Comparison of the Bronchodilator Effect of Inhaled Short- and Long-Acting beta(2)-Agonists in Children with Bronchial Asthma: A Randomised Trial

OBJECTIVE

This study compared the bronchodilator effects of short-acting (salbutamol and procaterol) and long-acting (salmeterol and formoterol) beta(2)-agonists in children with bronchial asthma.

PATIENTS

Twenty-seven (18 male, 9 female) children with bronchial asthma were enrolled in the study. Drugs were administered randomly in the morning for 5 days as follows: 1 single dose of two short-acting beta(2)-agonists, salbutamol 200microg and procaterol 20microg, and two long-acting beta(2)-agonists salmeterol 50microg and formoterol 24microg, and placebo.

RESULTS

All beta(2)-agonists demonstrated a significantly higher bronchodilator effect than that observed with placebo. This effect appeared to be due to the forced expiratory flows. Formoterol produced a higher bronchodilator effect than salbutamol, and salmeterol showed a bronchodilator effect comparable with salbutamol at 30 minutes but higher than salbutamol after 3 hours.

CONCLUSION

Our study confirmed the efficacy of the bronchodilator effects of the beta(2)-agonists. Salmeterol and formoterol, in particular, produced an improvement in respiratory function with a significant increase in forced expiratory flows in children with bronchial asthma.

ADMA, SDMA, L-Arginine and nitric oxide in allergic pediatric bronchial asthma

Published data regarding asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), L-arginine (L-ARG) and nitric oxide fraction in exhaled air (FeNO) in pediatric bronchial asthma are limited. Many question remain open about plasma concentration of these substances. The aim of this study is to evaluate ADMA, SDMA, L-ARG and FeNO concentration in allergic pediatric mild asthmatic patients in respect to healthy subjects. In this case-control study 60 children (50 asthmatics and 10 healthy) underwent a complete clinical visit, baseline respiratory function, allergy tests and biochemical analyses. The statistical significance of the different concentrations between the two groups were studied using one-way analysis of variance (ANOVA). A p value less than 0.05 was considered statistically significant. The mean plasma ADMA (0.58 vs 0.68 micromol/L), SDMA (0.40 vs 0.45 micromol/L) and L-ARG (52.2 vs 74.13 micromol/L) concentration were significantly lower (p less than 0.001) in the asthmatic patients in respect to healthy subjects (control group). The concentration of FeNO was significantly higher in the asthmatic subjects in respect to the control group (9.18 vs 4.2 micromol/L; p less than 0.001). Low plasma concentrations of ADMA, SDMA, L-ARG and high concentration of FeNO are associated with bronchial asthma and indicate an important role in airway disease through NO metabolism.

Pathogenesis and Clinical Approaches to Anticonvulsant Hypersensitivity Syndrome: Current State of Knowledge

Anticonvulsant hypersensitivity syndrome (AHS) is a rare, but severe and potentially fatal, adverse reaction that occurs in patients who are treated with commonly used older anticonvulsant drugs (phenytoin, carbamazepine and phenobarbital) and/or with some newer agents (lamotrigine). Paediatric patients are at an increased risk for the development of AHS for the higher incidence of seizure disorder in the first decade of life. Hypersensitivity reactions range from simple maculopapular skin eruptions to a severe life-threatening disorder. AHS is typically associated with the development of skin rash, fever and internal organ dysfunctions. Recent evidence suggests that AHS is the result of a chemotoxic and immunologically-mediated injury, characterized by skin and mucosal bioactivation of antiepileptic drugs and by major histocompatibility complex-dependent clonal expansion of T cells. Early recognition of AHS and withdrawal of anticonvulsant therapy are essential for a successful outcome. In vivo and vitro tests can be helpful for the diagnosis that actually depends essentially on clinical recognition.

Sublingual immunotherapy in polysensitized patients: effect on quality of life

BACKGROUND

Quality of life (QOL) is an important issue in allergic rhinitis and has been evaluated in a number of studies that have shown how it is impaired in untreated patients and improved by effective treatment. However, there are no data concerning QOL after sublingual immunotherapy (SLIT) in polysensitized patients.

OBJECTIVE

To evaluate the effect, in real-life clinical practice, of SLIT on QOL in a population of polysensitized patients with allergic rhinitis.

METHODS

We prospectively evaluated 167 consecutively enrolled polysensitized patients with allergic rhinitis. QOL was measured in all cases with the Rhinoconjunctivitis Quality of Life Questionnaire at baseline and after 1 year of SLIT (performed in approximately 70% of cases using single allergen extracts provided by the same manufacturer).

RESULTS

The most frequent causes of sensitization were grass pollen, Parietaria, and house dust mites. The mean number of sensitizations per patient was 3.65. SLIT was performed with 1 extract in 123 patients (73.6%), with 2 extracts in 31 patients (18.6%), and with more than 2 extracts in 13 patients (7.8%). The mean values of all the QOL items improved significantly (P < .01 in all cases), with the following reductions noted: activities, 3.96 to 2.89; sleep, 2.07 to 1.56; general problems, 2.16 to 1.5; practical problems, 3.69 to 2.58; nasal symptoms, 3.57 to 2.50; eye symptoms, 2.92 to 1.83; and emotional aspects, 2.2 to 1.44.

CONCLUSIONS

This study provides evidence that QOL can be improved in polysensitized patients treated with SLIT, and that the use of just 1 or 2 allergen extracts seems to be sufficient and effective in terms of improving QOL.

Sublingual immunotherapy in polysensitized allergic patients with rhinitis and/or asthma: allergist choices and treatment efficacy

Polysensitization is very common in allergic patients and was previously reported to be associated with more severe symptoms and impaired quality of life. Polysensitization is often considered as a contraindication for specific immunotherapy (SIT). This study is aimed at evaluating the allergist attitude for decision making in choosing SIT in a cohort of Italian polysensitized patients. Moreover, the 1-year effectiveness of the prescribed sublingual immunotherapy (SLIT) in this cohort was evaluated. The study was performed on 244 patients (109 males, 135 females, mean age 28.7 years, S.D. 12.0) with allergic rhinitis (assessed by ARIA criteria) and/or mild to moderate asthma (assessed by GINA criteria) treated with SLIT for 1 year. The kind and the number of prescribed allergen extracts, type of diagnosis, severity of symptoms, use of drugs, and adverse events were evaluated at baseline and after 1 year. A total of 230 patients were treated with SLIT: 165 with a single extract, and 65 with two different extracts (mix). SLIT treatment significantly improved disease staging, and reduced symptom severity and drug use. No systemic reaction was reported. In conclusion, these findings provide preliminary evidence that SIT is effective and safe in polysensitized patients after 1 year of treatment also using single extracts, and thus does not represent an obstacle for prescribing SIT.

Characteristics of patients with allergic polysensitization: the POLISMAIL study

BACKGROUND

The natural history of respiratory allergy is commonly characterized by a worsening of symptom severity, frequent comorbidity of rhinitis and asthma, and polysensitization to aeroallergens. The polysensitization phenomenon starts since childhood and is rare to find monosensitized adult patients. However, there are few studies investigating the characteristics of polysensitized patients.

METHODS

This study was performed on a large cohort of patients with allergic rhinitis (assessed by ARIA criteria) and/or mild to moderate asthma (assessed by GINA). The kind and the number of sensitizations, their patterns, and the relation with quality of life (QoL) measured by the Juniper's RQLQ guestionnaire, were evaluated.

RESULTS

Globally 418 patients (50.2% males, 49.8% females, mean age 26.4 years, range 3.5-65 years, 64 smokers, 371 non-smokers) were enrolled: 220 had allergic rhinitis alone, and 198 allergic rhinitis and asthma. The mean number ofsensitizations was 2.6. Three hundred-five patients (73%) had persistent rhinitis (PER), 220 of them with moderate-severe form. There was no significant derence in rate of rhinitis and asthma in monosensitized or polysensitized patients. Most patients were sensitized to pollens, whereas only 24.2% of them were sensitized to perennial allergens. Polysensitization was significantly associated with some issues of QoL, confirming previous findings, but not with number ofsensitizations.

CONCLUSIONS

This study provides data confirming for poly-sensitized patients the relevance of ARIA classification of AR. PER is the most common form of AR in this cohort, symptoms are frequently moderate-severe, and asthma is present in about the half of patients with AR.

Intermittent and Persistent Allergic Rhinitis and Association with Asthma in Children

The natural history of allergic rhinitis (AR) is commonly characterized by worsening of symptom severity, frequent comorbidity with asthma, and polysensitization to aeroallergens. The polysensitization phenomenon starts in early childhood. AR classification has been recently revised, and some studies investigated the new types: intermittent (IAR) and persistent (PER) AR. However, no study has been carried out on children regarding this issue. This preliminary study was performed on a large cohort of children with allergic rhinitis to evaluate the type and severity of rhinitis and its possible association with asthma, including severity grade. One hundred and thirty-nine children (86 males, 53 females, mean age 11.8 years, range 3.5–17.7 years) with allergic rhinitis were prospectively and consecutively evaluated. Seventy-one children had rhinitis alone and 68 had rhinitis associated with asthma. Forty children had IAR, 30 of whom with moderate-severe grade. Ninety-nine children had PER, 65 of whom had moderate-severe grade. The severity of AR was not associated with asthma presence (Fisher χ2 = 0.5765; Prob.=0.9018). Regarding asthma severity, 30 children had the intermittent form, whereas 38 had the persistent form: 15 mild, 22 moderate, and 1 severe. This study provides the first evidence concerning the ARIA classification in children, partially confirming findings obtained in adulthood.

Lack of correlation between clinical patterns of asthma and airway obstruction

To evaluate the relationship between the classification of asthma and obstruction of airways, we have studied 100 children suffering from allergic asthma: 65 males and 35 females, aged 4.2-16.3 years (mean, 7.6 +/- 2.8 years), who were evaluated at least 1 month after the last attack of airway obstruction. We analyzed personal history of all children with special reference to number of attacks of airway obstruction in the last year, severity, and presence of respiratory symptoms in the last month. The children studied have been classified in three groups according to the International Pediatric Respiratory Allergy Forum (IPRAF) '98 method (Third International Pediatric Consensus Statement on the management of childhood asthma). All children underwent the assessment of their respiratory function by means of analysis of the flow/volume loops with measurement of the obstruction indices (forced expiratory volume in 1 second [FEV1], peak expiratory flow [PEF], and maximal midexpiratory flow [MMEF]). The efficacy of the aforementioned method has been evaluated by analyzing the number of the subjects who showed indices of airway obstruction not in agreement with the group assigned. Eighty-five of the children studied were diagnosed with infrequent episodic asthma (IEA), 14 children were diagnosed with frequent episodic asthma (FEA), and 1 child was diagnosed with persistent asthma (PA). Thirty-six of 100 children showed obstruction indices not in agreement with the asthma group: in particular, 24 of 85 children with IEA had FEV1 < 80%, 11 children with FEA had FEV1 > 80%, and 1 child with PA had FEV1 > 80%. The high percentage of discordance between clinical classification and obstruction index in the subjects with IEA can be caused by the persistence of abnormalities of the respiratory function without clinical symptoms. The presence of a normal obstruction index in the subjects with FEA can be explained by the pharmacologic therapies. These data suggest the usefulness of a careful evaluation of the respiratory function associated with a clinical assessment to carry out a more appropriate therapy.

Sensitization to environmental antigens in asthmatic children from a central Italian area

This study was designed to evaluate the frequency of respiratory allergens in different age groups of asthmatic atopic children in the Chieti-Pescara area. We examined a pediatric population (507 children) aged between 1 to 17 years (mean 6.62 +/- 2.9). All the children were submitted to a panel of skin prick tests (SPT) for 12 common aeroallergens: Grass Pollens (G.), Parietaria (P.), Olive (O.), Artemisia (A.), Ragweed (R.), Dermatophagoides Pteronyssinus and Dermatophagoides Farinae (D.P. & D.F.), Cat and Dog dander (C.D.), Feathers (F.), Alternaria (Al.), Aspergillus (As.). All the subjects gave positive result to one or more allergens. The population was subdivided in to 4 groups according to their age (Group A: 1-3 years; Group B: 4-6 years; Group C: 7-9 years; Group D: 10-17 years). In each age group, we determined the number of subjects with 1, 2, 3, 4 or 5 and more than 5 positive SPT and the prevalence of positive SPT for different allergens. We found that 74% of 507 patients showed positive reaction to Dermatophagoides Pt, 71% to Dermatophagoides Fa, 45% to Grass, 23% to Parietaria, 21% to Olive, 17% to Artemisia, 17% to Cat's or Dog's danders, 13% to Alternaria, 5.9% to Ragweed, 5.9% to Feathers, and 4% to Aspergillus. In addition we detected that 12% of children examined were monosensitized; 56% were sensitized to 2 or 3 allergens; 22% were sensitized to 4 or 5 allergens, and then 8% were polysensitized to > 5 allergens. The allergy to grass pollens and to house dust mites was the most frequent in monosensitized. In the older patients, we found an increase in number of positives SPT to several allergens, and an increase in the frequency of Gr., P. and O. allergy, while the house dust mites sensitization remained constant in all groups and represented the dominant cause of asthmatic symptoms in this population. Our data confirm the importance of age in determining a respiratory polysensitization. In conclusion, our data suggest that house dust mites (D.P. and D.F.) and grass pollens are the most common allergens in asthmatic children of the Chieti-Pescara area.

Effectiveness of nedocromil sodium in preventing exercise-induced asthma in children

Exercise-induced asthma is a well-known phenomenon, particularly affecting children, with an important social impact. In order to assess the usefulness of nedocromil sodium in the prevention of exercise-induced asthma, we studied 49 (15 females, 34 males) children who suffered from asthma; their mean +/- SD age was 9.2 +/- 3.0 (range: 3.3-19.1) years. On the first day respiratory function was evaluated by spirometry, basally and after 6 minutes. The inhalation of nedocromil sodium had a great influence on post-exercise lung function measurements; in fact on the day of nedocromil sodium pretreatment, our patients showed an increase of respiratory function, significantly different from the parameters recorded during the first day. Our findings suggest that nedocromil sodium is effective in the prevention of exercise-induced asthma, in pediatric age.

Pulmonary function in diabetic children with and without persistent microalbuminuria

The principal spirometric and plethysmographic parameters were measured in 68 (38 female) diabetic children and adolescents, aged from 6.01 to 22.00 years; their duration of disease ranged from 1 to 247 months. Thirty-four patients had persistent microalbuminuria. The patients were studied basally and after the Bruce test. All the spirometric parameters were normal in all children, with and without microalbuminuria. The presence of microalbuminuria seems not to be a risk factor for the developing of abnormal pulmonary function.

Long-term therapy in childhood asthma: clinical and auxological effects

The authors studied the effect of different therapeutical regimens on the growth of children suffering from asthma. These patients were subdivided into four groups of ten patients according to their therapeutic regimens: Group A = ketotifene (1 mg, two times/day), Group B = diproprionate beclomethasone + salbuthamol (100 + 200 mcg, 3 times/day), Group C = ketotifene + diproprionate beclomethasone, Group D = disodiumcromoglycate (20 mg, 3 times/day). The patients were followed for at least 1 year. Our study has shown that all the children treated with the four different regimens had a normal growth and growth velocity.

[Evaluation of nasal eosinophils after specific provocation in the diagnosis of respiratory allergy]

The authors describe the results of a study of a group of children suffering from allergic rhinitis; the Authors evaluated eosinophils, basally and after nasal provocation test. Both clinical and cellular responses were evaluated. The basal results were: presence of eosinophils in 9/17 (52.9%) subjects allergic to Graminacee, in 42/61 (68.3%) subjects allergic to Dermatophagoides and in 3/3 (100%) subjects allergic to Parietaria. The results of the clinical response are the following: Graminacee: positive response in 20/22 (90.9%) tests; Dermatophagoides: 48/63 (76.2%); Parietaria: 6/6 (100%). The results of laboratory response are the following: Graminacee: positive response in 14/18 (77.8%) tests; Dermatophagoides: 45/59 (76.3%); Parietaria: 5/5 (100%). The evaluation of both responses is useful to increase the sensitivity of the nasal provocation test.

IgG subclass deficiency and recurrent respiratory infections in children

The aim of this study was to investigate the humoral immunity of children with recurrent respiratory tract infections. Fifty-seven (17 female, 40 male) children, aged from 1.1 to 12.0 years were evaluated, after 1 month from the last infectious disease. The total number of children with IgG subclasses deficiency was 29/57 with the following IgG deficiency distribution: IgG1 = 2 children, IgG2 = 13 children, IgG3 = 4 children, IgG4 = 25 children. Moreover, 13 children with IgG4 deficiency showed low levels of other (one or more) IgG subclasses. It is probable that these low IgG subclasses levels are an important immunological abnormality of these children.

[Chernobyl accident: dosimetric evaluation and estimation of risks]

The results of dosimetric evaluations carried out after Chernobyl accident in the Health Physics Department of Niguarda Ca' Granda Hospital (Milan) on air, rain and ground contamination are presented. The results obtained show that the incidence of stochastic late effects, both somatic and genetic, will be so low that practically will not be distinguishable from "natural" incidence.

[Clinical and functional sequelae of bronchiolitis]

The authors carried out a follow-up on twenty-five children, affected with bronchiolitis in the early years of life, at seven years of age, in order to evaluate their clinical status and pulmonary function. Their parents were questioned about diseases of the small airways following to acute bronchiolitis. PRIST and RAST were effected in fourteen children; an evaluation of the pulmonary function with spirometry, flow-volume curve and body-plethysmography was done in every child. Then the flow-volume curve was repeated after bronchial provocation test with exercise (free running). Abnormalities of the pulmonary function at resting significant for small airways' obstruction were observed. A great number of children with bronchial hyperreactivity (60%) was observed after bronchial provocation test with exercise, particularly in those with genetic predisposition; 6/14 (43%) showed sensitization to many inhalant allergens, without correlation with genetic predisposition, clinical sequences and bronchial hyperreactivity.

Evaluation of reproterol's effectiveness in preventing exercise-induced bronchospasm in children

The authors have evaluated the effectiveness of the protection of a new beta 2-adrenergic compound, reproterol, against broncho-constriction induced by physical exercise in a group of individuals of paediatric age sensitive to broncho-stimulation. This study has been carried out comparing reproterol with salbutamol, using placebo as a control, following a randomized single-blind crossover trial. The provocation test has been performed following the instructions of the Italian Society of Paediatrics. The drugs have been administered in the oral liquid form at the dose of 0.28 mg/kg and 0.1 mg/kg of reproterol and salbutamol, respectively. The two substances have shown a similar preventive effectiveness in controlling exercise-induced asthma up to 2 hours from administration with reproterol having a stronger action at the beginning of the observation.

[Kawasaki's syndrome: description of 4 cases]

In this study we present four cases of Kawasaki syndrome; in two of them were present some particular aspects, besides the characteristic signs of the lymphonodal-mucocutaneous syndrome. One little girl showed, during the acute phase of the disease, paralysis of facial nerve, without other signs of neurological involvement; in the second patient, the outcome of the syndrome was quite atypical, because of an osteoarticular involvement; we also observed the presence of immature white blood cells in the peripheral blood. Three of the four cases were treated with acetyl-salicylic acid for almost one year, two of them were also treated with dypiridamol. A four years follow-up, after the acute phase, demonstrated a complete recovery, a normal clinical status and no damage of the cardiocirculatory system.

[Study of somatosensory evoked potentials in full-term and premature neonates]

The electrophysiological maturation of both peripheral and 'central' (spinal + superspinal) nervous fibers belonging to peroneal and medial nerves was evaluated within the 1st month of extrauterine life. Thirty-five newborns with different gestational ages (15 FT, 20 PT), have been examined through the SEP technique during percutaneous stimulation of median (wrist and index finger) and peroneal (popliteal fossa) nerves. Recording electrodes were placed at Erb's point, lumbar and cervical spine, scalp sites corresponding to the sensory areas for upper and lower limb. Peripheral conduction velocities were correlated with chronological ages but they did not correlate neither with gestational ages nor with birth weightes. Central conduction velocities correlated with gestational ages. The role of maturation was faster for the former than for the latter.

[Pharmacological prevention of exercise-induced bronchospasm: review of the literature and trial of disodium cromoglycate, fenoterol and ipratropium bromide in a pediatric population]

Exercise-induced bronchospasm (EIB) is an instrumentally-measurable paraphysiologic phenomenon, related to bronchial hyperreactivity in asthmatic children. Therefore EIB is very useful to evaluate airways hyperreactivity and pharmacological treatment in asthmatic child. We have evaluate EIB inhibition and bronchodilator effect of three drugs: Disodiumcromoglycate (DSCG), Fenoterol (F), Ipratropium Bromide (IB), in a group of 27 asymptomatic and therapy-free asthmatic children. The bronchial provocation test was performed by physical exercise (free-running for six minutes) according to criteria stated by Paediatric Bronchopneumology Group of S.I.P. Therefore we have analysed the most recent studies to correlate our results with other's data: our study confirm DSCG and Beta-adrenergic drugs effectiveness; theophylline has a similar validity, but is less useful in clinical practice; anticholinergic drugs and corticosteroids seem less valid; the new drugs (Ketotifen, alpha-blockers and calcium antagonists) need further controlled studies.

[Physical exercise-induced bronchospasm in asthmatic children. Clinical usefulness of the specific free-running bronchial provocation test]

Exercise-induced bronchospasm (E.I.B.) is frequently observed in children. Here are reported the correlation between E.I.B. and some clinical-anamnestical parameters found in a group of thirty-eight asthmatic children examined by exercise. The aspecific bronchial provocation test was performed with six minutes free-running. The exercise-induced bronchospasm was estimated by bronchial obstruction index (b.o.i.). All the children were tested at 4 p.m., out of attacks, without clinical signs of airway obstruction, with basal pick-flow rate (PEFR) at least 80% of predicted. We have looked for the possible correlations between E.I.B. and the following parameters: sex, exercise-induced asthma, house heating, season, period of clinical remission, length of the disease and number of attacks per year. These results indicate that bronchial provocation test with free-running is useful in asthmatic children to objectify the bronchial hyperreactivity and to follow-up the course of the disease.

[Bronchiolitis: new pathogenetic aspects and personal cases]

The etiological, epidemiological and pathogenetical features of bronchiolitis and some clinical and biochemical data concerning seventy nine cases were discussed. It has been underlined the possible pathogenetical role of immunoallergic mechanism (immunoreactions type II, III, IV and VI), and of alterations of humoral immunocompetence (rise of IgM and deficit of IgA). Moreover it has been pointed out that hereditary, socioeconomical and environmental factors could play an important role in determining the seriousness of the clinical picture. The relationship between bronchiolitis and the respiratory diseases of the following years have been examinated.