Andrew Halkas

Disagreement Among Common Measures of Asthma Control in Children

BACKGROUND Asthma is a worldwide problem. It cannot be prevented or cured, but it is possible, at least in principle, to control asthma with modern management. Control usually is assessed by history of symptoms, physical examination, and measurement of lung function. A practical problem is that these measures of control may not be in agreement. The aim of this study was to describe agreement among different measures of asthma control in children. METHODS A prospective sequential sample of children aged 4 to 11 years with atopic asthma attending a routine follow-up evaluation were studied. Patients were assessed with the following four steps: (1) fraction of exhaled nitric oxide (FENO), (2) spirometry, (3) Childhood Asthma Control Test (cACT), and (4) conventional clinical assessment by a pediatrician. The outcome for each test was coded as controlled or uncontrolled asthma. Agreement among measures was examined by cross-tabulation and κ statistics. RESULTS Eighty children were enrolled, and nine were excluded. Mean FENO in pediatrician-judged uncontrolled asthma was double that of controlled asthma (37 parts per billion vs 15 parts per billion, P < .005). There was disagreement among measures of control. Spirometric indices revealed some correlation, but of the unrelated comparisons, those that agreed with each other most often (69%) were clinical assessment by the pediatrician and the cACT. Worst agreement was noted for FENO and cACT (49.3%). CONCLUSION Overall, different measures to assess control of asthma showed a lack of agreement for all comparisons in this study.

Allergic rhinitis in South Africa: 2012 guidelines.

Background. Allergic rhinitis (AR) is an important disease in South Africa. The South African Allergic Rhinitis Working Group (SAARWG) has published previous guidelines for AR diagnosis and management. Areas of concern have arisen that require additional information, including the management of AR in infancy, appropriate and inappropriate allergy testing, cost of AR management, diagnosis and distinguishing the condition from sinusitis, use of over-the-counter medications, and the concept of the ‘united airway’. Recommendations. Clinicians should consider the possibility of AR in infants with recurrent nasal symptoms. Allergy testing should be used wisely and based on local allergens. Total IgE testing is not routinely required to prove allergy. Acute and chronic sinusitis should be considered in conjunction with AR; treatment of rhinitis will improve these conditions. Over-the-counter medications should be used sparingly and with caution. Concern for long-term use of topical decongestants must be noted. Asthma should always be considered in AR diagnosis. Immunotherapy is available in SA and may be extremely useful in selected AR patients. Conclusion. The SAARWG proposed an algorithm for the diagnosis and management of rhinitis in South Africa. AR is common, important and troubling to patients; therefore, every effort should be made to target therapy correctly. Patient education is important in the management of AR.

Disagreement between common measures of asthma control in children

BACKGROUND Asthma is a worldwide problem. It cannot be prevented or cured, but it is possible, at least in principle, to control asthma with modern management. Control usually is assessed by history of symptoms, physical examination, and measurement of lung function. A practical problem is that these measures of control may not be in agreement. The aim of this study was to describe agreement among different measures of asthma control in children. METHODS A prospective sequential sample of children aged 4 to 11 years with atopic asthma attending a routine follow-up evaluation were studied. Patients were assessed with the following four steps: (1) fraction of exhaled nitric oxide (FENO), (2) spirometry, (3) Childhood Asthma Control Test (cACT), and (4) conventional clinical assessment by a pediatrician. The outcome for each test was coded as controlled or uncontrolled asthma. Agreement among measures was examined by cross-tabulation and κ statistics. RESULTS Eighty children were enrolled, and nine were excluded. Mean FENO in pediatrician-judged uncontrolled asthma was double that of controlled asthma (37 parts per billion vs 15 parts per billion, P < .005). There was disagreement among measures of control. Spirometric indices revealed some correlation, but of the unrelated comparisons, those that agreed with each other most often (69%) were clinical assessment by the pediatrician and the cACT. Worst agreement was noted for FENO and cACT (49.3%). CONCLUSION Overall, different measures to assess control of asthma showed a lack of agreement for all comparisons in this study.

Allergic rhinitis in South Africa: 2012 guidelines

Abstract Allergic rhinitis (AR) is an important disease in South Africa. The South African Allergic Rhinitis Working Group (SAARWG) has published previous guidelines on AR diagnosis and management. Areas of concern have arisen that require additional information, including the management of AR in infancy, appropriate and inappropriate allergy testing, the cost of AR management, diagnosis and distinguishing the condition from sinusitis, use of over-the-counter (OTC) medications and the concept of the “united airway”. Clinicians should consider the possibility of AR in infants with recurrent nasal symptoms. Allergy testing must be used wisely and be based on local allergens. Total immunoglobulin E testing is not routinely required to prove allergy. Acute and chronic sinusitis should be considered in conjunction with AR. Treatment of rhinitis will improve these conditions. OTC medications should be used sparingly and with caution. Concern for long-term use of topical decongestants must be noted. Asthma should always be considered in AR diagnosis. Immunotherapy is available in South Africa and may be extremely useful in selected AR patients. The SAARWG has proposed an algorithm for the diagnosis and management of rhinitis in South Africa. AR is common, important and troubling to patients, so every effort should be made to target therapy correctly. Patient education is important in the management of AR.

Original ResearchAsthmaDisagreement Among Common Measures of Asthma Control in Children

BACKGROUND Asthma is a worldwide problem. It cannot be prevented or cured, but it is possible, at least in principle, to control asthma with modern management. Control usually is assessed by history of symptoms, physical examination, and measurement of lung function. A practical problem is that these measures of control may not be in agreement. The aim of this study was to describe agreement among different measures of asthma control in children. METHODS A prospective sequential sample of children aged 4 to 11 years with atopic asthma attending a routine follow-up evaluation were studied. Patients were assessed with the following four steps: (1) fraction of exhaled nitric oxide (FENO), (2) spirometry, (3) Childhood Asthma Control Test (cACT), and (4) conventional clinical assessment by a pediatrician. The outcome for each test was coded as controlled or uncontrolled asthma. Agreement among measures was examined by cross-tabulation and κ statistics. RESULTS Eighty children were enrolled, and nine were excluded. Mean FENO in pediatrician-judged uncontrolled asthma was double that of controlled asthma (37 parts per billion vs 15 parts per billion, P < .005). There was disagreement among measures of control. Spirometric indices revealed some correlation, but of the unrelated comparisons, those that agreed with each other most often (69%) were clinical assessment by the pediatrician and the cACT. Worst agreement was noted for FENO and cACT (49.3%). CONCLUSION Overall, different measures to assess control of asthma showed a lack of agreement for all comparisons in this study.

The “Ten Commandments” of treating preschool children who wheeze

Abstract Wheezing in young children is problematic for most practitioners. Difficulties arise in both the diagnosis and management of this clinical phenotype. Not all preschool children who wheeze have asthma. Therefore, we suggest that the “Ten Commandments” of managing preschool wheezing include thinking that in very young infants (< 1 year) wheezing is likely to be viral in origin; realising that allergy testing is mandatory to diagnose the cause of early wheezing; taking a history of asthma and allergy in family members; noting that chronic coughing is a pointer to asthma; using the term “asthma” if that is the diagnosis; ensuring that the environmental avoidance of triggers is addressed; using a short course of montelukast for virus-induced wheezing episodes; avoiding steroids to treat virus-induced wheezing; treating associated nasal symptoms; and making sure that the follow-up of children addresses the issue of stopping therapy if it is not working.