M. McMorris

Predictors of Habitual Snoring and Obstructive Sleep Apnea Risk in Patients With Asthma

BACKGROUND A high prevalence of obstructive sleep apnea (OSA) symptoms was reported in patients with asthma. Our goal was to evaluate factors associated with habitual snoring and OSA risk in these patients. METHODS Patients with asthma were surveyed at specialty clinics with the Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ) and questions about the frequency of asthma symptoms (National Asthma Education and Prevention Program guidelines), followed by medical record review. SA-SDQ scores >or= 36 for men and >or= 32 for women defined high OSA risk. Logistic regression was used to model associations with habitual snoring and high OSA risk. RESULTS Among 244 patients, 37% snored habitually and 40% demonstrated high OSA risk. Independent predictors of habitual snoring included gastroesophageal reflux disease (GERD) [odds ratio (OR), 2.19; 95% confidence interval (CI), 1.19 to 4.02] and use of an inhaled corticosteroid (ICS) [OR, 2.66; 95% CI, 1.05 to 6.72]. High OSA risk was predicted by asthma severity step (OR, 1.59; 95% CI, 1.23 to 2.06), GERD (OR, 2.70; 95% CI, 1.51 to 4.83), and ICS use (OR, 4.05; 95% CI, 1.56 to 10.53). Linear, dose-dependent relationships of ICS with habitual snoring and high OSA risk were seen (p = 0.004 and p = 0.0006, respectively). Women demonstrated a 2.11 times greater odds for high OSA risk (95% CI, 1.10 to 4.09) when controlling for the above covariates. CONCLUSIONS Symptoms of OSA in patients with asthma are predicted by asthma severity, coexistent GERD, and use of an ICS in a dose-dependent fashion. The well-recognized male gender predominance for OSA symptoms is not apparent in these patients. Further exploration of these relationships may help to explain the increased prevalence of OSA in asthma and provide new insights into the reported female predominance of asthma morbidity.

Self-reported allergic reactions to peanut and tree nuts occurring on commercial airlines

To the Editors: Since publication of the first self-reported survey of in-flight peanut and tree nut allergic reactions, limited follow-up data exist. Given nearly a decade of expanded awareness and education, we sought to re-examine this subject to determine present-day characteristics from a public health perspective to inform allergists on how to better counsel and educate their patients. In conjunction with the Food Allergy and Anaphylaxis Network, a 45-question survey was designed using Survey Monkey (Portland, Ore) and posted on the Food Allergy & Anaphylaxis Network website from mid-August 2007 to early March 2008, available to both members and visitors to the site. Electronic informed consent was obtained, and this study was approved by the University of Michigan Medical School Institutional Review Board. Two hundred eighty-five persons responded, with 150 meeting the criteria for inclusion by affirming they had an inflight reaction to peanut or a tree nut. The remainder were excluded after completing 7 introductory questions. Respondents were not required to answer every question, and many questions allowed multiple responses. Reaction severity was graded according to published criteria for the diagnosis of anaphylaxis. Groups were stratified for statistical comparison on the basis of the presence or absence of symptoms constituting anaphylaxis, with differences in proportions between groups tested by using x and 2-sided Fisher exact tests where appropriate. Data were analyzed using SPSS, Version 16 (Chicago, Ill). This group reported their 150 most severe reactions occurring on board a commercial aircraft. Table I details the baseline characteristics of this population. Table II details the symptoms reported. Fifty individuals (33.3%) reported symptoms that satisfied criteria for anaphylaxis. No fatalities were reported. Causal allergens included peanut, 64.1%; tree nut, 16.9%; both peanut and tree nut, 4.7%; and 14.3% were unsure whether the symptoms were caused by peanut, tree nut, or both. In 63.8% of the cases, respondents provided advance notification of allergy to the airline and requested special accommodations, but only 38.6% who made such a request actually received an accommodation. Preboarding notification was significantly associated with reported self-injectable epinephrine (SIE) carriage (P 5 .0039). Reported routes of exposure included ingestion, 15.7%; inhalation, 48.6%; skin contact, 27.9%; and unknown, 7.8%. Although 76% reported carrying SIE while flying, only 10.6% of these individuals used their device, and overall, only 10% (15 persons) received epinephrine (SIE or epinephrine via syringe) as treatment. All initial doses of epinephrine were administered within 15 minutes of the reaction commencing. An additional dose was required in 6 of the 15 individuals (40%). In contrast, 77% reported having H1-antihistamine available, which was administered in 71.3% of reactions. Fig 1 compares SIE and antihistamine use among respondents carrying these medications. The flight crew was alerted of a reaction occurring in 44.7% of cases. Seven individuals (4.7%) reported in-flight reoccurrence of symptoms despite treatment. Despite this reaction, 52.4% reported not making any changes in their flying behavior. In addition, 25.7% reported they no longer consume food served on

A self-regulation intervention can improve quality of life for families with food allergy

Age (y) 6.1 (3.6) 5.1 (3.8) Male sex, no. (%) 14 (47) 17 (61) Years since diagnosis 3.5 (3.9) 3.5 (3.6) Race, no. (%) White 26 (87) 20 (71) Black 2 (6.7) 1 (3.6) Asian 0 (0) 5 (18) Other/unknown 2 (6.7) 2 (7.2) No. of allergist’s office visits 5.6 (4.6) 5.2 (5.7) No. of allergic foods 2.4 (1.3) 2.4 (1.6) History of anaphylaxis, no. (%) 10 (33) 6 (21) Median Income, USD 51,300 (2,063) 53,200 (1,964)

Carmine hypersensitivity masquerading as azithromycin hypersensitivity

Macrolide hypersensitivity is a rarely reported event. However, carmine dye has become increasingly important as a provocative agent. We present a case of a woman with documented carmine hypersensitivity, who reported anaphylaxis 90 minutes after ingestion of a generic azithromycin. Our investigations revealed that this was an allergy to the carmine dye in the tablets coating rather than to the antibiotic. Seven extracts were prepared including carmine dye, crushed dried female cochineal insects, crushed tablets of Zithromax (Pfizer Inc.) and generic azithromycin (Teva Pharmaceuticals), and the crushed colored coatings from both tablets. These were suspended in preservative-free normal saline, and then applied as a skin-prick test and read at 30 minutes. The skin-prick skin test results were 4+ to histamine and carmine dye, but negative to cochineal insect extract, Pfizer crushed tablets, and negative control. The patient was 1+ to the Teva crushed tablet, but was 4+ to the Teva brand coating and negative to the Pfizer brand coating, which did not contain carmine. The patient subsequently ingested Pfizer Zithromax without any sequelae. To our knowledge, this is the first reported case of carmine anaphylaxis attributed to carmine-containing medication. Careful history and skin-prick testing to the appropriate agents allowed elucidation of the subtlety of the true offending agent without unnecessary avoidance of the medication class. Patients with a carmine hypersensitivity should actively check with their pharmacy or prescribing physician to verify their medications are free of this offending agent.

Unusual cause of cough and wheeze in a 10-year-old child

HISTORY OF PRESENT ILLNESS A 10-year-old girl with a history significant for mild persistent asthma and allergic rhinitis presented to the clinic for evaluation of a harsh, nonproductive, unremitting cough of 6 weeks’ duration. There was no antecedent illness, and the cough was not noted to be associated with upper respiratory tract symptoms, fever, or chest tightness. She had been using both inhaled and nebulized -agonists and inhaled budesonide with no significant relief. During the ensuing weeks, she received various combinations of antibiotics, antitussives, inhaled and/or oral corticosteroids, long-acting -agonists, and leukotriene modifiers all with minimal relief of symptoms. Symptoms were worse during the day and aggravated by exposure to cold air. There was no history of nocturnal cough or disrupted sleep. Visits to the primary care physician’s office and once to the emergency department documented normal respiratory rate and quality and normal oxygen saturation, with diffuse expiratory wheezes and barky cough.