Acute and maintenance treatment of atopic dermatitis in children – two comparative studies with fluticasone propionate (0.05%) cream

BACKGROUND

Two multicentre, randomised, parallel group, double-blind, comparative studies in children (2-14 yr) evaluated fluticasone propionate (FP) 0.05% cream for both acute and maintenance treatment of moderate to severe atopic dermatitis (AD).

METHODS

One study compared FP with hydrocortisone (HC) 1% cream (FP 70, HC 67) and the other with hydrocortisone butyrate (HCB) 0.1% cream (FP 67, HCB 62). Treatments were applied twice daily, for 2-4 weeks until the AD was stabilised, and thereafter intermittently ('as required') for up to 12 weeks.

RESULTS

The primary outcome measure, Total AD Score, recorded at the end of the acute and maintenance phases, was significantly lower (indicating improvements in disease severity) following treatment with FP compared with either HC or HCB (acute phase difference vs. HC, -2.39, 95%CI -3.47, -1.31; p<0.001 and vs. HCB, -1.25, 95%CI -2.46, -0.05; p=0.042) and (maintenance phase difference vs. HC, -1.88, 95%CI -3.20, -0.56; p=0.006 and vs. HCB, -1.39, 95%CI -2.72, -0.05; p=0.042). In both studies treatments were equally well tolerated with no visible signs of skin atrophy.

CONCLUSION

In both the acute and longer term management of AD in children, FP demonstrated a high level of efficacy and maintenance of disease control with a tolerability similar to HC 1%, a lower potency corticosteroid.

Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction

BACKGROUND

Inhaled bronchodilator treatment given via a metered dose inhaler (MDI) and spacer is optimal for relief of bronchoconstriction. Conventional spacers are expensive or unavailable in developing countries, but there is little information on the efficacy of low-cost spacers in young children.

OBJECTIVE

To compare the response to bronchodilator treatment given via a conventional or a low-cost bottle spacer

METHODS

A randomised controlled trial of the efficacy of a conventional spacer compared with a bottle spacer for bronchodilator treatment in young children with acute lower airway obstruction. Bronchodilator treatment was given from an MDI via an Aerochamber or a bottle spacer. Clinical score and oximetry recording were carried out before and after 15 min of treatment. MDI-spacer treatment was repeated up to three times, depending on clinical response, after which nebulisation was used. The primary outcome was hospitalisation.

RESULTS

400 children, aged (median (25th-75th centile)) 12 (6-25) months, were enrolled. The number of children hospitalised (n = 60, 15%) was identical in the conventional and bottle spacer groups (n = 30, 15% in each). Secondary outcomes including change in clinical score (-2 (-3 to -1)), oxygen saturation (0 (-1 to 1)) and number of bronchodilator treatments (2 (1 to 3)) were similar in both groups. Oral corticosteroids, prescribed for 78 (19.5%) children, were given to a similar number in the conventional (37 (18.5%)) and bottle spacer groups (41 (20.5%)).

CONCLUSION

A low-cost bottle spacer is as effective as a conventional spacer for bronchodilator treatment in young children with acute obstruction of the lower airways.

Socioeconomic status and prevalence of allergic rhinitis and atopic eczema symptoms in young adolescents

Environmental factors are known to influence the development of allergic rhinitis and atopic eczema in genetically susceptible individuals. Socioeconomic status (SES) may be an important indicator of risk for these conditions. The International Study of Asthma and Allergies in Childhood (ISAAC) Phase 1 written questionnaire was used to determine the prevalence and severity of allergic rhinoconjunctivitis and atopic eczema symptoms in 4947 pupils aged 13-14 years attending 30 schools in socioeconomically diverse areas of Cape Town. Home addresses were used to stratify participants into five SES bands. Relationships between symptom prevalence and severity, and SES, recent urbanization and upward socioeconomic mobility were examined. Logistic regression was used to generate odds ratios (OR) and 95% confidence intervals (CI) in order to assess overall trends by SES. The prevalences of self-reported allergic rhinitis symptoms and recurrent itchy rash in the past year were 33.2% and 11.9% respectively. Girls had a significantly higher prevalence of all symptoms than boys. The prevalence of allergic rhinitis symptoms increased from lowest to highest SES (overall OR for rhinitis symptoms in past year = 1.16, 95% CI 1.11-1.21). There was no significant trend in reported eczema symptoms by SES other than for the question, 'Have you ever had eczema' (OR = 0.88, 95% CI 0.83-0.93). Longer period of urbanization was weakly associated only with recurrent itchy skin rash (OR = 1.05, 95% CI 1.01-1.09). 'Socially mobile' pupils, i.e. those resident in the lowest SES areas but attending highest SES schools showed significantly higher prevalences of eczema and some rhinitis symptoms than pupils attending lowest SES schools. These findings may reflect differences in reporting related to language, culture and access to medical care rather than real differences in prevalence.

Peak expiratory flow rate and symptom self-monitoring of asthma initiated from community pharmacies

OBJECTIVE

To compare the use of patient-performed peak expiratory flow (PEFR) and symptom monitoring as asthma self-management tools initiated from community pharmacies.

DESIGN AND SETTING

110 patients over 6 years of age were recruited from five private-sector community pharmacies. Patients were identified from pharmacist recall as having 'asthma'. Information on the frequency of their asthma symptoms, medication use, level of physical activity, school or work attendance and lung function was obtained using a questionnaire to classify patients as either mild, moderate or severe. Each patient was alternately assigned to either the symptom or PEFR monitoring procedure in the order they were recruited. Patients performing symptom monitoring used a visual analogue scale to assess symptoms, whereas those in the PEFR monitoring group assessed symptoms and used a pocket-size peak flow meter to measure lung function. Both self-monitoring groups were required to adhere to an individualized management plan based on guideline recommendations and to record their monitored data in a diary card for 2 months. Data from the diary cards were reviewed, collated, transcribed and analysed using the Student t and Mann-Whitney tests.

OUTCOME MEASURES

The average monthly frequency of appropriate patient responses determined from their adherence to the self-management plan was used to compare the usefulness of symptom and PEFR self-monitoring. In particular, appropriate use of medication and need for medical consultation was compared.

RESULTS

21 symptom and 40 PEFR-assigned patients completed 2 months' monitoring. The average monthly frequency of appropriate responses in patients using PEFR (0.76) was significantly higher than that of patients using symptom monitoring (0.53, P < 0.006). Patients applying symptom monitoring had a higher monthly frequency (0.39) of inappropriate medication use compared to the PEFR group (0.14). Furthermore, the patients' mean daily symptom scores (2.85) were significantly lower than that estimated by the researcher (4.12, P < 0.03). For all three asthma severity groups a higher monthly average of appropriate responses was observed in patients using PEFR monitoring compared to those who used symptom monitoring.

CONCLUSION

PEFR self-monitoring proved to be a more useful asthma tool than symptom self-monitoring. Patients applying symptom monitoring tend to underestimate the severity of their condition and use medication inappropriately. Active involvement of community pharmacists in facilitating and reinforcing out-patient self-monitoring would help to optimize asthma management.

PBMCs from both atopic asthmatic and nonatopic children show a TH2 cytokine response to house dust mite allergen

BACKGROUND

The hypothesis that in atopic diseases the T-helper response is skewed toward a T(H)2-type cytokine response was based on studies with mitogen stimulation, T-cell clones, or both.

OBJECTIVE

Using primary cultures, we investigated (1) whether atopic asthmatic patients have a T(H)2 response and nonatopic subjects have a T(H)1 response to allergen and (2) whether atopic patients have a decreased ability to mount T(H)1 immune responses to mycobacterial antigens.

METHODS

The responses of PBMCs to allergen (house dust mite [HDM]) or purified protein derivative of Mycobacterium tuberculosis (PPD) stimulation from 10 severely and 14 moderately asthmatic patients (all allergic to HDM) were compared with those of 17 nonatopic healthy black (Xhosa) children.

RESULTS

HDM-stimulated proliferation, IL-5 release, and the IL-5/IFN-gamma ratio were significantly increased in subjects with atopic asthma, whereas IFN-gamma release was not significantly different. IL-4 levels were below the level of detection. PPD-stimulated proliferation, IL-5 release, IFN-gamma release, and the IL-5/IFN-gamma ratio were not significantly different among the groups. Each group had a significantly higher IL-5/IFN-gamma ratio in response to HDM than to PPD (a T(H)1 stimulus).

CONCLUSION

Our study, which used primary cultures to investigate the hypothesis that nonatopic subjects have a T(H)1 response to allergens, indicates that HDM stimulates a T(H)2 cytokine response in both atopic and nonatopic subjects but that the response is enhanced in atopic patients. Our results with PPD suggest that normal and atopic asthmatic subjects can have a T(H)1 cytokine response to mycobacteria, but there is a subgroup of atopic subjects that have a T(H)2 response.

Lung deposition of aerosol--a comparison of different spacers

AIMS

To investigate (1) aerosol lung deposition obtained from two small volume conventional spacers (Babyhaler and Aerochamber) and a home made spacer (modified 500 ml plastic cold drink bottle); (2) the effect of using a face mask or mouthpiece; and (3) the relation between age and pulmonary deposition.

METHODS

Lung deposition of aerosolised technetium-99m DTPA inhaled via spacer was measured in 40 children aged 3-7 years with stable asthma. Each patient performed sequential randomly assigned inhalations using two spacers. Three studies were performed: Babyhaler compared to Aerochamber (with facemasks); Babyhaler with facemask compared to Babyhaler with mouthpiece; and Babyhaler with mouthpiece compared to a 500 ml bottle.

RESULTS

Median lung aerosol deposition from a Babyhaler and Aerochamber with masks were similar (25% v 21%, p = 0.9). Aerosol lung deposition from a Babyhaler with mask compared to a Babyhaler with mouthpiece was equivalent (26% v 26%, p = 0.5). Lung deposition was higher from a 500 ml bottle compared to a Babyhaler in both young (25% v 12.5%, p = 0.005) and older children (42% v 22.5%, p = 0.003). A notable reduction in pulmonary deposition occurred at 50 months of age.

CONCLUSION

A Babyhaler or Aerochamber produce equivalent lung deposition of aerosol. There is no difference in lung deposition when a mask or mouthpiece is used. A modified 500 ml plastic bottle produces greater pulmonary aerosol deposition than a conventional small volume spacer.

Guideline for the management of chronic asthma in children--2000 update. Allergy Society of South Africa Working Group

OBJECTIVE

To increase awareness of asthma and diagnose asthma early in children. To make recommendations regarding management of chronic childhood asthma in a country with diverse cultural, socio-economic and educational characteristics. The guideline should be used by health professionals involved in the treatment of asthma at all levels of care.

OPTIONS

Various management options were considered. Ideal treatment includes use of the new generation inhaled corticosteroids (fluticasone, budesonide), housedust mite intervention for asthma control using impermeable covers for pillows and mattresses, and if needed use of inhaled long-acting beta 2 agonists (LABAs) and leukotriene receptor antagonists (LRAs). Alternative therapeutic approaches for situations where resources are limited include simple housedust mite control measures (e.g. airing mattresses and bedding), avoidance of exposure to passive smoking, use of lower doses of beclomethasone than recommended by other guideline documents and/or sustained-release (SR) theophylline as preventer treatment and use of plastic bottles as cheap spacer devices.

OUTCOMES

The main potential outcomes considered were: to reduce morbidity and mortality by correct diagnosis of asthma, to achieve the best quality of life for the child with asthma, to minimise side-effects from medication and to prevent development of permanently abnormal lung function.

EVIDENCE

Current international guideline documents for diagnosis and management of childhood asthma were evaluated. Clinical studies before 1998 pertaining to the various aspects of management of childhood asthma were reviewed, including controlled studies on the use of inhaled corticosteroids in children with asthma, randomised controlled trials on the use of LRAs and two studies evaluating the efficacy of LABAs. Current data on the anti-inflammatory effects of SR theophylline were also reviewed as well as a randomised controlled trial on the benefits of SR theophylline as adjunct treatment in childhood asthma. The benefit of simple spacer devices, based on well-conducted local studies (published in an international peer-reviewed journal) was also considered.

VALUES

The South African Childhood Asthma Working Group (SACAWG) committee members, appointed by the Allergy Society of South Africa (ALLSA), were selected to represent the interests of health professionals involved in the care of childhood asthma and to co-opt other colleagues with expertise relevant to the guideline. The committee was divided into six task groups headed by a chairperson--each task group had to review critically the previous SACAWG guideline (for deficiencies and obstacles to implementation), review current trends in asthma management (evidence-based where available) and submit proposals and recommendations to their respective chairperson. The chairperson then compiled a report for discussion by the SACAWG executive committee. The executive group convened a meeting to discuss the recommendations and obtain consensus. An editorial board was appointed to compile the final report. Cultural factors, patient preferences, cost, availability and education were considered important.

BENEFITS, HARMS AND COSTS

Proper treatment should enable most children with asthma to lead normal or near-normal lives. The guideline could be implementable at all levels of care. The risk of systemic effects due to inhaled corticosteroids should be minimised in children with mild to moderate persistent asthma (risk of systemic effects is more likely at daily beclomethasone doses exceeding 400 micrograms or the equivalent dose of other inhaled corticosteroids). Promotion of simple environmental control measures and use of inhaled beclomethasone and/or SR theophylline should make treatment more widely available and more affordable and improve adherence to treatment. Alternative cheap plastic bottle spacer devices will increase availability and assist with overcoming the problem of incorrect inha

Treatment preferences of adolescent patients with asthma

The study objective was to assess whether asthmatic adolescents who were regular users of inhaled corticosteroids preferred treatment with zafirlukast tablets or inhaled beclomethasone dipropionate (BDP), and, secondarily, to assess adolescents' inhaler technique and their opinions about treatment. An open-label, randomized, two-period, crossover study was conducted in 18 centres (primary care to specialist asthma centres) in South Africa, the UK, Finland and the Czech Republic. One hundred and thirty-two adolescents aged 12-17 years with asthma for at least 1 year and FEV1 > or = 75% of predicted, treated with short-acting bronchodilators and inhaled corticosteroids, entered the study. Patients received oral zafirlukast tablets (Accolate) 20 mg b.i.d. or inhaled BDP 100 or 200 microg b.i.d., provided by a standard pressurized metered-dose inhaler, for 4 weeks each. One questionnaire was used to determine preference (the primary outcome measure) and a second questionnaire was used to determine patients' likes and dislikes of treatment. Investigators also scored inhaler technique. Of 113 adolescents, 79 (70%) preferred zafirlukast compared with 31 (27%) who preferred the BDP inhaler (p < 0.001); three had no preference. Only 35 (29%) of 122 adolescents could use their inhaler correctly at study entry. Seventy-six patients (65%) rated zafirlukast tablets as 'very easy' to use, compared with 35 (30%) for the BDP inhaler. Both treatments were well-tolerated. This study shows that asthmatic adolescents prefer zafirlukast tablets by a ratio of 2.6:1 over inhaled BDP, and these results may have implications for improving adolescent patient compliance with asthma therapy.

Urbanization and childhood asthma: an African perspective

The increasing prevalence of childhood asthma in the developed world is a cause for concern. Much research is currently being conducted in an attempt to identify possible reasons for this occurrence. A so-called Western lifestyle has been the factor most commonly cited to explain this worrying increase in asthma prevalence. In essence, this implies a way of life where children are exposed from early infancy to a wide range of foods, infections, indoor and outdoor allergens, and irritants and to the effects of motor vehicle pollution. Until fairly recently, children in many African countries lived mainly in rural areas and were not exposed to the effects of a Western lifestyle. Early studies in a limited number of African countries showed a very low rural prevalence of childhood asthma, especially where children lived according to a traditional lifestyle. These same studies showed that asthma was not uncommon in urbanized African children. There has been an increasing tendency over the past 20 years for those in rural communities to move to the large urban centers. More recent childhood asthma prevalence studies, especially those from Kenya and Ghana, have confirmed the urban-rural differences but have shown a much narrower gap. In part this may be the result of exposure of rural children to agricultural pesticides and irritants as well as of an increasing tendency to adopt a more Westernized lifestyle such as the use of beds with mattresses, pillows, and blankets. These circumstances on the African continent provide a natural laboratory in the quest for factors that influence the development of asthma in susceptible children. Once more fully elucidated, it is possible that much valuable information will be available to combat the relentless increase in childhood asthma both here as well as in the developed world.

Urbanization and childhood asthma: an African perspective

The increasing prevalence of childhood asthma in the developed world is a cause for concern. Much research is currently being conducted in an attempt to identify possible reasons for this occurrence. A so-called Western lifestyle has been the factor most commonly cited to explain this worrying increase in asthma prevalence. In essence, this implies a way of life where children are exposed from early infancy to a wide range of foods, infections, indoor and outdoor allergens, and irritants and to the effects of motor vehicle pollution. Until fairly recently, children in many African countries lived mainly in rural areas and were not exposed to the effects of a Western lifestyle. Early studies in a limited number of African countries showed a very low rural prevalence of childhood asthma, especially where children lived according to a traditional lifestyle. These same studies showed that asthma was not uncommon in urbanized African children. There has been an increasing tendency over the past 20 years for those in rural communities to move to the large urban centers. More recent childhood asthma prevalence studies, especially those from Kenya and Ghana, have confirmed the urban-rural differences but have shown a much narrower gap. In part this may be the result of exposure of rural children to agricultural pesticides and irritants as well as of an increasing tendency to adopt a more Westernized lifestyle such as the use of beds with mattresses, pillows, and blankets. These circumstances on the African continent provide a natural laboratory in the quest for factors that influence the development of asthma in susceptible children. Once more fully elucidated, it is possible that much valuable information will be available to combat the relentless increase in childhood asthma both here as well as in the developed world.

Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial

BACKGROUND

A metered-dose inhaler (MDI) with spacer is the best way to deliver bronchodilator therapy for treatment of acute asthma. In developing countries, commercially produced spacers are generally unavailable or too costly. We tested the efficacy of home-made spacers (500 mL plastic bottle, polystyrene cup) compared with a conventional spacer for delivery of a beta2 agonist via MDI for children with acute asthma.

METHODS

We studied children aged 5 to 13 years with acute asthma, stratified into those with mild airways obstruction (peak expiratory flow [PEF] 60-79% of predicted value) or moderate to severe airways obstruction (PEF 20-59% of predicted value). A beta2 agonist (fenoterol hydrobromide) was given via MDI and one of four randomly assigned spacers (conventional spacer, sealed 500 mL plastic bottle, unsealed 500 mL bottle, 200 mL polystyrene cup). Clinical score, pulmonary function tests, and oximetry were recorded at baseline and 15 min after treatment. If a second bronchodilator treatment was needed, nebulised fenoterol was given and the assessment repeated 15 min later. Primary outcome measures were changes in clinical score and pulmonary function, and need for and response to nebulisation.

FINDINGS

88 children were eligible for study. In 44 children with moderate to severe airways obstruction, a cup gave significantly less bronchodilation (median increase in: forced expiratory volume in 1 s [FEV1] 0%; PEF 12%) compared with the conventional spacer (37%; 59%), sealed bottle (33%; 36%), or unsealed bottle (18%; 21%, p<0.05 for difference between groups). Nebulisation was required by ten of 11 who had used a cup, nine of 11 who had used an unsealed bottle, eight of 11 who had used a sealed bottle, and only four of 11 who had used a conventional spacer. After nebulisation, improvement in FEV1 (15.5%) and PEF (26%) was more marked in children who had used a cup than in those who had used a conventional spacer (5.5% FEV1; 4% PEF), sealed bottle (3%; 0%), or unsealed bottle (7%; 9%). For 44 children with mild airways obstruction, response to bronchodilator was similar for all spacers and need for nebulisation was not associated with use of a particular spacer.

INTERPRETATION

A conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction. Use of bottle spacers should be incorporated into guidelines for asthma management in developing countries.

The efficacy of alternative spacer devices for delivery of aerosol therapy to children with asthma

Spacer devices are important aids for use with metered dose inhalers in children with asthma. However, expense and unavailability of commercially produced spacers in developing countries have limited their use. Home-made spacers in the form of cups or bottles are widely used despite a lack of data confirming their efficacy. We investigated the relative efficacy of three spacers (a commercially available spacer, a modified 500-ml cold drink bottle and a polystyrene cup) for delivery of aerosolized drugs to asthmatic children older than 5 years. We also investigated the effect of leaks in the delivery system by comparing delivery via a sealed and an unsealed cold drink bottle. Lung deposition of aerosolized Tc-99m DTPA inhaled via spacer was measured in 30 patients. The median aerosol deposition in the lungs was significantly greater for the conventional spacer than for the cup (31.5% vs 9.5%; Z = -2.8, p = 0.005). Median aerosol deposition for the conventional spacer and sealed bottle were equivalent (40.5% vs 44%). Aerosol deposition from the sealed and unsealed bottle was significantly different (43.5% vs 24%; Z = -2.54, p = 0.01); however, the unsealed bottle was more efficient than the cup. We conclude that a modified 500-ml cold drink bottle is an efficient spacer. Leaks in this system are a major factor affecting the amount of drug deposited. The modified polystyrene cup is not an efficient spacer, delivering between a third and a fifth of the dose that other spacers were capable of delivering.

An assessment of asthmatic patients at four Western Cape community pharmacies

OBJECTIVES

To identify the profile of asthmatic patients visiting community pharmacies and to assess the appropriateness of their current asthma therapy.

DESIGN

Patients were identified as either chronic, newly diagnosed or undiagnosed. Asthma status was assessed from their current symptom and medication profiles and from performance in an airways responsiveness test. Reversibility of > 15% was suggestive of probable airflow obstruction and such patients were referred to a medical practitioner.

SETTING

Four community pharmacies located in different socio-economic areas, viz. Khayelitsha, Wynberg, Mitchell's Plain and Vrijzee, were selected.

SUBJECTS

Participants over the age of 6 years, who suffered from recurrent cough, wheeze, chest tightness and/or breathlessness and used over-the-counter (OTC) and/or asthma medications, completed a questionnaire and participated in the airways responsiveness test.

OUTCOME MEASURES

Effective control of asthma based on minimal symptoms, appropriate use of bronchodilator and anti-inflammatory therapies and absence of airflow obstruction.

RESULTS

Of the 220 participants, 120 were identified as chronic, 7 as newly diagnosed and 93 as undiagnosed. Chronic asthmatics suffered daily symptoms and used inadequate prophylactic anti-inflammatory therapy. Many undiagnosed asthmatics were unaware of their symptoms and took OTC medication indiscriminately. Based on peak expiratory flow rate measurements, > 50% of the screened patients displayed a reversibility of > 15%.

CONCLUSIONS

Chronic and many undiagnosed asthmatic patients frequent community pharmacies for their medication. Such patients suffer recurrent asthma symptoms and use medication inappropriately, which results in suboptimal lung function. Pharmacists should play a more participatory role in the detection and management of asthma in the community.

Reduced interferon-gamma but normal IL-4 and IL-5 release by peripheral blood mononuclear cells from Xhosa children with atopic asthma

BACKGROUND

Allergic asthma is increasing in black South Africans, a cohort with inherently high basal IgE levels. Atopy has been linked to an excess of the T helper 2 cytokines IL-4 and IL-5 relative to the T helper 1 cytokine interferon-gamma (IFN-gamma); however, most studies have utilized T cell clones. Studies on peripheral blood mononuclear cells (PBMC) have shown decreased IFN-gamma release in patients with atopic dermatitis. It is uncertain whether this finding extends to atopic asthma.

OBJECTIVES

To characterize cytokine release by mitogen-activated PBMC from Xhosa children and to investigate whether reduced IFN-gamma release is a feature of atopic asthma and whether there is a relationship between cytokine profiles and asthma severity.

METHODS

Cytokine release and proliferation of phytohemagglutinin-stimulated PBMC from 10 patients with severe asthma and 14 patients with moderate asthma (highly allergic to house dust mites) and 17 healthy controls was assessed. Total serum, allergen-specific, and Ascaris-specific IgE was measured.

RESULTS

Proliferation did not differ between the groups. The release of IFN-gamma was progressively decreased (and the IL-4/IFN-gamma ratio increased) in the groups with moderate or severe asthma. Tumor necrosis factor-alpha release was reduced, but IL-4, IL-5, and granulocyte-macrophage-colony stimulating factor release was unchanged. The presence of Ascaris-specific IgE did not influence the cytokine profiles.

CONCLUSION

Our study extends the findings observed for other atopic disorders and suggests that defective IFN-gamma release is a generalized feature of atopic diseases. This study-the first to investigate both severe and moderate asthma, with the groups having similar atopic profiles-indicates that the extent of the defect in IFN-gamma release might be related to asthma severity.

Granulocyte proteins in serum in childhood asthma: relation to spirometry and therapy

BACKGROUND

Measurement of markers of eosinophil activation in asthmatics provides information indicative of ongoing inflammatory processes in the airways.

OBJECTIVES

This study was conducted to determine the correlations between serum markers of allergic inflammation with spirometry parameters in asthmatic children in different treatment groups.

METHODS

Blood eosinophils, serum levels of eosinophil cationic protein (ECP), eosinophil protein X (EPX), myeloperoxidase (MPO) and tryptase were measured simultaneously with serial measurements of FEV1/FVC, FEF25-75 and FEF in 60 children with acute asthma on admission and after 2, 14, 30 and 60 days. Group A received bronchodilators only (n = 20), group B received sodium cromoglycate (SCG) (n = 20) and group C received oral and/or inhaled corticosteroids (n = 20).

RESULTS

Oral steroid treatment (2 mg/kg/day), given at the onset of the asthma attack, resulted in significant reduction in the ECP and EPX levels in all the children. However, these reduced ECP and EPX levels were not sustained in the children, even in those who continued on maintenance steroid treatment. Significant, but inconsistent, correlations between ECP, EPX with total eosinophil count, Percentage eosinophils and spirometry parameters were observed at the different time-points. Tryptase levels were normal in all subjects. There were no significant correlations between myeloperoxidase levels and the spirometry parameters or eosinophil parameters. Serial monitoring of ECP and EPX levels was found to be of some use in predicting clinical outcome in certain steroid-dependent asthmatics (group C) but of no value in the mild asthmatics (group A).

CONCLUSION

While elevation of ECP, EPX and MPO in the serum of childhood asthmatics suggests ongoing inflammation and may inversely correlate with spirometry parameters in some patients, the relationship between these markers and airway function is not a simple one.

Prevalence and reliability of asthma symptoms in primary school children in Cape Town

BACKGROUND

Childhood asthma is believed to be a serious problem in Cape Town, South Africa. This study aimed to measure the prevalence and reliability of asthma symptoms and reported asthma in Cape Town schoolchildren aged mainly 7 and 8 years, and to assess underdiagnosis.

METHOD

A questionnaire was completed by parents of 1955 children, followed by 620 personal interviews repeating the questions.

RESULTS

The prevalence of recent wheeze (previous 12 months) (26.8%) was high by international comparison, but not that of reported asthma (10.8%). Among children with more than 12 recent attacks of wheeze, only 60% were reported as asthmatic and 55% as receiving regular treatment. Symptom prevalences varied with the respondent's familial relationship to the child. On some questions the interview produced higher wheeze prevalences than the self-administered questionnaire. Repeatability of questions varied: asthma over (kappa = 0.69), recent wheeze (kappa = 0.59), and recent sleep disturbance by wheeze (kappa = 0.56) were the most reliable.

CONCLUSIONS

Prevalence based on symptom reports may vary with the respondent and between self- and interviewer-administered questionnaires. Also, certain questions currently proposed for childhood asthma questionnaires may be unreliable. Nevertheless, it can be concluded that the prevalence of wheeze is high in this population, and that underdiagnosis and undertreatment of asthma are a problem.

Accumulation of house-dust mite (Der-p-1) levels on mattress covers

Mattresses serve as a large reservoir for house-dust mite antigens and harbour the highest mite levels within the household. Mite reduction measures have previously been shown to be unsuccessful. The effect of mattress covers and acaracides on Der-p-1 levels in the mattresses of 60 patients with mite-allergic asthma was studied. Der-p-1 levels were measured using monoclonal antibodies (ELISA method). Baseline levels were recorded and re-assessed at 8-week intervals over a 6-month period. Patients were randomised into three equal groups. In group A mattresses were treated with Metsan (Snowchem) and benzylbenzoate only; group C had their mattresses covered with mattress covers (Allergy Control Products). Group B was the control group. We were unable to demonstrate any reduction of mite levels in the beds of all 3 groups. In fact all 3 groups demonstrated an increase in Der-p-1 levels over the study period, viz. group A (mean pre: 14.28, post: 34.18 micrograms/g dust); group C (mean pre: 8.26, post: 20.80 micrograms/g dust) and group B (mean pre: 18.21, post 38.47 micrograms/g dust). However, 12 patients in group C had their mattress covers washed in hot water at weekly intervals over a 5-week period at the end of the study. The results demonstrated a significant reduction in mite levels (mean pre: 41.95, post: 26.2 micrograms/g dust; P = 0.027). We therefore conclude that the use of mattress covers per se does not reduce Der-p-1 levels. The regular application of benzylbenzoate and Metsan does not prevent the accumulation of Der-p-1 on mattresses either.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of a single treatment of an acaricide, Acarosan, and a detergent, Metsan, on Der p 1 allergen levels in the carpets and mattresses of asthmatic children

Baseline levels of the house-dust mite allergen, Der p 1, were measured on the carpets and mattresses of 60 pure-mite-sensitive asthmatic children in the Cape Peninsula, by means of an enzyme-linked immunosorbent assay (ELISA). High levels of mite allergens were recorded (range 2-50 micrograms Der p 1/g dust). In order to investigate the efficacy of the application of acaricides to carpets and bedding, 3 groups of 20 children were studied. Carpets and mattresses in group A were treated with a detergent, Metsan (Snowchem), and in group B with Metsan combined with the acaricide, Acarosan (Noristan). Group C was a control group in which no treatment was applied. The level of airway hyperreactivity (PC20) to histamine was measured at the beginning of the study and again 3 months after acaricide treatment. Significant reductions in carpet Der p 1 levels were achieved in group A (22.83 v. 13.26 micrograms Der p 1/g dust; P = 0.04) and group B (21.76 v. 13.26 micrograms Der p 1/g dust; P = 0.01), but mite levels were not reduced in any of the mattresses treated. There was also no improvement in airway hyperreactivity in any of the groups. This study clearly demonstrates that at present it is not possible to reduce Der p 1 antigen levels in mattresses in the Cape Peninsula with the available acaricides, even when one of these is combined with a detergent solution. Until strategies are developed which will significantly reduce Der p 1 levels in the bedding of sensitive individuals, a reduction in ongoing airway inflammation and airway hyperreactivity cannot be expected.

Increase in hospital admissions for acute childhood asthma in Cape Town, 1978-1990

To determine whether hospital admissions for acute childhood asthma were rising in Cape Town in line with the experience of other countries, Red Cross War Memorial Children's Hospital's records for the period 1978-1990 were analysed. These were compared with total admissions for non-surgical causes and lower respiratory tract illness as well as those for bronchiolitis and pneumonia. Asthma admissions showed a sharp upward trend from 1978 to 1984, a slower rise through 1987 and a levelling off since. The profile of hospital admissions for respiratory illness was also analysed. Black children were under-represented among asthma admissions compared with those for pneumonia. Asthma admissions occurred throughout the year but showed seasonal peaks in May and November. Reasons for these trends and patterns are discussed, as well as hypotheses for further research into the epidemiology of asthma in South Africa.

Comparison between the Acarex R test and a Der p 1 ELISA for the detection of house-dust mites in the homes of asthma sufferers

Exposure to house-dust mite allergens in early childhood is an important determinant of the subsequent development of asthma. The Acarex R semi-quantitative test (Noristan) is marketed for use in patients' homes to assess mite levels in house dust. In order to evaluate the reliability of the test in a coastal area where house-dust mites are known to be prevalent, house-dust mite levels were estimated in 119 dust samples obtained from the homes of asthmatic children in a comparative study, by means of the Acarex R test and a Der p 1 enzyme-linked immunosorbent assay (ELISA). A linear regression of the 4 Acarex classes against log Der p 1 revealed a significant correlation (P = 0,0001) but there was a poor correlation between low Acarex R scores and the Der p 1 allergen levels determined by ELISA. Acarex R scores of 2 and 3 were usually associated with Der p 1 levels greater than 10 micrograms/g dust. Our studies indicate that the Acarex R test will identify high levels of mite allergens. Although its application may be limited in coastal areas such as the Cape Peninsula, it may be more useful inland, in climates where house-dust mites are not commonly encountered in all homes.

A placebo controlled trial of fluticasone propionate in asthmatic children

Fluticasone propionate is a synthetic steroid for use by the inhaled route. It's high topical potency and low systemic bioavailability make it suitable for use in asthmatic children. A total of 258 children were randomised in a double-blind study to receive fluticasone propionate (50 micrograms bd) as the dry powder formulation inhaled via a Diskhaler inhaler, or matched placebo (with current therapy) for 4 weeks throughout which time diary cards were completed. During clinic visits lung function and adrenal function were measured. Fluticasone propionate produced a significantly greater increase in morning peak expiratory flow rate (PEFR) (adjusted mean difference over days 1-28, 17 l/min (95% CI; 10, 24); P < 0.001) and evening PEFR (adjusted mean difference over days 1-28, 16 l/min (95% CI; 9, 23); P < 0.001). In addition, diary card symptom scores, beta 2-agonist rescue and clinic lung function improved significantly on fluticasone propionate. There were few adverse events and basal plasma cortisol remained within the normal range. In conclusion fluticasone propionate at 50 micrograms bd is superior to placebo (current therapy) in the treatment of childhood asthma with no evidence of adverse effects.

Seasonal and recurrent intensive care unit admissions for acute severe asthma in children

Life-threatening attacks of asthma requiring intensive care unit (ICU) management at Red Cross War Memorial Children's Hospital in Cape Town were noted to occur in some patients in the same or adjacent months of different years. A retrospective case-controlled study was performed of 21 such 'seasonal' patients who presented to the ICU over a 14-year period. The group made up 6.5% of all asthma patients admitted to the ICU and their 65 admissions made up 15.6% of all ICU asthma admissions during this period. The control group consisted of patients with recurrent admissions that occurred in 'random' months. The two groups were compared in respect of demographic and clinical data. Patients requiring seasonal admissions were shown to form a distinct sub-population of children with severe asthma, some with a family history of fatal asthma, who were less likely to 'outgrow' asthma in childhood, were more likely to require maintenance steroid therapy for asthma management, and significantly more often had positive radioallergosorbent tests to Aspergillus and Cladosporium sp. and to grass pollen. A retrospective analysis of dates of severe asthma attacks may identify individual seasonality, which is a risk factor for life-threatening and intractable asthma.

Hydration in severe acute asthma

Twenty children were studied during severe attacks of acute asthma to find out how dehydrated they were on admission to hospital. Mean body weight on admission was 97.8% of their reference stable weight seven to 10 days after the attack and in only three children was it less than 95% of the stable weight. Bedside assessment of dehydration was unreliable. The mean packed cell volume was significantly higher on admission than 7-10 days later (0.44 compared with 0.42, difference 0.02 SE 0.01). Serum sodium and potassium concentrations and osmolality on admission were within normal ranges. The degree of dehydration correlated best with a fall in blood pH. There was no association between the degree of dehydration and the recovery of the peak expiratory flow rate during the first 24 hours or thereafter. We conclude that mild dehydration is common in severe acute childhood asthma. Fluid given at a rate of 50 ml/kg/24 hours was safe and appropriate for these children.

Genetic and environmental influences on cord blood serum IgE and on atopic sensitisation in infancy

It has recently been reported that cord blood serum IgE (CBsIgE) concentrations in a black Third-World cohort were significantly higher than those in a similar cohort of white and coloured newborns, and were not influenced by an atopic family history (aFH). This study reports on the 1-year follow-up of these newborns carried out to determine whether statistical differences in median CBsIgE values at birth could be found between infants in each ethnic group who subsequently developed clinical atopy in the first year of life and those who remained healthy. The infants were seen at 3, 7 and 12 months of age. At each visit a detailed history was taken from the mothers, the infants were examined clinically for the presence of atopic disease and blood was taken for immunological assay (total serum IgE by paper-disc radio-immunosorbent testing, and radio-allergosorbent testing for egg-white, cow's milk and Dermatophygoides pteronyssinus). A combination of clinical and immunological variables was assessed in order to categorise the infants into 'atopic' or 'not atopic' groups at the end of the 1-year follow-up period. The black infants who completed the study had the lowest incidence of aFH (16%), but 64% of them developed atopic disease during infancy. The median CBsIgE values for the black infants who became atopic were lower than, but not statistically different from, those for the group who remained non-atopic (P = 0.57). The white and coloured infants who completed the study had 81.6% and 30.4% incidences of aFH respectively, with 47.4% and 58.7% respectively developing atopic disease during infancy.(ABSTRACT TRUNCATED AT 250 WORDS)

A multi-allergen screening test for suspected allergic disease in coloured children

The measurement of total serum IgE levels is widely used as a screening test for allergic disease but lacks specificity in South African subjects because of the presence of ethnic and environmental factors, e.g. parasite infestation, which also raise total serum IgE. The reliability of a new in vitro multi-allergen test, Phadiatop (Pharmacia), which is not influenced by parasitic infestation, was investigated as a screen for allergic disease in coloured children. Phadiatop assays and total serum IgE levels performed on 18 children with known allergic disease were compared with 21 non-allergic individuals. All the allergic, but only 2 of the non-allergic children had a positive Phadiatop result (P = less than 0.01; chi-square test) but there was no significant difference between the number of allergic or non-allergic children with elevated total serum IgE levels (P = greater than 0.1). The Phadiatop test demonstrated a specificity of 90% compared with 28% for total serum IgE. The predictive value of a negative Phadiatop result was 90% compared with 54% for total serum IgE levels. These data indicate that the Phadiatop test is a more specific screening test for allergic disease than total serum IgE levels in coloured children.

The influence of ethnicity, an atopic family history, and maternal ascariasis on cord blood serum IgE concentrations

Raised concentrations of cord blood serum (CBs) IgE have previously been demonstrated to reflect a hereditary predisposition for atopy in First World, predominantly white populations. A cross-sectional study of 53 black, 52 white, and 58 mixed race newborn infants and maternal pairs was performed in a multiethnic, mixed First and Third World society. The CBs IgE concentrations were measured with a modification of the standard IgE PRIST, which could reliably determine IgE concentrations to an accuracy of 0.01 kU/L. The black group had the highest geometric mean and median CBs IgE concentrations (0.21; 0.16 kU/L), followed by the white group (0.12; 0.12 kU/L) and the mixed group (0.10; 0.08 kU/L). If those newborn infants with an atopic family history and maternal ascariasis were excluded, the remainder had geometric mean and median CBs IgE concentrations of 0.20; 0.16 kU/L in the black subgroup, followed by values of 0.06; 0.05 kU/L in the mixed subgroup, and 0.05; 0.07 kU/L in the white subgroup. Statistically significant ethnic differences in the median CBs IgE concentrations of these subgroups were demonstrated between the black-white (p less than 0.05) and the black-mixed (p less than 0.005) ethnic groups. A positive family history of atopy influenced the CBs IgE concentrations in the white and mixed groups but not in the black group. Of those newborn infants with a CBs IgE concentration greater than 0.5 kU/L, a family history of atopy was found in 100% of the white newborn infants, in 58.3% of the mixed newborn infants, and only in 14.3% of the black newborn infants. Many of the black newborn infants without a family history of atopy had extremely high CBs IgE concentrations. The influence of maternal ascariasis was equivocal in the mixed group but of no significance in the black group. The high CBs IgE concentrations in the black newborn infants, independent of an atopic family history and maternal ascariasis, suggest that this atopic marker may therefore be of limited use in identifying the "high allergic-risk" newborn infant in black Third World populations who appear to represent a pool of genetic high IgE-responder phenotypes.

Anti-Staphylococcus aureus-specific IgE in atopic dermatitis

Serum samples from 60 adults and 64 children with atopic dermatitis were tested for antistaphylococcal IgE antibodies with RAST discs coupled to cellular proteins from Wood 46 strain S. aureus. Anti-S. aureus IgE antibodies were detected in 19 (29.6%) of the children and 14 (23.3%) of the adult patients. Anti-S. aureus IgE-positive adults had more severe and prolonged disease than those who were negative. Two groups of children comprising 10 who were anti-S. aureus IgE positive and 10 who were negative were compared. Children with anti-S. aureus IgE antibodies had more severe and more extensive disease (p less than 0.05), a greater prevalence of cutaneous S. aureus infections (p less than 0.05), higher mean total serum IgE level (p less than 0.05), a greater prevalence of specific IgE responses to food allergens (p less than 0.05), and a higher percentage of helper T cells (p less than 0.05) than children who were negative for these antibodies.

The effects of soft-drink preservatives on asthmatic children

Sulphites, used extensively as preservatives in foods and soft drinks, are known to precipitate asthma attacks in 5-10% of susceptible children. Among children attending the Allergy Clinic at the Red Cross War Memorial Children's Hospital, Cape Town, many were found to be sensitive to sulphites. The basis of asthma therapy is modification of the environment and avoidance of precipitating factors. Medical personnel counselling parents of asthmatic children should be aware of this factor. A list of soft drinks containing sulphites and other preservatives is included.

Is Mycoplasma pneumoniae a precipitating factor in acute severe asthma in children?

A randomized prospective trial in 39 children with acute severe asthma admitted to the emergency ward of the Red Cross War Memorial Children's Hospital and a matched comparative group showed that Mycoplasma pneumoniae was not a precipitating factor.

Bee venom allergy

Bee venom allergy is a common problem in medical practice. The immunological mechanisms and management thereof are reviewed.

Sodium cromoglycate in asthma therapy. A retrospective survey

The data obtained in a retrospective survey of the use and effectiveness of sodium cromoglycate (Lomudal; Fisons) therapy in 635 children and young adults support the findings of other long-term studies that this drug is effective and safe in the treatment of children and young adults with clear evidence of allergy contributing towards their asthma. Its administration by Spinhaler can be commenced successfully at 4 years of age or even younger and continued for as long as is required. The drug is worth a therapeutic trial in any patient with asthma requiring regular medication to control symptoms. The absence of demonstrable allergy does not entirely preclude a favourable response. Once a patient's asthma has been stabilized, sodium cromoglycate enables concomitant therapy (especially with beta 2-adrenergic stimulants and corticosteroids) to be reduced.

The effect of terbutaline sulphate on exercise-induced asthma in children

Terbutaline sulphate (Bricanyl; Keatings) aerosol or placebo aerosol was administered in a randomized fashion to 26 asthmatic children with proven exercise-induced asthma. The children were then subjected to the modified standard exercise challenge test involving running on the level for 6 minutes. Terbutaline sulphate aerosol had a marked protective effect against exercise-induced asthma in these children. Compared with placebo, a significant reduction in exercise-induced bronchospasm was achieved. The improved design of the mouthpiece, incorporating a newly introduced 'misting tube' enabled the children to handle the apparatus easily. The need to synchronize the activation of the aerosol with inhalation was eliminated. Terbutaline aerosol can be recommended to protect children affected by exercise-induced asthma. The preparation can be given prior to the exercise challenge and will offer prolonged and adequate protection against exercise asthma.

'Honking': Psychogenic cough tic in children

Psychogenic cough tic is a troublesome complaint. The cough is a noisy bark or honking, repeated frequently while the child is awake, but absent during sleep. Clinical and laboratory findings are negative, and cough suppressants and other medications are ineffective. The cough usually starts in the winter months and may be preceded by an upper respiratory tract infection. School phobia is frequently a contributory cause, but other psychological problems must also be considered. Treatment is usually by suggestion and identification of the underlying psychological problem. In some cases tranquillizers may be required.