James T.C. Li

Attained adult height after childhood asthma: Effect of glucocorticoid therapy

BACKGROUND Although oral and inhaled glucocorticoid therapy may impair growth in children with asthma, the effect of glucocorticoid therapy and asthma on attained adult height has not been extensively studied in representative children in the community. OBJECTIVES The study was designed to compare the attained adult height of children with asthma with the attained adult height of nonasthmatic children and to compare the attained adult height of asthmatic children treated with glucocorticoids with the attained adult height of asthmatic children who did not receive glucocorticoids. METHODS Residents of Rochester, Minnesota, with onset of asthma from 1964 to 1987 and age- and sex-matched non-asthmatic residents of Rochester were studied. Glucocorticoid exposure was assessed from medical records. The mean of 5 stadiometer measurements of adult height, adjusted for sex and parental height, was analyzed. RESULTS One hundred fifty-three patients with asthma (mean age at onset, 6.1 +/- 4.8 years) and 153 age- and sex-matched nonasthmatic subjects were studied. Adult height of patients with asthma (mean age at measurement, 25.7 +/- 5.2 years) was not significantly different from the adult height of non-asthmatic subjects; the overall difference, adjusted for mid-parental height, was -0.20 cm (95% confidence interval from -0.27 to 1.64). The adult height of asthmatic children treated with glucocorticoids was not significantly different from the adult height of patients with asthma not treated with glucocorticoids; the difference after adjusting for mid-parental height was -0.2 cm (95% confidence interval from -0.1 to 0.6). CONCLUSIONS We conclude that the attained adult height of patients with asthma is not different from the adult height of age- and sex-matched nonasthmatic subjects and that the attained adult height of asthmatic children treated with glucocorticoids is not significantly different from the adult height of children not treated with glucocorticoids.

Aerosol beclomethasone dipropionate spray compared with theophylline as primary treatment for chronic mild-to-moderate asthma

BACKGROUND Inhaled corticosteroids and oral theophylline are effective treatments for moderate asthma. OBJECTIVE We sought to compare the benefits and adverse reactions of theophylline and aerosol beclomethasone spray. METHODS A multicenter, double-blind, double-placebo, randomized, controlled trial of 1-year duration was performed. Seven hundred forty-seven patients with asthma received either beclomethasone dipropionate aerosol spray (84 microg four times per day) or sustained-release theophylline twice per day in doses adjusted for optimum control of the disease. The main outcome measures were daily diary of symptoms and peak flow rates (recorded on a mark-sense computer-readable form); supplemental bronchodilator use; doctors office or hospital visits and absence from work or school; spirometry; methacholine testing; adverse experiences; and cortisol blood measurements. RESULTS Both treatment strategies reduced symptoms promptly and achieved low absenteeism from work or school and low rates of emergency treatment for asthma. Both maintained nearly normal pulmonary function. Beclomethasone was statistically significantly more effective in reducing symptoms, supplemental bronchodilator and systemic glucocorticoid doses, bronchial hyperresponsiveness, and eosinophilia. However, the magnitude of these differences was small. Theophylline caused more headache, nervousness, insomnia, and gastrointestinal distress, and more patients discontinued treatment because of side effects. Beclomethasone caused more oropharyngeal candidiases and hoarseness and reduced morning plasma cortisol levels before and after cosyntropin. It reduced the rate of growth in children. No new cataracts or glaucoma developed. CONCLUSION Theophylline effectively controlled symptoms at lower than the customarily recommended blood level. The risk/ benefit profiles of these agents suggest that inhaled corticosteroids may be the preferred agent for most adult patients and for some children.

Lack of suppression of IgE production by recombinant interferon gamma: A controlled trial in patients with allergic rhinitis

Recent evidence suggests that interferon-gamma (IFN-gamma) is a potent inhibitor of IgE synthesis in rodents. We conducted a randomized, placebo-controlled, two-period clinical trial of human recombinant IFN-gamma in the treatment of allergic rhinitis. Forty-five adults with well-documented ragweed-allergic rhinitis were randomized into three groups of 15 adults each and received subcutaneous injections three times weekly. The first treatment period (4 weeks during the off season) began on April 18, 1988; the second treatment period (6 weeks during ragweed pollination) began on August 15, 1988. All subjects received the same treatment in both periods. Group 1 received 0.2 mg per injection of IFN, group 2 received 0.02 mg of IFN, and group 3 received placebo. One subject in group 1 and three subjects in group 2 withdrew because of adverse reactions, and three subjects withdrew for personal reasons. There were no significant differences in mean weekly symptom scores or supplemental medication scores among the three groups in either treatment period. Furthermore, there were no significant differences in the changes of serum IgE antibody to crude ragweed extract or in serum total IgE among the three groups during or before the ragweed-pollination season. These results indicate that this treatment regimen with IFN-gamma does not alter IgE production in patients with ragweed hay fever and indicate the need for further clinical research of lymphokine modulation of IgE production.

Source of the aeroallergen of soybean dust: A low molecular mass glycopeptide from the soybean tela

Airborne soybean allergens in the dust generated during the unloading of soybeans in the harbor caused asthma epidemics in Barcelona, Spain. The major allergen causing the epidemics was a glycopeptide less than 14 kd molecular mass abundant in soybean dust. This allergen occurs in all parts of the soybean plant at all stages of growth, but the telae (hulls) and pods are by far the richest source. Small amounts of a similar cross-reacting allergen are found in some other grain dusts. The botanical function and significance of this soybean plant component is not known nor is the potential for airborne dispersion of this allergen at other grain-handling sites.

Proper Use of Aerosol Corticosteroids To Control Asthma

Aerosol glucocorticoids are highly effective in the treatment of bronchial asthma. Clinically apparent systemic hypercortisolism is virtually nonexistent in patients who receive such therapy, although local effects of candidiasis or dysphonia may occur. Treatment failures can often be attributed to poor patient compliance or incorrect use of the pressurized aerosol inhaler. The addition of a spacer device to the inhaler improves the technique and the results in many patients. Furthermore, many patients with asthma require 2 or 3 times the conventional dose of aerosol corticosteroids for optimal control of pulmonary function. Careful coaching is essential for the successful use of aerosol corticosteroids.

Development of the asthma control test (ACT)

Abstract Background Asthma guidelines indicate that the goal of treatment should be optimum asthma control. In a busy clinic practice with limited time and resources, there is need for a simple method for assessing asthma control with or without lung function testing. Objectives The objective of this article was to describe the development of the Asthma Control Test (ACT), a patient-based tool for identifying patients with poorly controlled asthma. Methods A 22-item survey was administered to 471 patients with asthma in the offices of asthma specialists. The specialists rating of asthma control after spirometry was also collected. Stepwise regression methods were used to select a subset of items that showed the greatest discriminant validity in relation to the specialists rating of asthma control. Internal consistency reliability was computed, and discriminant validity tests were conducted for ACT scale scores. The performance of ACT was investigated by using logistic regression methods and receiver operating characteristic analyses. Results Five items were selected from regression analyses. The internal consistency reliability of the 5-item ACT scale was 0.84. ACT scale scores discriminated between groups of patients differing in the specialists rating of asthma control (F = 34.5, P P 1 (F = 4.3, P = .0052). As a screening tool, the overall agreement between ACT and the specialists rating ranged from 71% to 78% depending on the cut points used, and the area under the receiver operating characteristic curve was 0.77. Conclusion Results reinforce the usefulness of a brief, easy to administer, patient-based index of asthma control.

Management of Insect Sting Hypersensitivity

Approximately 1 to 3% of the general population has had a systemic reaction to insect stings. Adults whose reactions include urticaria, obstruction of the upper or lower airway, or hypotension and children whose reactions include obstruction of the upper or lower airway or hypotension have an increased risk of future systemic reactions to stings. Allergy skin tests to Hymenoptera venoms can help to identify the offending insect and to classify the reactions as allergic; however, because 15% of the general population may have positive results to such tests, persons who have not experienced a systemic reaction to insect stings should not be tested. Venom immunotherapy is highly effective and confers 98 to 99% protection in patients who have experienced previous systemic reactions to insect stings. Reaction rates to venom skin tests or venom immunotherapy are low and are similar to those in allergy testing and immunotherapy for hay fever. Generally, patients who have had systemic reactions to stings should be assessed by an allergist to determine whether they are candidates for immunotherapy with Hymenoptera venom. The decision to institute venom immunotherapy should be based on the disposition of the patient, the severity of the reaction, and the risk of subsequent stings. Deliberate sting challenges are clinically useful for guiding immunotherapy.