Pavadee Poowuttikul

Asthma consultations with specialists: what do the pediatricians seek?

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma includes guidelines for referral to an asthma specialist. Because most cases of asthma are managed by primary care physicians, we intended to explore the referral practices of pediatricians managing childhood asthma. This study was designed to identify important considerations by pediatricians while referring a child to an asthma specialist. An electronic survey was sent to 1200 graduated pediatricians enlisted in the Michigan Chapter, American Academy of Pediatrics directory. The questions explored asthma disease characteristics, physician preferences when referring children with asthma, and reasons and barriers for asthma consultations. All responses were collected anonymously. We received 240/1200 (20%) questionnaires. The majority of pediatricians considered referral to a specialist if a child had severe persistent asthma (201/236 [85.2%]) or had a single life-threatening asthma event (188/229 [82.1%]). The top two likely reasons of referral included poor asthma control (200/224 [89.3%]) and unclear diagnosis (139/224 [62.1%]). We found 74/219 (33.8%) preferred consultation to a pediatric pulmonologist when compared with 93/219 (42.5%) allergists. We found the minority of pediatricians always recommended referral to a specialist for the following reasons: allergy skin testing (30/222 [13.5%]), possible allergen immunotherapy (54/223 [24.2%]), and spirometry (26/221 [11.8%]). The major barrier for childhood asthma specialist consultations was issues with medical insurance coverage (137/205 [66.8%]). Allergists have to educate primary care providers about the importance of allergen control, role of allergen immunotherapy, and updating current asthma treatment guidelines when treating a child with allergic asthma.

Vitamin D Insufficiency/Deficiency in HIV-Infected Inner City Youth

Background: High prevalence of vitamin D deficiency among HIV-infected individuals has been reported in many studies. Increasing evidence for vitamin D’s role in innate and cell-mediated immunity suggests that vitamin D insufficiency or deficiency is worrisome particularly for HIV-infected individuals who are already at increased risk of infection. It is unknown whether vitamin D deficiency and supplementation will have any effects on HIV infection, including CD4 counts/CD4% and HIV plasma RNA. Method: Serum vitamin D levels, 25-hydroxyvitamin D (25-(OH)D), were obtained from 160 HIV-infected youth, aged 2 to 26 years as part of routine care. The HIV plasma RNA and CD4 counts were compared between patients with normal vitamin D and vitamin D insufficiency/deficiency. Individuals whose vitamin D level was ≤35 ng/mL received vitamin D3 supplementation. We compared the HIV plasma RNA, absolute CD4 counts, and CD4% in pre– and post–vitamin D supplementation. Categorical comparisons between the groups were examined using a nonparametric Fisher exact test, while continuous variables, pre– and post–vitamin D supplementation, were examined using a parametric paired samples t test. Results: The majority (152 of 160; 95%) of our patients were African American. Only 8 (5%) of 160 had normal vitamin D. Of the 160 patients with HIV, 37 (23.1%) had vitamin D insufficiency (25-(OH)D level between 21 and 35 ng/mL) and 11 of 160 (71.9%) had vitamin D deficiency (25-(OH)D level ≤20 ng/mL). Absolute CD4 counts averaged lower in patients who have severe vitamin D deficiency (25-(OH)D ≤10 ng/mL; mean 574.41 ± 306.17 cells/mm3) compared to those who had higher vitamin D level (mean 701.15 ± 444.19 cells/mm3). The CD4% were also lower (mean 25.12% ± 12.5%) in those who have severe vitamin D deficiency compared to those whose vitamin D level was ≥11 ng/mL (mean 29.47% ± 11.62%). The HIV plasma RNA was similar in all the groups. Our patients who were prescribed tenofovir (TDF) and/or efavirenz (EFV) did not have different vitamin D levels than patients who were prescribed other antiretroviral (ARV) medications. Only 60 (39.5%) of the 152 patients who received vitamin D supplement showed improvement in vitamin D level. Of the 60 patients, 10 (16.7%) had normalized vitamin D level (25-(OH)D level > 35 ng/mL). We did not see any significant change in the absolute CD4 counts or CD4%. Conclusions: A higher prevalence of vitamin D insufficiency/deficiency was found in our study compared to the previous large cohorts. However, patients who were prescribed TDF/EFV did not have lower vitamin D levels. Inadequate sunlight exposure in temperate latitudes and the cloud effect of the Great Lakes as well as large number of African American participants who live in the inner city area with poverty and poor diet may combine to explain these results. The effect of ARV medications on vitamin D may be washed out by the numerous other factors affecting vitamin D in our patients. Severe vitamin D deficiency seemed to be related to lower CD4 counts and CD4% but not related to HIV plasma RNA. Vitamin D supplementation did not increase CD4 counts/CD4% in our study.

Pneumococcal Antibody Titers: A Comparison of Patients Receiving Intravenous Immunoglobulin Versus Subcutaneous Immunoglobulin

Purpose: Immunoglobulin replacement is the mainstay treatment in patients with humoral immunodeficiencies, yet a handful of patients continue to develop sinopulmonary infections while on therapy. The objective of our study was to compare immunoglobulin G (IgG) pneumococcal antibody levels in patients with humoral immune deficiencies who have been on intravenous immunoglobulin (IVIG) replacement for at least 1 year to those on subcutaneous immunoglobulin (SCIG) therapy for at least 1 year. Methods: A retrospective chart review was completed on 28 patients. These patients’ ages ranged between 1 and 61 years. Pneumococcal serotype titers obtained at least 1 year after initiating therapy were compared between patients on IVIG (19 patients) and SCIG (9 patients). Results: A comparison between the groups demonstrated that SCIG achieved a higher percentage of serotype titers protective for noninvasive disease (≥1.3) and 100% protection for invasive disease (≥0.2). Our data also demonstrated a similar lack of protection (less than 50% ≥1.3) in 9N, 12F, and 23F on IVIG and 4, 9N, 12F, and 23F on SCIG. Conclusions: Our data demonstrated that serotypes 1, 3, 4, 9N, 12F, and 23F exhibited the lowest random IgG means while on IVIG, which was comparable to other published studies that looked at the mean IgG levels. In addition, our retrospective chart review demonstrated a greater number of therapeutic pneumococcal titers with SCIG in comparison to IVIG.

Deficit of Anterior Pituitary Function and Variable Immune Deficiency Syndrome: A Novel Mutation

Common variable immunodeficiency (CVID) is a complex primary immunodeficiency disorder with hypogammaglobulinemia as a major feature. Most of the patients do not have a specific genetic abnormality. Autoimmune disorders occur commonly in patients with CVID. We report a case of a girl with secondary adrenal insufficiency who developed a disseminated varicella zoster infection and zoster meningoencephalitis with vaccine strain. The laboratory evaluation of this patient led to the final diagnosis of CVID with a new variant of TACI (transmembrane activator and calcium-modulator and cyclophilin ligand interactor) mutation and DAVID syndrome (deficit of anterior pituitary function and variable immune deficiency).1

Poor Adherence With Medication Refill and Medical Supplies Maintenance as Risk Factors for Inpatient Asthma Admission in Children

Background. Asthma results in significant pediatric hospitalizations in the inner city. Many asthmatic children were admitted to our hospital as a result of lack of medications or medical supplies that had been previously prescribed (“ran out,” “broken,” or “lost”). Objective. To identify the incidence of children admitted for asthma because of lack of prescribed medications/supplies and to assess risk factors for poor adherence between groups. Methods. This was a prospective chart review of 200 asthmatic children admitted to Children’s Hospital of Michigan, Detroit. The data included asthma severity, lack of prescribed medications/medical supplies, and outpatient management. Results. In all, 35.5% or 71/200 of asthmatic children admitted had lack of prescribed medication/supplies (9% lacked both). The most common deficiency was β2-agonist (20.5%; 41/200). Teenagers had the highest lack of medications/medical supplies (55.6%; 5/9) compared with toddlers (17.2%; 16/93) and preschoolers (17.9%; 5/28). Patients with severe persistent asthma had a higher incidence of lacking medicine (31.8%; 7/22) compared with 25% (14/56) with moderate persistent asthma and 23.4% (15/64) of mild asthmatics. We found the lack of asthma medical supplies, including nonfunctioning or lost nebulizers/spacers, in 44.4% (4/9) of teenagers, 17.2% (16/93) of toddlers, and 21.4% (6/28) of preschool-aged children. We found no significant difference in these deficiencies whether patients were managed by asthma specialists or primary care providers. Conclusions. Significant numbers of asthmatic children admitted reported lack of prescribed medications/medical supplies. The most severe asthmatics were most likely to run out of medications. Interventions targeted at these deficiencies may avoid hospitalizations.