Pediatric Allergy,Immunology,and Pulmonology

The objective of this study was to determine the effect of an asthma education and management intervention, offered as part of an emergency department (ED) visit, on functional severity, use of asthma controller medication, and risk of needing crisis care. Designed as a randomized, controlled clinical trial, Medicaid-insured children aged 2 years to 18 years were seen in an inner-city hospital ED for acute asthma. In the intervention group, the adult accompanying the child received basic asthma education, a written asthma management plan (illustrated by zones colored green, yellow, and red), and prescriptions for both quick-relief and long-term control medication as part of the ED visit. The control group received routine care. Functional severity of asthma was assessed at baseline and at 1 month after the intervention. Medicaid claims data were used to determine frequency of asthma medication dispensing and dates of hospital-based events (ED visits and hospital admissions) during the 6 months after the intervention. Twenty-eight subjects were enrolled in each arm of the study. In the 6 months after enrollment, more asthma controller medication (predominantly inhaled corticosteroid medicine) was dispensed for the intervention group than for the control group (mean 2.1 vs. 0.63 dispensing events; p = 0.004). However, much undertreatment remained in both groups: 61% of subjects in the intervention group and 89% of subjects in the control group had ≤ 1 dispensing of asthma controller medication (p = 0.01). No statistically significant difference in asthma functional severity score was seen at 1 month after intervention. No significant difference in dispensing of quick-relief medication or in presence of hospital-based events was seen during the 6 months after the intervention. Among inner-city children who require ED care for asthma, a single session of ED-based educational and management intervention did improve use of long-acting asthma controller medication, but we were not able to demonstrate a large impact on functional severity of asthma or subsequent hospital-based events.

There is epidemiological and preliminary clinical evidence that exposure to moisture and mold growth is associated with wheezing and asthma in children. Lung function and challenge tests may find obstructive changes in the airways before clinically evident symptoms. The aim of the study was to evaluate lung function and bronchial reactivity in school children in a follow-up setting, and relate them to changes in mold exposure over a 3-year observation period. We performed flow-volume spirometry and an exercise challenge test by outdoor free running 3 years apart to the same 139 students from moisture-problem and control schools. The subjects were classified into four exposure groups: exposure continued, eased, started, and no exposure. There were no significant differences in spirometry or in the exercise challenge test among the children in the four different exposure groups. However, there was a trend that, on average, bronchial reactivity increased when exposure started, and decreased when exposure eased. Spirometry and exercise challenge offer no benefits over symptoms in the follow-up of symptomatic children exposed to moisture and/or molds.

In recent years, an increasing number of observations has lent support to the concept that dysregulation of apoptosis may play a role in the development of airway inflammation in asthma. In the present study, serum sFas and soluble Fas ligand (sFasL) levels were measured by enzyme-linked immunosorbent assay (ELISA), during and 2 weeks after the treatment of the acute attack in 15 asthmatic children (range, 2–14 years; median, 5 years) to evaluate the possible role of the Fas-FasL system in asthmatic inflammation. Serum sFas levels of stable asthmatic patients were significantly higher than both the ones with acute attack and the controls (p < 0.001, p < 0.01, respectively). sFas levels were higher in nonatopic asthmatics, both in the acute and stable phases, than those of the atopics. sFasL levels during the acute attack were significantly higher than those of the controls (p < 0.05). sFasL levels of patients receiving inhaler corticosteroid (ICS) treatment were significantly higher than those of the patients who did not receive ICS treatment during the acute attack (p < 0.05). The significant increase of sFas levels in asthmatic children during the stable phase of the disease rather than the acute phase made us consider that antiapoptotic mechanisms such as sFas may have a great role in ongoing persistent chronic inflammation. The increased levels of sFasL in patients with acute asthma may be the reflection of the effort of immune system for limitation of inflammation by increasing apoptosis of inflammatory cells.

Patients with atopic dermatitis (AD) are afflicted with a distressing, chronically relapsing, extremely pruritic eczema. The pruritus often produces stress in these patients. However, many "triggers" (i.e., sweating, xerosis, some allergens, etc.) are known to produce their itch. "Stress" is well-recognized as another "trigger" of their pruritus. In contrast, laughter reduces allergic responses. The effect of laughter on plasma neurotrophic levels caused by viewing humorous videos was studied in AD patients. The study was conducted using a cross-over design. Twenty-four patients with moderate AD (SCORAD index mean age 14 years, range 13–15 years) and 24 normal subjects (mean age 14 years, range 13–15 years) randomly viewed an 87-minute-long nonemotional weather information video and an 87-minute-long humorous video movie (Modern Times, featuring Charlie Chaplin). Just before and immediately after viewing each video, stress levels were measured using a one-item overall stress-rating scale. Simultaneously, blood was drawn and plasma levels of nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), and neutrophin-4 (NT-4) were measured. Stress levels and plasma levels of NGF, BDNF, NT-3, and NT-4 were significantly elevated in patients with AD. Viewing the humorous video reduced the one-item rating scale and plasma levels of NGF, BDNF, NT-3, and NT-4 in AD patients, whereas viewing the weather information video failed to do so. In contrast, viewing the humorous video or the weather information video had no effect on these parameters in normal subjects. Collectively, laugher caused by viewing the humorous video reduced stress levels with a concomitant decrease in plasma neurotrophins in AD patients. These results may be useful in the study of neuroimmunology and treatment of AD.

The aim of this study was to investigate the relative importance of perinatal, social, and environmental factors in a birth cohort for the risk of developing asthma in a 10-year followup. A group of children (n = 144) with medically diagnosed asthma was matched to a control group of demographic twins (n = 144) from the same birth cohort and region. In a defined region in Sweden, children with a well-documented and medically confirmed asthma diagnosis were retrospectively identified and followed from birth up to the age of 10. Asthma diagnosis, perinatal and obstetric factors, and social data for both the case and control groups were collected through medical records at all health centers in primary care, privately practicing pediatricians, and the public pediatric clinic in the region. The parents of these children answered the standardized ISAAC postal questionnaire, with an overall response rate of 87%. Family history of asthma and allergic rhinitis and low birth weight indicated an increased asthma risk. The social class of the mother and life-style factors concerning mothers smoking habits and indication of passive smoking were also related to increased asthma risk. Also residential factors like mist or mold damage, unusual odors, and dry air were found to indicate increased asthma risk. Maternal asthma, low birth weight, and exposure to passive smoking in the family were all found to be independent predictors for childhood asthma.

Diagnostic criteria for allergic bronchopulmonary aspergillosis (ABPA) in patients with cystic fibrosis have required an absolute increase in total serum immunoglobulin E (IgE) to > 1000 IU/mL (2400 ng/mL). Current guidelines recommend in depth evaluation for those with IgE > 500 IU/mL (1200 ng/mL), or even for those with lower values if there is clinical suspicion for ABPA. We present a case of a patient who met all criteria for ABPA with the exception of elevation of IgE above the diagnostic level. An increase in serum IgE from the baseline level, but not > 1000 IU/mL, and subsequent return to baseline corresponded to a clinical exacerbation and resolution of presumptive ABPA.

Idiopathic pulmonary hemosiderosis (IPH) is a rare condition of unknown etiology, characterized by hemoptysis, alveolar pulmonary infiltrates on chest radiograph, and iron deficiency anemia. The estimated incidence of IPH is 0.24 and 1.23 cases per million in selected populations. We report a case of a 3-year-old girl with acute onset of respiratory distress, microcytic hypochromic anemia, and bilateral alveolar infiltrates on chest radiograph. Pulmonary hemorrhage was confirmed on bronchoalveolar lavage (BAL) and lung biopsy. Other causes of pulmonary hemorrhage were excluded. She was treated with prednisolone, and when her anemia relapsed, azathioprine was added to prednisolone with a good response.

JAY M. PORTNOY, M.D., is Chief, Section of Allergy, Asthma, and Immunology, at the Children's Mercy Hospital and Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine in Kansas City, Missouri. He received a bachelor's degree from the University of Michigan, Ann Arbor, and his M. D. from the University of Missouri-Columbia School of Medicine. Dr. Portnoy completed a residency in pediatrics at the Children's Mercy Hospital in Kansas City and an allergy/immunology fellowship at the University of Michigan School of Medicine. He is an allergy training program director, is a section editor of the Annals of Allergy and Asthma, and serves on the editorial boards of Annals of Allergy and Asthma and Current Allergy Practice.