Bernard Silverman

Once-daily mometasone furoate dry powder inhaler in the treatment of patients with persistent asthma.

BACKGROUND Although inhaled glucocorticoids are recommended for all stages of persistent asthma, compliance with long-term therapy is often poor, leading to significant morbidity and mortality. A simplified, once-daily dosing regimen may foster improved compliance. OBJECTIVE To compare the efficacy and safety of once-daily (AM) administration of mometasone furoate dry powder inhaler (MF DPI) 200 microg and 400 microg with placebo in patients with asthma previously maintained only on short-acting inhaled beta-adrenergic receptor agonists. METHODS This was a 12-week, double-blind, placebo-controlled, parallel group study. The mean change from baseline to endpoint (last treatment visit) for FEV1 was the primary efficacy variable. RESULTS At endpoint, both doses of MF DPI were significantly more effective than placebo (P < or = .05) in improving FEV1. Based on morning peak expiratory flow rate, once-daily MF DPI 400 microg was more effective than placebo (P < or = .001) at endpoint. Both active treatments also demonstrated improvement at endpoint in asthma symptom scores, physician-evaluated response to therapy and use of rescue medication. Although both MF DPI dosages were efficacious, MF DPI 400 microg provided additional improvement in some measures of pulmonary function (eg, morning PEFR) when these agents were administered once daily in the morning. Both doses of MF DPI were well tolerated and treatment-related adverse events occurred at a similar incidence among the three treatment groups. CONCLUSIONS The results of this study indicate that once-daily (AM) MF DPI provides a convenient and effective treatment option for patients with mild or moderate persistent asthma.

Prevalence of migraine headaches in patients with allergic rhinitis

BACKGROUND Histamine has been implicated in the pathogenesis of migraine headaches. Because allergic rhinitis (AR) is a histamine-driven syndrome and the nasal passage is in close proximity to the central nervous system, we hypothesize that AR may trigger migraine headaches. OBJECTIVE To determine the prevalence of migraine headaches in patients with and without AR. METHODS Allergic rhinitis was diagnosed based on skin or radioallergosorbent test results, clinical history, and physical examination findings. The diagnosis of migraine headache was made if patients fulfilled the International Headache Society criteria. Surveys were obtained from hospital-based allergy, pediatric, and internal medicine clinics, all serving the same inner-city population. RESULTS A total of 294 surveys were completed. Of 76 patients in the AR group, 26 (34%) had headaches meeting the International Headache Society criteria for migraines, and of the 57 patients in the non-AR group, only 2 (4%) had headaches that met the criteria. A Fisher exact test showed P = 8.2 x 10(-6). The odds ratio was 14.3, which signifies that the odds of having migraine headaches is 14.3 times higher in the AR group than in the non-AR group. CONCLUSIONS There is a high prevalence of migraine headaches in patients with AR compared with those without AR. We propose that histamine plays a key role in triggering migraines by means of vasodilation and inflammation in the pathogenesis of migraine headaches.

Allergic rhinitis in children with attention-deficit/hyperactivity disorder

BACKGROUND Both allergic rhinitis and attention-deficit/hyperactivity disorder (ADHD) are common pediatric conditions associated with learning difficulties and sleep disturbances. There are conflicting research data regarding the association between ADHD and atopic disorders. OBJECTIVE To determine the prevalence of allergic rhinitis in patients with physician-diagnosed ADHD. METHODS Patients 5 to 18 years of age who presented with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of ADHD to an outpatient pediatric psychiatry clinic were screened for allergic rhinitis with focused history, physical examination, and skin prick testing to common aeroallergens. RESULTS Thirty patients were interviewed, with 23 of these undergoing physical examination and skin prick testing. Eighty percent reported allergic rhinitis symptoms, whereas 61% had at least 1 positive prick skin test result. Forty-three percent showed typical physical signs of allergic rhinitis, 100% had a positive atopic family history, and 53% had other associated atopic disorders. CONCLUSIONS Most children with ADHD displayed symptoms and skin prick test results consistent with allergic rhinitis. Nasal obstruction and other symptoms of allergic rhinitis could explain some of the cognitive patterns observed in ADHD, which might result from sleep disturbance known to occur with allergic rhinitis. Therefore, evaluation and treatment of allergic rhinitis could benefit patients with ADHD.

Current practices among allergists on writing self-injectable epinephrine prescriptions for immunotherapy patients

Supported by the Richard and Edith Strauss Foundation, the Canada Research Chair on Genetic Determinants of Asthma, and an American Thoracic Society research grant. The CAMP Genetics Ancillary Study is supported by grants U01 HL075419, U01 HL65899, P01 HL083069, R01 HL086601, and T32 HL07427 from the National Heart, Lung, and Blood Institute/National Institutes of Health. Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest.

Unusually persistent rhinorrhea in a patient with allergic rhinitis

History of Present Illness A 49-year-old woman who worked as an administrative assistant presented to the allergist office with symptoms of allergic rhinitis and worsening asthma. She had been diagnosed as having asthma 5 years earlier during which time her condition was well controlled with an albuterol metered-dose inhaler used as needed. However, several months before the visit, her symptoms worsened, with coughing, wheezing, and shortness of breath that required 2 emergency department visits and 4 courses of prednisone. Her rhinitis also worsened, including nasal congestion, watery nasal discharge, sneezing fits, and postnasal drip. Symptoms were perennial and subjectively worse with dust, feather pillows, animals, grass, weed, cigarettes smoke, and heat. Most notable was the copious clear, watery rhinorrhea, which initially began 4 years ago. During that time, she noted the symptoms to occur intermittently, lasting a day or two and then recurring in a few days. Symptoms initially predominated during the winter, but the rhinorrhea gradually worsened, and 2 years later, it occurred during all seasons of the year and on a daily basis. The rhinorrhea was predominantly from the left nostril, caused a sensation of postnasal drip in the supine position, and was worse when bending forward.

Twenty-one year old woman with severe eosinophilia and left bundle branch block.

Peripheral and tissue eosinophilia can occur in a wide variety of disease processes that include infectious, allergic, and primary hematologic disorders, and other more rare diseases such as hypereosinophilic syndromes (HES). We describe a case of a patient with severe eosinophilia and left bundle branch block. A 21-year-old woman with asthma and allergic rhinitis presented with neck pain and cough for >6 months with no other complaints. Physical exam was normal except for fever and minimal expiratory wheezes. Chest CT revealed diffuse airway inflammation with bronchiectasis. Admission electrocardiogram (EKG) was normal. Initial laboratory tests showed an absolute eosinophil count of 30,000 cells/mL. A thorough workup for eosinophilia was initiated, but the patient subsequently left against medical advice. The next day, in the outpatient pulmonary clinic, she was found to be tachycardic and an EKG showed sinus tachycardia with a new left bundle branch block. Laboratory tests revealed an eosinophil count of 33,200 cells/mL and elevated troponins. She was started on i.v. Solu-Medrol (Pfizer, Inc.). The next day, her EKG returned to normal. Three days later her absolute eosinophil count normalized. Identifying the cause of marked, persistent eosinophilia is a challenging problem. Excluding the more common causes of severe eosinophilia is required before making a diagnosis of HES and early therapeutic intervention can prevent morbidity from the disease.

The Food Challenge Risk Index: Predicting Positive Open Food Challenges to Milk, Egg, and Peanuts in Children

Abstract Rationale Suspected food allergy is commonly encountered. Proper diagnosis may require skin testing, RAST testing and ultimately a food challenge. In previous studies, food specific IgE threshold levels have predicted greater than 95% of the patients with a positive food challenge. However, in patients with food specific IgE antibodies less than the threshold, a food challenge is still required to exclude food allergy. Oral food challenges are time consuming and may subject patients to allergic reactions. We developed a food challenge risk index (FCRI) to predict positive food challenges. Methods Fifty-five open food challenges were retrospectively reviewed. Skin prick tests, food specific IgE levels, and time since last reaction were utilized to develop a formula and SPSS program was used to generate ROC curves, and correlations. The FCRI=[(skin prick test wheal (mm) x3) + (RASTx10) - (time since last reaction (months)]. The FCRI value was calculated and compared to the food challenge results. Threshold levels determined were 15, 20, and 20 for milk, egg and peanut respectively. Results Comparison of the FCRI to the actual food challenges across all groups revealed a sensitivity of 0.842 and a specificity of 0.861. An overall negative predictive value indicated that the proposed risk index is accurate 91.2% of the time. Conclusions We have derived a simple and accurate formula which uses readily available clinical data, to predict positive food challenges. The food challenge risk index may be used in a prospective fashion to reduce frequency of food challenges necessary for diagnosis of milk, egg, and peanut allergy.

An unusual etiology of persistent cough in an 8-year-old girl with cystic fibrosis

HISTORY OF PRESENT ILLNESS An 8-year-old child with cystic fibrosis was admitted in late August 1999 because of persistent mildly productive cough for 1 month which did not respond to oral and inhaled antibiotics. Over the month, her cough had become unremitting and she experienced a 2-pound weight loss and was admitted for intravenous antibiotic therapy. There was no history of fever, shortness of breath, wheezing, or chest pain. Her usual medications included albuterol, and pancrelipase (Pancrease; Ortho-McNeil Pharmaceuticals, Raritan, NJ) capsules with meals and snacks. She had three previous admissions before this for pulmonary exacerbations, the last one in December 1998. She has had Pseudomonas sp. in her sputum for the past 3 years. There was no significant travel history.

Implications of persistent cough in a 3-year-old female

HISTORY OF PRESENTING ILLNESS A 3-year-old female was seen by a family physician for daily, persistent nonproductive cough for the past 6 months. Vigorous activity or upper respiratory infections did not provoke the cough; seasonal changes did not alter its frequency. It did occasionally worsen at night. Although there was no complaint of wheezing or dyspnea, use of an albuterol inhaler helped somewhat, but not always. The patient did not complain of any nasal symptoms. The mother did not recall any past choking episodes to suggest ingestion of a foreign body. A diagnosis of mild persistent asthma based on clinical presentation was made and she was empirically started on albuterol metered-dose inhaler as needed, and beclomethasone dipropionate 42 g, three puffs, twice daily. She had never received oral or intravenous steroids, nor had she been hospitalized. Other medications included cetirizine syrup 2.5 mg nightly and mometasone nasal inhaler one spray each nostril nightly. Further questioning revealed occasional episodes of a “fast heartbeat,” excessive sweating, and persistent hoarseness.