C. Warren Bierman

Cromolyn versus triamcinolone acetonide for youngsters with moderate asthma

Although both cromolyn (C) and inhaled corticosteroids are anti-inflammatory therapies for childhood asthma, there are few controlled comparisons of these medications for asthma therapy in children. None were conducted in the United States, and none specifically study triamcinolone acetonide (T) versus C. This 12-week evaluation followed 31 youths, aged 8 to 18 years, with moderate asthma who were assigned to receive C or T according to a prerandomized and blinded code. Patients were instructed to take two inhalations from the study metered-dose inhaler (active T or placebo) and to inhale the contents of one study-provided ampule (C, 20 mg, or placebo) from a compressor-driven home nebulizer three times per day. Patients also used albuterol, two inhalations from a metered-dose inhaler, three times a day (before study medication) and, additionally, if needed. Patients maintained a daily diary, recording extra medication use, adverse experiences, peak flow rates morning and night, and asthma symptom scores. Laboratory assessment of pulmonary function was done at 1, 4, 8, and 12 weeks. Cosyntropin challenge and methacholine bronchoprovocation challenge were performed at the beginning and end of the study. C and T provided similar, adequate asthma control. Symptoms of wheezing, cough, and chest tightness decreased, and daily peak expiratory flow rate increased with both regimens compared to during a 2-week baseline when patients received medication only as needed. There was no significant change in methacholine sensitivity and no change in endocrine function, as measured with fasting plasma control before and after administration of cosyntropin.(ABSTRACT TRUNCATED AT 250 WORDS)

Intranasal fluocortin butyl in patients with perennial rhinitis: A 12-month efficacy and safety study including nasal biopsy

Fluocortin butyl (FCB) is a recently developed topical intranasal corticosteroid that is inhaled as a powder and has been demonstrated to be well tolerated and to improve symptoms and signs of perennial rhinitis in previous short-term studies. This multicenter, open-label study evaluated the efficacy and safety of FCB during a 12-month treatment period in patients with perennial rhinitis. Treatment was initiated with one inhalation of FCB in each nostril three times a day (total dosage, 3 mg/day). In subsequent months, one third of the patients was maintained at the dosage of 3 mg/day, one third at a lower dosage of 2 mg/day, and the remaining one third of the patients at a larger dosage of 4 to 8 mg/day. Of 109 patients enrolled in the study, 90 patients (82.6%) completed all 12 months of treatment. Symptom and sign scores decreased significantly (p less than 0.001) at the 2-month evaluation compared to scores at baseline, and the improvement was maintained throughout the 12-month study period. After 12 months, greater than 80% of the patients had substantial control of symptoms. Specimens of nasal biopsies, performed at the beginning and end of treatment, revealed a decrease in eosinophils and other cellular infiltrates, a slight tendency of an increase in mast cell counts, and a trend toward normalization of the nasal mucosa. There were few adverse effects. Mean plasma cortisol levels were normal before and after corticotropin stimulation at baseline and after 12 months of FCB therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Diseases of the ear

Otitis media with effusion is a major disorder in children and the most common cause for both major surgery (adenoidectomy with or without tonsillectomy) and minor surgery (middle ear ventilating tubes) in both the United States and Britain. It is frequently associated with respiratory allergy. Medical evaluation, diagnosis, and therapy are discussed. Environmental control measures and pharmacotherapy are reviewed, with a critical review of published appropriately designed studies for its treatment and prevention.

Intestinal obstruction in a premature infant treated by resection and primary end-to-end anastomosis

Summary 1. An infant with intestinal obstruction associated with volvulus and duplication of the ileum treated by surgical resection and primary end-to-end anastomosis is described. She is one of the smallest patients to survive such a procedure. 2. The advantages and disadvantages of various types of bowel surgery in infants with intestinal obstruction are discussed.

The use of inhaled medications in school by students with asthma

Students with asthma frequently have the sudden onset of asthma symptoms from a variety of causes, including exercise. In most cases, asthma can be prevented or treated by inhaled medications. For many students with asthma to function normally at school, these prescribed medications must be readily accessible to the individual. Students whose parents and physician judge that they have sufficient maturity to control the use of these inhaled medications should be allowed to retain these inhalers in their possession. School policies that require inhalers to be kept in school official’s or nurse’s offices result in an interference in the medical needs of the patient and may seriously delay treatment. Most students will not properly use their medications under these circumstances, School officials should discuss with parents or physicians of students with asthma any problems regarding appropriateness and responsibility of use of these medications. Otherwise, schools should cooperate in the best interest of the patient by permitting the student to have possession of their inhaled medication. There is no indication that these medications have any potential for abuse by students without asthma. Therefore, it should not be argued that this policy presents any danger to other students. It is reasonable to expect that the student requiring inhaled medication to be sufficiently responsible and discreet in its use to avoid drawing attention to treatment. Therefore, we recommend that students with asthma be permitted to have in their possession inhaled medications for the treatment and the prevention of asthma symptoms when they are prescribed by that student’s physician.

Evaluation and Treatment of the Child with Asthma

Asthma is a pulmonary disorder characterized by reversible periods of airway obstruction, bronchial hyperresponsiveness, and associated airway inflammation. A comprehensive approach to asthma therapy in children should include assessment of disease severity and scrutiny for exacerbating factors followed by appropriate environmental modifications as well as pharmacotherapy. Long-term successful management is clearly linked to education of patients and their parents about asthma, proper use of medication, and a plan of action for periods of exacerbation.

NASAL RESISTANCE AND NASAL HISTAMINE CHALLENGE IN ALLERGIC SUBJECTS STUDIED BY POSTERIOR RHINOMETRY

Posterior rhinometry allows quantitative measurement of nasal airway resistance and nasal power. We used this research tool in two separate studies.Initially 10 atopic and 6 nonatopic adults had nasal resistance and nasal power measured at 2 hour intervals for 6 hours on two separate days. A computer digital program was used to collect and analyze the data. Statistical analysis showed considerable intra subject and inter subject variability as well as significantly higher mean measurements of nasal resistance in the allergic population. Nonatopic subjects showed very constant lower values for nasal resistance.We then evaluated whether intranasal insufflation of histamine would cause eustachian tube dysfunction (ETD) in atopic adults. These subjects had normal baseline nasal power measurements by posterior rhinometry and normal eustachian tube function by swallow test. All had quantifyable changes in nasal power after a single dose of 0.55 mgm histamine delivered into each nares for 6 seconds. Four of the five atopic subjects had eustachian tube obstruction documented by 9-step tympancmetry within 5 to 20 minutes after peak nasal power was recorded.In both studies, posterior rhinometry was a useful tool to objectively quantify measurement of nasal resistance so that we could document the higher and more variable measurements found in atopic patients and correlate nasal resistance changes caused by histamine with ETD in these patients.

UNIQUE FEATURES OF HYPERSENSITIVITY PNEUMONITIS IN CHILDREN

Five cases of hypersensitivity pneumonitis from doves and/or pidgeons in children presented within a 8 month period. Patients were 11 to 15 years of age; there were 2 females and 3 males. The diagnosis in all patients was confirmed by the presence of precipitating antibody to dove or pigeon serum and/or droppings. Clinical improvement was noted in all patients after exposure to the birds ceased.Although hypersensitivity pneumonitis is generally considered to occur primarily in non-atopic individuals, 3 of our 5 patients had histories suggestive of atopy.While HP can occur as an acute, intermittent systemic and respiratory illness, all of these patients developed insidious and progressive respiratory disease; 3 had profound weight loss.The children were followed for up to 3 years after initial diagnosis, with interval history, physical exam, serum precipitins, nasal smears, skin tests, pulmonary function studies and methacholine challenges.On follow-up evaluations, 4 out of 5 patients had continuing respiratory disease and 1 had bronchial hyperreactivity with a strongly positive methacholine test. One of the patients continues to have precipitating antibody to avian antigen 3 years after termination of exposure.Early identification of HP is important to avoid the development of chronic pulmonary disease with progressive pulmonary fibrosis.