delay asthma-specific treatment. Few studies have investigated whether a delay in asthma diagnosis impacts the use of health care services. This study was designed to assess whether a delay in diagnosis of asthma influences the use of health care services. This was a retrospective cohort study with subjects elicited from a convenience sample of 839 healthy children. The criteria for asthma was met in 276 (33%) subjects; of these subjects 179 (65%) had a delay in the diagnosis of asthma and 97 (35%) had a timely diagnosis. Data on health care services (e.g., flu shot, availability of a peak flow meter, hospitalizations, and urgent care or emergency department visits) and the frequency of systemic steroid treatments were collected from medical records during the first 18 years of life. The frequencies of health service and use of systemic steroids were compared using Poisson and logistic regression models in asthmatic children with and without a delay in asthma diagnosis. Children with a delay in asthma diagnosis were more likely to visit urgent care centers at least once (40.8% versus 21.6%; p < 0.001), compared with those with a timely diagnosis. There were no significant differences in other health care service or systemic steroid use. A delay in the diagnosis of asthma was associated with an increase in urgent care visits suggesting suboptimal care. Clinicians should be aware that a delay in the diagnosis of asthma in children may result in the use of suboptimal health care services.
doi:10.2500/aap.2010.31.3358
PMCID: PMC3920287  PMID: 20819315
Accessibility; adolescent; asthma; child; control; delivery of health care; diagnosis; health services; treatment; urgent care
9.  A 71-year-old man with anaphylaxis after eating grits 
The allergist is frequently called on to evaluate patients after episodes of anaphylaxis to determine the cause and implement preventive measures that will reduce the patient’s risk from future episodes. The etiology of anaphylaxis can be the result of numerous causes that may go undiagnosed if a thorough evaluation is not performed. We present a 71-year-old man with no history of food allergy or atopy who presented to the emergency room and then our allergy clinic for evaluation after suffering anaphylaxis after a meal of grits and shrimp. The underlying diagnosis, which was subsequently determined, requires a high index of suspicion and should be included in the differential diagnosis of any patient presenting with unexplained anaphylaxis.
doi:10.2500/aap.2012.33.3476
PMCID: PMC3894600  PMID: 22370536
10.  A cross-sectional analysis of pet-specific immunoglobulin E sensitization and allergic symptomatology and household pet keeping in a birth cohort population 
Allergy and Asthma Proceedings  2013;34(6):504-510.
It is unknown whether family members with detectable specific immunoglobulin E (sIgE) and/or allergic symptoms to pets are more or less likely to reside in a household with pets. We cross-sectionally investigated potential relationships between family members' allergic sensitization and symptoms to dogs and cats and current household pet-keeping practices, using birth cohort data. Blood samples taken from children enrolled in a birth cohort and their biological mothers and fathers, when the children were aged 18 years, were assessed for sIgE to dog and cat allergens. Interviews assessed subjects' self-reported pet exposure symptoms, current household pet-keeping practices, and socioeconomic characteristics. Overall, household dog or cat keeping was not associated with sIgE to these animals and/or self-reported allergic symptoms in the presence of these animals, even after controlling for factors such as education and household income. In subgroup analyses, current household dog keeping among dog-symptomatic teens (n = 40) was significantly lower than among teens who were not dog symptomatic (n = 289), at 48.8 and 61.1%, respectively (p = 0.036). Current household cat keeping was significantly lower among cat-symptomatic mothers (n = 27) compared with mothers who were not cat symptomatic (n = 120), at 24.3 and 37.0%, respectively (p = 0.015). However, when considering those who were both sensitized and reported symptoms, only the mother and cat-keeping associations persisted (p = 0.049). When cat-sensitized mothers report allergic symptoms to cats, these pets may be less likely to be kept in homes. Elevated dog and cat allergen sIgE does not appear to be associated with the keeping of these pets.
doi:10.2500/aap.2013.34.3698
PMCID: PMC3808752  PMID: 24169057
Allergen-specific IgE; allergic symptoms; allergy; asthma; birth cohort; cat; dog; pet keeping; rhinoconjunctivitis; selective avoidance; sensitization
11.  Retrospective analysis of the efficacy of omalizumab in chronic refractory urticaria 
Allergy and Asthma Proceedings  2013;34(5):446-452.
Omalizumab has been shown to be effective in chronic urticaria (CU) patients in numerous reports. However, it remains unknown whether there are specific phenotypes of CU that are more responsive to omalizumab therapy. We sought to identify CU phenotypes responsive to treatment with omalizumab by characterizing patients and their response patterns. A retrospective chart review analysis of refractory CU patients unresponsive to high-dose H1-blockers and immunomodulators and subsequently treated with omalizumab at the University of Wisconsin Allergy Clinic was performed with particular focus on their autoimmune characteristics, response to therapy, and dosing parameters. We analyzed 19 refractory CU patients (16 patients failed or had toxic side effects to immunomodulators) treated with omalizumab with an overall response rate of 89% (17/19). Of these 19 patients, 9 patients (47%) had a complete response, 8 patients (42%) had a partial response, and 2 patients (11%) had no response. In comparing the response patterns to omalizumab, we found no statistically significant differences among “autoimmune positive” versus “autoimmune negative” patients. No statistically significant differences in responses were observed when comparing demographic parameters including age, gender, IgE levels, or dosing regimen. Our study shows that omalizumab has robust efficacy in refractory CU patients regardless of their autoimmune status, age, gender, IgE levels, or dosing protocol.
doi:10.2500/aap.2013.34.3694
PMCID: PMC3753597  PMID: 23998242
Age; ANA; antithyroid antibodies; autoimmune; CU Index; gender; high-dose antihistamine; IgE; omalizumab; urticaria
12.  Atopic conditions other than asthma and risk of the 2009 novel H1N1 infection in children: A case–control study 
Allergy and Asthma Proceedings  2013;34(5):459-466.
A recent study showed an increased risk of 2009 novel H1N1 influenza (H1N1) infection among asthmatic children. Little is known whether this is true for other atopic conditions. This study was designed to determine the association between atopic dermatitis and/or allergic rhinitis and the risk of H1N1 infection among children. We conducted a case–control study in Olmsted County, MN. We randomly selected children ≤18 years of age with a positive test for H1N1. Controls were randomly selected from a pool of residents with negative H1N1 tests and were matched to cases with regard to birthday, gender, clinic registration date, diagnostic test, and month of influenza testing using frequency matching. We compared the frequency of atopic conditions other than asthma between cases and their matched controls. We enrolled 168 cases and 172 controls. Among cases, 91 (54.2%) were male patients, and 106 (63.1%) were white. The median age of cases was 6.3 years (interquartile range, 3.1–11.5). Among cases, 79 (47.0%) had atopic dermatitis and/or allergic rhinitis diagnosed before or after the index date, whereas 54 (31.4%) controls had such conditions (odds ratio [OR], 1.89; 95% CI, 1.15–3.12; p = 0.012, adjusting for asthma status, 2008–2009 seasonal influenza vaccine, time of illness at index date, and other comorbid conditions). History of receiving 2008–2009 seasonal influenza vaccine was associated with H1N1 infection (adjusted OR, 2.06; 95% CI, 1.32–3.28; p = 0.002). Our results suggest an association between H1N1 infection and atopic conditions other than asthma. The association between 2008–2009 seasonal influenza vaccinations and the risk of H1N1 requires further investigation.
doi:10.2500/aap.2013.34.3686
PMCID: PMC3973814  PMID: 23998244
Allergic rhinitis; atopic dermatitis; atopy; case–control; children; epidemiology; H1N1; influenza; Olmsted County; risk
13.  Prenatal determinants of cord blood total immunoglobulin E levels in Mexican newborns 
Allergy and Asthma Proceedings  2013;34(5):e27-e34.
Asthma and allergic diseases have increased worldwide; however, etilogic factors for this increase are still poor. Prenatal consumptions of fatty acids are hypothesized, although few clinical trials in developing countries have been performed. This study was designed to identify predictors of immunoglobulin E (IgE) levels in cord blood of Mexican newborns. Total IgE was measured in umbilical cord blood from 613 infants whose mothers participated in a double-blind randomized controlled trial of 400 mg of docosahexaenoic acid or placebo from 18 to 22 weeks gestation through delivery. During pregnancy, information on sociodemographic characteristics, environmental exposures, and perceived maternal stress were obtained; a maternal blood sample was also collected to determine atopy via specific IgE levels. Logistic regression models were used to identify the main prenatal predictors of detectable total IgE levels in cord blood. IgE was detectable in cord blood from 344 (53.7%) infants; the main predictors in multivariate analyses were maternal atopy (odds ratio [OR] = 1.69; 95% CI, 1.19–2.42; p < 0.05) and pesticide use in the home (OR = 1.49; 95% CI, 1.04–2.14; p < 0.05). When stratified by maternal atopy, season of birth was a significant predictor in the atopic group only (OR = 2.48; 95% CI, 1.00–6.16; p < 0.05), and pesticide use was a significant predictor for infants born to nonatopic mothers (OR = 1.64; 95% CI, 1.07–2.51; p < 0.05). No differences were seen in the proportion of infants with detectable IgE by treatment group. Prenatal supplementation with omega-3 polyunsaturated fatty acid did not alter the detectable cord blood IgE levels. Maternal atopy and pesticide use during pregnancy are strong predictors of cord blood IgE levels in newborns. Clinical trial NCT00646360, www.clinicaltrials.gov.
doi:10.2500/aap.2013.34.3688
PMCID: PMC3973815  PMID: 23998234
Clinical trial; cord blood; maternal atopy; newborn; omega-3 polyunsaturated fatty acid; pregnancy supplementation; total immunoglobulin E
14.  For the Patient! 
doi:10.2500/aap.2013.34.0011
PMCID: PMC3644764  PMID: 23676567
15.  A comparison of clinician-rated neuropsychological and self-rated cognitive assessments in patients with asthma and rheumatologic disorders 
Allergy and Asthma Proceedings  2013;34(2):170-175.
Although data are mixed, asthma and rheumatologic conditions may be associated with cognitive impairment. Medications may play a role because corticosteroids are associated with memory impairment. Therefore, an easily administered assessment of cognition would be useful in these patients. We assessed relationships between self-rated and clinician-rated cognitive performance and mood in patients with asthma and rheumatologic diseases. Participants included 31adults treated for asthma or rheumatologic disorders (17 receiving chronic prednisone therapy, and 14 not receiving prednisone). An objective assessment of a variety of cognitive domains was administered through clinician and patient-rated assessments of cognition. Composite scores for the objective (Global Clinical Rating [GCR]) and subjective (Neuropsychological Impairment Scale: Global Measure of Impairment [GMI]) measures of cognition were derived. Depression was assessed with the 17-item Hamilton Rating Scale for Depression (HRSD-17). A linear regression was conducted with GMI scores as dependent variable and GCR, HRSD-17 scores, and prednisone-use status, as independent variables. Significant differences between prednisone-treated patients and other patients were observed on the GCR, GMI, and HRSD-17. In the regression analysis, HRSD-17 scores, but not GCR scores, significantly predicted GMI scores. Prednisone-treated patients had higher levels of depressive symptoms and subjective and objective cognitive deficits than those not taking prednisone. In the combined patient groups, subjective cognitive assessment was more strongly related to depressive symptoms than objective cognition. Findings suggest physicians should be aware of the potential for cognitive deficits in patients taking corticosteroids and, when appropriate, should consider the use of objective neurocognitive tests or neuropsychology consultation to better characterize its presence and severity.
doi:10.2500/aap.2013.34.3642
PMCID: PMC3587715  PMID: 23484893
Asthma; cognition; corticosteroid; depression; impairment; memory; objective; prednisone; rheumatoid arthritis; subjective
17.  Clinical and laboratory factors associated with negative oral food challenges 
Allergy and Asthma Proceedings  2012;33(6):467-473.
Children with food-specific IgE (FSIgE) ≤2 kUa/L to milk, egg, or peanut (or ≤5kUa/L to peanut without history of previous reaction) are appropriate candidates for oral food challenge (OFC) to investigate resolution of food allergy, because these FSIgE cutoffs are associated with ∼50% likelihood of negative OFC. This study was designed to identify characteristics of children undergoing OFC, based on these FSIgE levels, who are most likely to show negative OFC. We collected demographics, severity of previous reaction, history of atopic diseases, total IgE and FSIgE values, and skin tests results on children who underwent OFCs to milk, egg, or peanut, based on the recommended FSIgE cutoffs. We identified independent factors associated with negative OFCs. Four hundred forty-four OFCs met our inclusion criteria. The proportions of negative OFCs performed based on FSIgE cutoffs alone were 58, 42, and 63% to milk, egg, and peanuts, respectively. Regression models identified independent factors associated with negative OFCs: lower FSIgE levels (all three foods), higher total IgE (milk), consumption of baked egg products (egg), and non-Caucasian race (eggs and peanuts). Combinations of these factors identified subgroups of children with proportions of negative OFCs of 83, 75, and 75% for milk, eggs, and peanuts, respectively. Combinations of clinical and laboratory elements, together with FSIgE values, might identify more children who are likely to have negative OFCs compared with current recommendations using FSIgE values alone. Once validated in a different population, these factors might be used for selection of patients who are most likely to show negative OFCs.
doi:10.2500/aap.2012.33.3607
PMCID: PMC3522388  PMID: 23394503
Children; food allergy; food specific IgE; oral food challenge; regression models; skin test; total IgE
18.  Discrepancies between lung function and asthma control: Asthma perception and association with demographics and anxiety 
Allergy and Asthma Proceedings  2012;33(6):500-507.
Understanding asthma symptom perception is necessary for reducing unnecessary costs both for asthma sufferers and society and will contribute to improving asthma management. The primary aim of this study was to develop and test a standardized method for classification of asthma perceiver categories into under-, normal, and overperceiver groups based on the comparison between self-report and lung function components of asthma control. Additionally, the degree to which demographic variables and anxiety contributed to the classification of patients into perceiver groups was examined. Patients underwent methacholine or reversibility testing to confirm asthma diagnosis. Next, participants completed lung function testing over 3 days before their next appointment. Finally, patients filled out demographic and self-report measures including the Asthma Control Test (ACT). Each self-report category of control assessed by the ACT (interference, shortness of breath, nighttime awakenings, rescue inhaler usage, and a composite total score) was compared with lung function measurements using a modified version of the asthma risk grid. Using the modified asthma risk grid to determine perceiver categorization, this sample included 14 underperceivers, 29 normal perceivers, and 36 overperceivers. A discriminant analysis was performed that indicated that a majority of underperceivers were characterized by being African American and having low asthma-specific anxiety. Normal perceivers in this sample tended to be older. Overperceivers tended to be female. Our findings encourage further research using the reported method of classifying asthma patients into perceiver categories.
doi:10.2500/aap.2012.33.3611
PMCID: PMC3522394  PMID: 23394508
anxiety; asthma; asthma control; asthma management; asthma risk grid; asthma-specific anxiety; classification; lung function; race; symptom perception
19.  Assessment of fractionated exhaled nitric oxide as a biomarker for the treatment of eosinophilic esophagitis 
Allergy and Asthma Proceedings  2012;33(6):519-524.
Diagnosis of eosinophilic esophagitis (EoE) and determination of response to therapy is based on histological assessment of the esophagus, which requires upper endoscopy. In children, in whom a dietary approach is commonly used, multiple endoscopies are needed, because foods are eliminated and then gradually reintroduced. Ideally, noninvasive methods could supplement or replace upper endoscopy to facilitate management. Fractionated exhaled nitric oxide (FeNO) has been proposed as a useful measure for monitoring disease activity in studies of patients with eosinophil-predominant asthma and in other atopic disorders. Thus, we evaluated whether FeNO levels could be a useful biomarker to assess the response to therapy in EoE patients. This study was designed to determine whether there is a change in FeNO levels during treatment with topical corticosteroids and whether changes correlated with clinical response. This was a prospective, multicenter study that enrolled nonasthmatic patients with established EoE. FeNO levels and symptom scores were measured at baseline, biweekly during 6-week swallowed fluticasone treatment, and 4 weeks posttreatment. Twelve patients completed the trial. We found a statistically significant difference between median pre- and posttreatment FeNO levels [20.3 ppb (16.0–29.0 ppb) vs 17.6 ppb (11.7–27.3 ppb), p=0.009]. However, neither the pretreatment FeNO level, a change of FeNO level after 2 weeks of treatment, nor the FeNO level at the end of treatment confidently predicted a clinical or histological response. Although our findings suggest nitric oxide possibly has a physiological role in EoE, our observations do not support a role of FeNo determination for management of EoE.
doi:10.2500/aap.2012.33.3606
PMCID: PMC3522397  PMID: 23394511
Biomarker; disease activity; eosinophilic esophagitis; fractionated exhaled nitric oxide; monitoring; noninvasive; treatment
20.  Role of specific IgE and skin-prick testing in predicting food challenge results to baked egg 
Allergy and Asthma Proceedings  2012;33(3):275-281.
Previous studies suggest that children with egg allergy may be able to tolerate baked egg. Reliable predictors of a successful baked egg challenge are not well established. We examined egg white–specific IgE levels, skin-prick test (SPT) results, and age as predictors of baked egg oral food challenge (OFC) outcomes. We conducted a retrospective chart review of children, aged 2–18 years, receiving an egg white–specific IgE level, SPT, and OFC to baked egg from 2008 to 2010. Fifty-two oral baked egg challenges were conducted. Of the 52 challenges, 83% (n = 43) passed and 17% (n = 9) failed, including 2 having anaphylaxis. Median SPT wheal size was 12 mm (range, 0–35 mm) for passed challenges and 17 mm (range, 10–30 mm) for failed challenges (p = 0.091). The negative predictive value for passing the OFC was 100% (9 of 9) if SPT wheal size was <10 mm. Median egg white–specific IgE was 2.02 kU/L (range, <0.35–13.00 kU/L) for passed challenges and 1.52 kU/L (range, 0.51–6.10 kU/L) for failed challenges (p = 0.660). Receiver operating characteristic (ROC) curve analysis for SPT revealed an area under the curve (AUC) of 0.64. ROC curve analysis for egg white–specific IgE revealed an AUC of 0.63. There was no significant difference in age between patients who failed and those who passed (median = 8.8 years versus 7.0 years; p = 0.721). Based on our sample, SPT, egg white–specific IgE and age are not good predictors of passing a baked egg challenge. However, there was a trend for more predictability with SPT wheal size.
doi:10.2500/aap.2012.33.3544
PMCID: PMC3372532  PMID: 22584194
21.  Effect of cat and daycare exposures on the risk of asthma in children with atopic dermatitis 
Allergy and Asthma Proceedings  2012;33(3):282-288.
Background
Atopic dermatitis in young children is often followed by the development of asthma (atopic march). The role of environmental exposures is unclear in this high risk population.
Objective
We aimed to determine the predictive relationship between indoor allergen exposures, particularly pets, rodents and cockroaches, to the development of asthma in a prospective pediatric cohort.
Methods
Children with atopic dermatitis and a family history of allergy were followed prospectively with questionnaire ascertainment of environmental exposure to cat, dog, cockroach, rat, and mouse. Asthma was diagnosed by study physicians based on caregiver reports of symptoms continually assessed over the course of the study period.
Results
Fifty-five of the 299 children developed asthma by the end of the study. Cat exposure had a strong and independent effect to reduce the risk of developing asthma across all analyses (odds ratio (OR) 0.16; 95% confidence interval (CI) 0.05 – 0.53). Dog, mouse, rat and cockroach exposures did not significantly influence the development of asthma. Daycare exposure had the largest risk reduction for the development of asthma (OR 0.08; 95% CI 0.03 – 0.19). Maternal asthma (OR 2.93; 95%CI 1.29 – 6.67), baseline body mass index (BMI) (OR 1.23; 95%CI 1.08 – 1.42) and specific immunoglobulin E (sIgE) to house dust mix (HDM) at 3 years were each independent risk factors for the development of asthma.
Conclusion
In children with atopic dermatitis, cat and daycare exposure may reduce the risk of developing early childhood asthma.
doi:10.2500/aap.2012.33.3572
PMCID: PMC3354731  PMID: 22584195
Asthma; Atopic dermatitis; Atopy; Cat allergy; Pediatric; Allergy; Pet allergy; Daycare; epidemiology; atopic march; environmental exposure
22.  Effect of cat and daycare exposures on the risk of asthma in children with atopic dermatitis 
Allergy and Asthma Proceedings  2012;33(3):282-288.
Atopic dermatitis (AD) in young children is often followed by the development of asthma (atopic march). The role of environmental exposures is unclear in this high-risk population. We aimed to determine the predictive relationship between indoor allergen exposures, particularly pets, rodents, and cockroaches, to the development of asthma in a prospective pediatric cohort. Children with AD and a family history of allergy were followed prospectively with questionnaire ascertainment of environmental exposure to cats, dogs, cockroaches, rats, and mice. Asthma was diagnosed by study physicians based on caregiver reports of symptoms continually assessed over the course of the study period. Fifty-five of the 299 children developed asthma by the end of the study. Cat exposure had a strong and independent effect to reduce the risk of developing asthma across all analyses (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.05–0.53). Dog, mouse, rat, and cockroach exposures did not significantly influence the development of asthma. Daycare exposure had the largest risk reduction for the development of asthma (OR, 0.08; 95% CI, 0.03–0.19). Maternal asthma (OR, 2.93; 95% CI, 1.29–6.67), baseline body mass index (OR, 1.23; 95% CI, 1.08–1.42), and specific immunoglobulin E to house-dust mix at 3 years were each independent risk factors for the development of asthma. In children with AD, cat and daycare exposure may reduce the risk of developing early childhood asthma.
doi:10.2500/aap.2012.33.3572
PMCID: PMC3354731  PMID: 22584195
Allergy; asthma; atopic dermatitis; atopic march; atopy; cat allergy; daycare; environmental exposure; epidemiology; pediatric; pet allergy
23.  Role of specific IgE and skin-prick testing in predicting food challenge results to baked egg 
Allergy and Asthma Proceedings  2012;33(3):275-281.
Previous studies suggest that children with egg allergy may be able to tolerate baked egg. Reliable predictors of a successful baked egg challenge are not well established. We examined egg white–specific IgE levels, skin-prick test (SPT) results, and age as predictors of baked egg oral food challenge (OFC) outcomes. We conducted a retrospective chart review of children, aged 2–18 years, receiving an egg white–specific IgE level, SPT, and OFC to baked egg from 2008 to 2010. Fifty-two oral baked egg challenges were conducted. Of the 52 challenges, 83% (n = 43) passed and 17% (n = 9) failed, including 2 having anaphylaxis. Median SPT wheal size was 12 mm (range, 0–35 mm) for passed challenges and 17 mm (range, 10–30 mm) for failed challenges (p = 0.091). The negative predictive value for passing the OFC was 100% (9 of 9) if SPT wheal size was <10 mm. Median egg white–specific IgE was 2.02 kU/L (range, <0.35–13.00 kU/L) for passed challenges and 1.52 kU/L (range, 0.51–6.10 kU/L) for failed challenges (p = 0.660). Receiver operating characteristic (ROC) curve analysis for SPT revealed an area under the curve (AUC) of 0.64. ROC curve analysis for egg white–specific IgE revealed an AUC of 0.63. There was no significant difference in age between patients who failed and those who passed (median = 8.8 years versus 7.0 years; p = 0.721). Based on our sample, SPT, egg white–specific IgE and age are not good predictors of passing a baked egg challenge. However, there was a trend for more predictability with SPT wheal size.
doi:10.2500/aap.2012.33.3544
PMCID: PMC3372532  PMID: 22584194
Anaphylaxis; baked egg challenge; egg allergy; food allergy; food challenge; IgE; ImmunoCap; ovomucoid; RAST; skin prick test
24.  Assessment of the association between atopic conditions and tympanostomy tube placement in children 
Allergy and Asthma Proceedings  2012;33(3):289-296.
This study assesses the relationship between otitis media and atopic conditions in children by comparing the incidence of tympanostomy tube placement between children with and without atopic conditions: asthma, allergic rhinitis, and atopic dermatitis. Study subjects were a cohort of 323 healthy children who participated in a study of vaccine response. All episodes of tympanostomy tube placement and physician diagnoses of allergic rhinitis and atopic dermatitis were collected through comprehensive medical record review. Asthma status was ascertained through application of established criteria. We compared incidence rates of tympanostomy tube placement between children with and without atopic conditions. We fitted data to a Poisson regression model to calculate relative risk ratios (RRs) and their corresponding 95% confidence intervals (95% CI). Three subjects were excluded who did not have parental authorization for using records for research. Of the remaining 320 subjects, 170 (53%) were male subjects, 268 (94%) were white, 124 (39%) were asthmatic patients, and 20 (6%) had tympanostomy tube placement. Children with asthma before the index date of tympanostomy tube placement were more likely to have tympanostomy tube placement compared with those without asthma (RR, 19.33; 95% CI, 11.41; 32.75; p < 0.001). We found a similar association between asthma ever (before or after index date) and the incidence of tympanostomy tube placement (RR, 1.53; 95% CI, 0.93–2.53; p = 0.095). This was true for children with allergic rhinitis compared with those without allergic rhinitis (RR, 1.70; 95% CI, 1.01–2.86; p = 0.007). Atopic dermatitis was not associated with the incidence of tympanostomy tube placement. Asthma or allergic rhinitis may be unrecognized risk factors for recurrent or persistent otitis media. However, given the small sample size of the study, a cohort study with a larger sample size is necessary.
doi:10.2500/aap.2012.33.3529
PMCID: PMC3490504  PMID: 22584196
Allergic rhinitis; asthma; atopic dermatitis; atopy; child; infection; otitis media; pediatrics; tympanostomy tube
25.  Prolonged urticaria and fever in a toddler 
Allergy and Asthma Proceedings  2012;33(3):297-301.
We describe a 14-month-old girl who initially presented with 8 days of fever, conjunctival injection, rash, and irritability, admitted with a presumptive diagnosis of Kawasaki disease. Further history revealed intermittent urticarial-like rash since 3 months of age and pathological evaluation showed a perivascular infiltrate of neutrophils and lymphocytes. Here, we discuss the key points surrounding her diagnostic workup and our therapeutic approach.
doi:10.2500/aap.2012.33.3567
PMCID: PMC3490505  PMID: 22584197
Anakinra; cryopyrin; cryopyrin-associated periodic syndrome; fever; IL-1; infliximab; IVIG; Kawasaki; neutrophil; pediatric; urticaria

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