Ejaz Yousef

Association Between Peanut Allergy and Asthma Morbidity

OBJECTIVE To evaluate the relationship between peanut allergy and asthma morbidity in school-age children. STUDY DESIGN The study involved a medical chart review to assess the association of peanut allergy with asthma morbidity in children beyond age 3 years. Peanut allergy was assessed by specific and validated criteria. A Poisson regression model was used to compare the frequency of systemic steroid use and of hospitalization for asthma beyond age 3 years in children with asthma with and without peanut allergy. RESULTS Children with peanut allergy had a 2.32-times greater rate of hospitalization (P = .03) and a 1.59-times greater rate of systemic steroid use (P <.001) after controlling for covariates. CONCLUSIONS Peanut allergy serves as an early marker for asthma morbidity. Early prevention and intervention can improve quality of care.

Lactic acidosis and status asthmaticus: how common in pediatrics?

BACKGROUND Lactic acidosis is a well described phenomenon in adult patients with severe asthma. However, this entity is rarely reported in children with status asthmaticus. OBJECTIVE To report our experience in a 13-year-old girl who developed lactic acidosis as a complication of status asthmaticus and to investigate the prevalence of this complication of severe asthma. We sought to determine the frequency of lactic acidosis in such patients and to review etiologies of lactic acidosis. METHODS 1) Observations on the clinical and laboratory findings in an adolescent girl with status asthmaticus who developed lactic acidosis were recorded. 2) The medical records of 100 children and adolescents with status asthmaticus admitted to an intensive care unit were reviewed for laboratory evidence of lactic acidosis. 3) We also reviewed our own previous experience of status asthmaticus with respiratory failure. RESULTS Among 100 patients admitted to a pediatric intensive care unit for status asthmaticus, a single case of isolated metabolic acidosis was identified. This proved to be attributable to lactic acidosis. When records of patients with severe respiratory failure were examined, no cases of metabolic acidosis were found. CONCLUSIONS Although rare, lactic acidosis does occur in pediatric-aged patients during status asthmaticus. It is important that this complication be recognized and treated because acidosis may inhibit the effectiveness of bronchodilator therapy, produce electrolyte disturbances, and cause serious adverse effects on the patients cardiovascular system.

Air Quality and Pediatric Asthma-Related Emergencies

Background: Previous studies suggest a relationship between air pollutants, aeroallergens, and asthma exacerbations. Objective. To simultaneously examine the role of seasonality, air quality, aeroallergens, and climate on asthma-related pediatric emergency department (ED) visits. Methods: A retrospective 4-year study of asthma-related ED visits was conducted. Results: September had the highest number of visits (p < 0.01). There were lower temperatures and precipitation (p < 0.01) and higher tree and weed pollen levels (p = 0.05) on days with more visits (p = 0.05), while grass pollen, mold, ozone, NO2, and PM2.5 levels showed no significant differences. Conclusions: Asthma-related visits were associated with aeroallergens and climatic factors and not air-quality factors.

Prevalence of positive skin prick test results in children with Down syndrome: a case-control study

BACKGROUND Because many of the same otologic and nasal problems experienced by children with Down syndrome are also frequent in children with atopic disease, many children with Down syndrome are referred to an allergist for evaluation. OBJECTIVE To determine the prevalence of positive skin prick test (SPT) reactions to common aeroallergens in children with Down syndrome. METHODS Using a case-control design, we reviewed the medical records of children with Down syndrome who had undergone SPT. Each case was matched by sex and age with a control who had been evaluated by SPT at an initial visit. RESULTS Thirty-nine cases and controls were identified. Eighteen percent of cases were found to have at least 1 positive SPT result compared with 54% of controls. This closely approximates the percentage of the general population with at least 1 positive SPT result (54.3%) as reported in the Third National Health and Nutrition Examination Survey. CONCLUSIONS Given the low prevalence of positive SPT results in children with Down syndrome, it is unlikely that allergic rhinitis will be identified as the cause of many of the chronic rhinitis symptoms that many of these children are referred to an allergy practice to have evaluated. It may be helpful to the parents and to the patients themselves to avoid involving another specialist and appointment because they frequently are involved with many specialists for medical care. A larger study would be helpful in confirming the prevalence of positive SPT results in children with Down syndrome.

Correlates of outcome for atopic dermatitis

BACKGROUND The worldwide incidence and prevalence of atopic dermatitis (AD) are increasing. Few good studies have addressed AD in terms of the factors affecting disease prognosis. OBJECTIVE To identify significant correlates of persistent AD because this would be clinically valuable information. METHODS Potential correlates of AD, including race, onset age, age of solid food introduction, breastfeeding, sinopulmonary infections, other atopic diseases, peripheral eosinophilia, total IgE level, and eosinophilic cationic protein levels, were investigated in 177 patients aged 5 to 18 years. Correlates were compared with AD remission vs nonremission status. RESULTS A total of 133 patients (75.1%) were not in remission at the age of 5 years or older and were, thus, classified as having persistent AD. Patients with histories of peanut allergy (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.30-6.55), egg allergy (OR, 2.71; 95% CI, 1.17-6.30), or dust mite allergy (OR, 4.02; 95% CI, 1.84-8.82) were significantly more likely to have persistent AD than those without these factors. There was a trend toward increased odds of persistence in those with peripheral eosinophilia (P = .06) and decreased odds of persistence in those with frequent sinopulmonary infections (OR, 0.51; 95% CI, 0.25-1.03). CONCLUSIONS Egg, peanut, and dust mite allergies are significant correlates of AD persisting beyond school age. There may also be increased odds in those with peripheral eosinophilia and decreased odds in those with frequent sinopulmonary infections. This highlights the importance of assessing these correlates in patients with AD and modifying the correlates that can be modified. Further studies on whether modification of these correlates and/or early aggressive AD management improves outcome are needed.

Patient, Home Residence, and Neighborhood Characteristics in Pediatric Emergency Department Visits for Asthma

Objective. To identify patient, home residence, and neighborhood characteristics of children with asthma-related emergency department visits. Methods. Medical records of children with one (group A) or more than one (group B) asthma-related pediatric emergency department visit were reviewed. Results. A significantly higher percentage of group B had Medicaid insurance (p = 0.04), history of asthma-related hospitalizations (p = 0.04), and passive tobacco smoke exposure (p = 0.03). Neighborhood characteristics were similar between the two groups. Conclusions. Smoking cessation counseling and close monitoring of patients with a history of asthma-related hospitalizations and patients with Medicaid insurance may be helpful in decreasing emergency department visits.

Diagnosis of Common Variable Immunodeficiency in a Patient With Primary Ciliary Dyskinesia

In this case report we describe the first account in the literature of a patient with primary ciliary dyskinesia and common variable immunodeficiency. A 17-year-old boy with previously diagnosed Kartagener syndrome and stable lung disease developed a deteriorating clinical course that prompted the search for a secondary diagnosis. Although both of these rare conditions can result in similar lung pathology, they require different management strategies, which illustrates the need to consider associated diagnoses in complicated clinical situations.

Evaluation of the relationship between IgE level and skin superinfection in children with atopic dermatitis.

Increased Th2 polarity weakens the innate immune response and predisposes children with atopic dermatitis (AD) to skin superinfection. This study was designed to evaluate the relationship between IgE level and bacterial superinfection in children with AD. A medical chart review was performed on 103 children with AD to assess the association between IgE level and skin superinfection. A multivariable logistic regression model was used to assess the relationship between categorized IgE level and the presence of bacterial superinfection after adjusting for cofounding variables including allergic rhinitis, asthma, and food allergy. A Wilcoxon signed-rank test was used to compare pre- and postskin superinfection median IgE levels in a subset of patients. Compared with children with an IgE level of <300 IU/mL, children with an IgE level of >1001 IU/mL were 66.00 times more likely to have a skin superinfection (p = 0.003) and children with an IgE level between 301 and 1000 IU/mL were 12.38 times more likely to have a skin superinfection (p < 0.001). After controlling for cofounding variables including asthma, allergic rhinitis, and food allergy, children with an IgE level of >1001 IU/mL were 71.89 times more likely to have a skin superinfection (p = 0.018) and children with an IgE level between 301 and 1000 IU/mL were 8.79 times more likely to have a skin superinfection (p < 0.001) when compared with children with an IgE level of <300 IU/mL. There was a significant increase in IgE levels from baseline in 13 children treated for a skin superinfection (p = 0.001). IgE level is associated with Staphylococcus aureus superinfection in children with AD.

Radiologic outcomes in children with chronic rhinosinusitis and ostiomeatal complex obstruction after medical management

BACKGROUND The presence of ostiomeatal complex obstruction can be a key component in chronic rhinosinusitis, and the medical management of this condition has not been well studied, particularly in children. OBJECTIVE To compare the effectiveness of antibiotics, intranasal topical corticosteroids, and oral systemic corticosteroids on radiologic outcomes in children with chronic rhinosinusitis and ostiomeatal complex obstruction. METHODS We reviewed the reports of 1,741 computed tomography scans performed on children at Alfred I. duPont Hospital for Children, Wilmington, Delaware, from October 1, 2001, through February 28, 2007, identifying those patients who had 2 scans performed at least 2 weeks apart but no more than 6 months apart. Forty-five instances involving abnormal ostiomeatal complex anatomy documented on the initial study with obtainable treatment information were selected for further review. RESULTS Of the 3 treatment modalities examined, only oral systemic corticosteroids (P = .03) and intranasal topical corticosteroids (P = .03) were found to provide significant independent contributions to predicting treatment outcome, with the former promoting a positive outcome and the latter predicting a negative outcome. The model that contained just these 2 factors also provided a significant fit to the outcome data (P = .01), producing a diminished rate of improvement expected from a combination of positive and negative influences. Neither antibiotics nor any other combination of modalities contributed to a significant improvement in model fit. CONCLUSION The use of oral systemic corticosteroids was found to be the only beneficial intervention, with regard to radiologic improvement, in the treatment of ostiomeatal complex obstruction in children.

Systemic reaction to pneumococcal vaccine: how common in pediatrics?

The 23-valent-polysaccharide pneumococcal vaccine (PPV23) is currently recommended for patients at high risk for invasive disease from Streptococcus pneumoniae. It is also frequently used in the evaluation of patients with suspected immunodeficiency. Reports of systemic adverse reactions are rare. Our objective is to describe a patient with an apparent systemic reaction to PPV23 and review our hospitals 2-year experience with pneumococcal vaccine. Chart review of 173 patients given PPV23 between January 1, 2004 and December 31, 2005 revealed five who had significant adverse reactions, including local cellulitis, fever, and vomiting. Variables considered included age at immunization, indication for PPV23, and prior pneumococcal vaccines. The mean age of all patients given PPV23 during the defined time period was 8.6 years, and the most common indication for vaccination was recurrent infection. Of those patients who had adverse reactions, the mean age was 6.5 years. The time from prior pneumococcal vaccination was a mean of 20 months in children who did not have an adverse reaction. None of the patients who had an adverse reaction had documentation of receiving PPV23 before. Local reactions to PPV23 occur in approximately 50% of recipients, and revaccination of immunocompetent individuals increases the risk for local reaction. Systemic reactions are less common and only occur in approximately 1% of recipients. Our patient had no identifiable risk factors for development of an adverse reaction. Additional studies are indicated to determine whether there are identifiable risk factors for the development of adverse reactions to PPV23.