Neetu Talreja

Modifiable factors associated with severe asthma exacerbations in urban patients

BACKGROUND Rates of asthma morbidity, mortality, and resource use are highest among African American individuals residing in inner-city locations, yet factors associated with adverse outcomes are not well established. OBJECTIVE To identify modifiable factors associated with asthma exacerbations. METHODS A total of 104 adult patients who presented to an inner-city hospital or emergency department (ED) with an asthma exacerbation from October 1, 2009, through June 31, 2010, completed surveys of clinical status, acute events, sociodemographic characteristics, current asthma knowledge, self-efficacy, attitudes toward asthma self-management, and perceived barriers to asthma care questionnaires. Associations with asthma hospitalizations and ED visits were assessed. RESULTS The mean age of the patients was 42 years, 91% were African American, 33% were insured, 57% were taking a controller medication, and 63% had an income level below the federal poverty line. On bivariate analysis, males, years of asthma, history of smoking, self-classification of asthma severity, history of admission to intensive care unit or intubation, use of peak flow meter or asthma action plan, controller medication use, and history of oral corticosteroid bursts were positively associated, whereas self-efficacy was negatively associated with number of ED visits or hospitalizations. No association was found for asthma knowledge, perceived barriers to care, or attitudes toward asthma management. On multivariate analysis, low self-efficacy remained associated with both asthma hospitalizations and ED visits. CONCLUSION Short-term use of health services for asthma is negatively associated with asthma self-efficacy. Self-management programs that enhance self-efficacy, rather than those that focus on knowledge or attitudes, may be effective in reducing adverse asthma outcomes for inner-city, predominantly African American populations.

Debunking myths about “allergy” to radiocontrast media in an academic institution

Abstract Purpose: Patients with “allergy” to iodine and shellfish often do not obtain necessary radiologic procedures due to anxiety about potential radiocontrast media reactions. This study assesses the impact of an educational intervention to dispel these myths. Methods: The authors surveyed 252 internal medicine, emergency medicine, pediatrics, radiology, obstetrics/gynecology, and surgery health professionals before and after an educational intervention. Pre- and posttest responses were analyzed to assess the impact of the intervention on beliefs about radiocontrast media reactions and their perceived relationship to shellfish allergy and iodine “allergy.” Results: The mean pre- and posttest correct response scores were 41% and 91%, respectively. The intervention had a greater impact on respondents’ knowledge about iodine allergy than shellfish allergy, most likely due to the difference in baseline knowledge (P < 0.005). Emergency medicine garnered the highest pretest correct response score (54%). Internal medicine earned the lowest pretest score (30%). There was a significant difference between the highest and lowest scoring specialties on the pretest (P = 0.037). There was no statistically significant correlation with training levels. There was a considerable decrease in the percentage of respondents who would withhold radiologic studies from patients suspected of shellfish or iodine allergy. The percentage of respondents who would premedicate patients with antihistamines or steroids also decreased significantly. Conclusion: An educational intervention helps rectify misconceptions among health care professionals about radiocontrast media reactions and their perceived relationship to shellfish or iodine allergy.

Successful desensitization to agalsidase beta after anaphylaxis

Fabry disease is a X-linked inherited lysosomal storage disorder caused by mutations of the GLA gene that results in an inborn deficiency of the enzyme a-galactosidase. Affected individuals include hemizygousmales and heterozygous (carrier) females.1 This deficiency results in the accumulation of globotriaosylceramide and other neutral glycolipids, which leads to cellular abnormalities and triggers inflammation and fibrosis of the skin, kidney, nervous system, and heart.1 Life expectancy is approximately 50 years for males and 70 for females.2e5 Treatment includes enzyme replacement therapy with either agalsidase alfa or beta isozymes (A-b). A-b is a foreign antigen to humans because it is produced in Chinese hamster ovary cells and undergoes nonhuman glycosylation. IgG antibodies to A-b are present in approximately 80% of untreated individuals, and IgE responses that result in anaphylaxis to A-b have been reported in 1% of individuals undergoing replacement therapy.6,7 A case of anaphylaxis to A-b followed by successful reintroduction after desensitization is presented. A 50-year-old, white man with end-stage renal disease after cadaver kidney transplantation who is taking tacrolimus and mycofenolate mofetil developed A-b hypersensitivity 1 year after beginning intravenous A-b therapy. The patient was adherent to therapyandwas receiving therapyonceor twice amonth, depending on the availability of the medication. He developed a pruritic, erythematous, maculopapular skin eruption on the torso and angioedema of the periorbital areas and lips during the infusion of 60 mg of A-b at 40 mL/h. Within a few minutes, he became hypotensive and was transferred to the intensive care unit. His signs and symptoms rapidly resolved with discontinuation of A-b therapy and administration of 0.3 mg of intramuscular epinephrine in the right deltoid, 50mgof intramuscular diphenhydramine in the left deltoid, 125mgof intravenousmethylprednisolone, and 2 L of normal saline. The patient was lost to follow-up for 8 months. Serum IgE and IgG test results to A-b were positive, and a baseline tryptase level measured during a visit at that timewas normal. The result of a skin prick test (SPT) to A-b at 0.0014 mg/mL also was positive, with a wheal of 4 6 mm with no reaction to the negative control and 6 6 mm with histamine phosphate (0.1 mg/mL). The patient was premedicated with 40 mg of oral prednisone at 12 hours and 20 mg at 4 hours before the procedure and then given incremental doses of A-b, a total of 35mg (due to a shortage of A-b), to desensitize him (Fig 1). Intravenous diphenhydramine, 25 mg,and famotidine, 20 mg, were administered 20 minutes before beginning the procedure. Thereafter, he tolerated 35mgof intravenous A-b once monthly using the same premedication and desensitization protocol. However, 1 month later, using the same protocol, he developed generalized pruritus, rhinorrhea, and cough. The infusion was discontinued. Intravenous diphenhydramine, 25 mg, and

Asthma diagnosis and treatment - 1018. Effect of inhaled corticosteroids with long-acting beta2 agonists vs. inhaled corticosteroids alone on asthma control in children: results from national ashtma survey.

Methods Data from the National Asthma Survey were analyzed to compare asthma control in children (5 to 11 yrs) using ICS/LABA vs. ICS alone. Both short term (symptoms within last 2 weeks, day and night symptoms in last 30 days and use of systemic glucocorticoids in last 3 months) and long term (asthma attack, emergency department visits, hospitalizations and activity limitations in the prior year) outcomes were compared. Demographics, availability of health insurance, indoor allergen exposure and asthma education were compared between the two groups. Asthma control in an adult population (18 to 44 years) was also assessed for the same parameters.

Case of recurrent exophthalmos: angioedema versus idiopathic orbital pseudotumor.

FIGURE 2. Left orbital swellingwith exophthalmos, right lateral view. A 67-year-old white woman with a medical history of aspirinexacerbated respiratory disease, hypertension, and hyperlipidemia presented to the clinic with painless, isolated left orbital swelling and exophthalmos. The orbital swelling began a week before presentation and progressed, as depicted in Figures 1-3. Swelling was unassociated with aspirin and other nonsteroidal antiinflammatory drugs, other medications, trauma, urticaria, or angioedema; there were no visual defects. The swelling resolved with prednisone 20 mg three times daily for 7 days, followed by a taper over 1 month. However, orbital swelling recurred within a week, and she again was placed on prednisone, 20 mg three times daily, tapered to a dose of 5 mg daily with complete resolution over a year. Ten years later, the swelling and exophthalmos reappeared in the same eye. Again, a similar history was obtained, and a complete history and physical examination were normal. Her nasal polyps were controlled with mometasone 50 mg two sprays/nostril twice daily, and her asthma was controlled with budesonide/formoterol 160/4.5 mg two puffs twice daily and albuterol metered-dose inhaler 90 mg two puffs every 6 hours as needed. She is also on irbesartan/hydrochlorothiazide 300 mg/12.5 mg one tablet by mouth daily, Diltiazem CD (Lexicomp) 240 mg one tablet by mouth daily, and rosuvastatin 10 mg one tablet by mouth daily. There was no family history of urticaria, angioedema, or orbital swelling. There was no history of tobacco, alcohol, or illicit drug use. A complete blood cell count, comprehensive metabolic panel, thyroid function tests, and the C1 esterase deficiency evaluation were negative. Magnetic resonance imaging of the orbits revealed a left isolated proptosis, swelling of the medial and inferior rectus muscles with mild hypertrophy, and swelling of the left lacrimal gland. Prednisone 20 mg three times daily until resolution was followed by a slow taper and a maintenance of 5 mg daily, with complete resolution over a year. Idiopathic orbital pseudotumor (IOP) is usually a nongranulomatous inflammatory orbital mass without an identified local or systemic etiology. It represents 4.7% to 6.3% of orbital disorders, with an age range from 2.5 weeks to 92 years. The

591 A Case of Idiopathic Recurrent Isolated Orbital Angioedema with Exophthalmos

Background Idiopathic angioedema is a term applied to recurrent episodes of angioedema of unknown etiology. The following is a case report of idiopathic recurrent isolated orbital angioedema with exophthalmos which responds to prolonged courses of oral corticosteroids. Methods A 67 year old Caucasian female with aspirin exacerbated respiratory disease (AERD) sought treatment for an acute, progressive painless left eye swelling with exophthalmos without visual deficits or urticaria. High dose corticosteroids were initiated followed by a low maintenance dose. The swelling subsided after one year of corticosteroid therapy. Ten years later, orbital swelling with exophthalmos returned in the same eye. No medications, such as aspirin1 or non steroidal anti-inflammatory drugs,2 were associated with the swelling. A CT of the orbits revealed an isolated proptosis with swelling of the medial and inferior rectus muscles and mild hypertrophy and swelling of the left lacrimal gland. A complete history and physical examination were negative. The family history likewise was negative. Results High-dose systemic glucocorticoid therapy was initiated. Symptoms resolved after 1 month of tapered corticosteroid therapy, however, swelling reoccurred in the orbit within one week. Low dose maintenance corticosteroids were reinitiated with resolution of the orbital swelling. Work-up for acquired C1 esterase deficiency is negative. Conclusions An atypical case of recurrent idiopathic isolated orbital angioedema with exophthalmos in a patient with AERD and no triggering factor, systemic findings and a negative evaluation is presented.