Preparing the Allergist/Immunologist for the Next Pandemic

The COVID-19 pandemic had a profound impact on society in general and allergists' practices in particular. The adverse effects included a loss of practice productivity and income, staffing, and in-office procedures due to concerns about the spread of infection and the need for social/physical distancing as well as isolation. Allergy training programs and research activities also suffered. Federal financial assistance, rapid adoption of telehealth with Medicare waivers, and adaptation of practice sites, training programs, and research activities allowed for some return to normal, although still with significant restrictions in staffing and in-office procedures. There were positive aspects to the pandemic in the form of telehealth initiatives, pathways for rapid development and approval of tests and treatments, opportunities for new collaborations, and expertise in vaccines. Preparation for the next pandemic needs to be considered now to avoid the mistakes and missteps that occurred with the COVID-19 pandemic. On a national level, a strategy to overcome the societal divisions, misinformation/disinformation, and distrust of science needs to be developed based on better communication, as well as advocacy for continued improvement in our public health system. Practices and training programs as well as research centers need to institutionalize changes made during the pandemic so they can quickly be reinitiated when necessary.

Pharmacologic Management of Chronic Urticaria in Pediatric Patients: The Gap Between Guidelines and Practice

Chronic urticaria is an uncommon disorder in children but can present considerable morbidity, as well as frustration for the healthcare provider and parent. The prevalence is 0.1-0.3% but can vary considerably by country. Chronic spontaneous urticaria (no identifiable cause) is responsible for 70-80% of chronic urticaria, about half of this due to a subtype called chronic autoimmune urticaria identified by the presence of autoantibodies to IgE or the IgE receptor. Chronic urticaria that is triggered by external physical stimuli is called chronic inducible urticaria and is present in another 15-20%. Allergies, infection, and other underlying diseases such as thyroid disease, celiac disease, or Helicobacter pylori infection cause a minor proportion of cases. Chronic urticaria has considerable impact on quality of life and healthcare costs. An adverse impact on quality of life is more prevalent in older children and adolescents and can be comparable to other diseases of childhood such as diabetes and epilepsy. Healthcare costs can be 50% higher than the national estimates for healthy patients and include more hospitalizations, longer duration of hospitalizations, and more emergency department (ED) and outpatient visits. Allergic and autoimmune diseases can be comorbidities that add to healthcare utilization. Resolution can take years. Guidelines are available for diagnosis and treatment. A good history is the key to identifying the cause. Minimal laboratory tests are required and should be guided by the history. Patients with easily controlled urticaria may not need any laboratory tests. Suggested treatment emphasizes the use of non-sedating antihistamines, utilized in a step-wise fashion beginning with normal doses and advancing the dose based on the response up to four times the recommended dose for age. Other treatments are left to the urticaria specialist and are not discussed in this paper. These guidelines are not well utilized based on real-world studies; sedating antihistamines and oral steroids are overutilized. Medications should be taken daily, not as needed. Additional medications, if required, should be added to prior medications in a step-wise fashion. The gap between the guidelines for diagnosis and treatment and what is happening in the real world needs to be closed to reduce the cost and morbidity associated with this disorder.

The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods

This clinical report updates and replaces a 2008 clinical report from the American Academy of Pediatrics, which addressed the roles of maternal and early infant diet on the prevention of atopic disease, including atopic dermatitis, asthma, and food allergy. As with the previous report, the available data still limit the ability to draw firm conclusions about various aspects of atopy prevention through early dietary interventions. Current evidence does not support a role for maternal dietary restrictions during pregnancy or lactation. Although there is evidence that exclusive breastfeeding for 3 to 4 months decreases the incidence of eczema in the first 2 years of life, there are no short- or long-term advantages for exclusive breastfeeding beyond 3 to 4 months for prevention of atopic disease. The evidence now suggests that any duration of breastfeeding ≥3 to 4 months is protective against wheezing in the first 2 years of life, and some evidence suggests that longer duration of any breastfeeding protects against asthma even after 5 years of age. No conclusions can be made about the role of breastfeeding in either preventing or delaying the onset of specific food allergies. There is a lack of evidence that partially or extensively hydrolyzed formula prevents atopic disease. There is no evidence that delaying the introduction of allergenic foods, including peanuts, eggs, and fish, beyond 4 to 6 months prevents atopic disease. There is now evidence that early introduction of peanuts may prevent peanut allergy.

Treatment Patterns, Healthcare Resource Utilization, and Spending Among Medicaid-Enrolled Children with Chronic Idiopathic/Spontaneous Urticaria in the United States

Introduction

Few studies have described chronic idiopathic/spontaneous urticaria (CIU/CSU) healthcare burden in adults, while this information remains largely unknown in children. We aimed to describe treatment patterns, healthcare resource utilization (HRU), and costs in CIU/CSU pediatric patients, as well as to compare HRU and costs in CIU/CSU and CIU/CSU-free pediatric patients.

Methods

Medicaid claims from four states (09/01/2013–03/31/2016) were used to identify patients less than 12 years old. The CIU/CSU cohort included patients with either at least two claims for idiopathic, other, or unspecified urticaria at least 6 weeks apart, or at least one claim for urticaria and at least one claim for angioedema at least 6 weeks apart (index date defined as the first claim). The control cohort included patients without urticaria/angioedema claims (index date randomly assigned). Patients without at least 6 months of continuous Medicaid eligibility pre- and post-index were excluded. HRU and costs were compared between propensity score-matched cohorts during the post-index follow-up.

Results

A total of 548 CIU/CSU patients (mean [SD] age 4.5 [3.3] years; 51.3% male) were matched 1:1 with controls. In the CIU/CSU cohort, 51.8% used non-sedating prescription H₁-antihistamines, 24.3% used oral corticosteroids, and 23.5% used other prescription H₁-antihistamines; 13.5% consulted allergist/immunologists and 2.4% consulted dermatologists in the first 6 months of follow-up. Compared to controls, CIU/CSU patients had significantly more per patient per year (PPPY) inpatient (incidence rate ratio [IRR] 2.05), outpatient (IRR 2.20), and emergency department (IRR 1.64) visits (all p values < 0.05). Moreover, CIU/CSU patients also had significantly higher PPPY healthcare costs (mean cost difference [MCD] $1853), driven by incremental outpatient (MCD $1286) costs (all p values < 0.01).

Conclusions

CIU/CSU pediatric patients had low use of non-sedating H₁-antihistamines and high use of oral corticosteroids. Compared to CIU/CSU-free controls in the same age group, CIU/CSU pediatric patients had higher HRU and healthcare costs.

Funding

Novartis Pharmaceuticals Corporation

Genetics and Genomics of Longitudinal Lung Function Patterns in Individuals with Asthma

RATIONALE

Patterns of longitudinal lung function growth and decline in childhood asthma have been shown to be important in determining risk for future respiratory ailments including chronic airway obstruction and chronic obstructive pulmonary disease.

OBJECTIVES

To determine the genetic underpinnings of lung function patterns in subjects with childhood asthma.

METHODS

We performed a genome-wide association study of 581 non-Hispanic white individuals with asthma that were previously classified by patterns of lung function growth and decline (normal growth, normal growth with early decline, reduced growth, and reduced growth with early decline). The strongest association was also measured in two additional cohorts: a small asthma cohort and a large chronic obstructive pulmonary disease metaanalysis cohort. Interaction between the genomic region encompassing the most strongly associated single-nucleotide polymorphism and nearby genes was assessed by two chromosome conformation capture assays.

MEASUREMENTS AND MAIN RESULTS

An intergenic single-nucleotide polymorphism (rs4445257) on chromosome 8 was strongly associated with the normal growth with early decline pattern compared with all other pattern groups (P = 6.7 × 10^-9; odds ratio, 2.8; 95% confidence interval, 2.0-4.0); replication analysis suggested this variant had opposite effects in normal growth with early decline and reduced growth with early decline pattern groups. Chromosome conformation capture experiments indicated a chromatin interaction between rs4445257 and the promoter of the distal CSMD3 gene.

CONCLUSIONS

Early decline in lung function after normal growth is associated with a genetic polymorphism that may also protect against early decline in reduced growth groups. Clinical trial registered with www.clinicaltrials.gov (NCT00000575).

Patterns of Growth and Decline in Lung Function in Persistent Childhood Asthma

BACKGROUND

Tracking longitudinal measurements of growth and decline in lung function in patients with persistent childhood asthma may reveal links between asthma and subsequent chronic airflow obstruction.

METHODS

We classified children with asthma according to four characteristic patterns of lung-function growth and decline on the basis of graphs showing forced expiratory volume in 1 second (FEV1), representing spirometric measurements performed from childhood into adulthood. Risk factors associated with abnormal patterns were also examined. To define normal values, we used FEV1 values from participants in the National Health and Nutrition Examination Survey who did not have asthma.

RESULTS

Of the 684 study participants, 170 (25%) had a normal pattern of lung-function growth without early decline, and 514 (75%) had abnormal patterns: 176 (26%) had reduced growth and an early decline, 160 (23%) had reduced growth only, and 178 (26%) had normal growth and an early decline. Lower baseline values for FEV1, smaller bronchodilator response, airway hyperresponsiveness at baseline, and male sex were associated with reduced growth (P<0.001 for all comparisons). At the last spirometric measurement (mean [±SD] age, 26.0±1.8 years), 73 participants (11%) met Global Initiative for Chronic Obstructive Lung Disease spirometric criteria for lung-function impairment that was consistent with chronic obstructive pulmonary disease (COPD); these participants were more likely to have a reduced pattern of growth than a normal pattern (18% vs. 3%, P<0.001).

CONCLUSIONS

Childhood impairment of lung function and male sex were the most significant predictors of abnormal longitudinal patterns of lung-function growth and decline. Children with persistent asthma and reduced growth of lung function are at increased risk for fixed airflow obstruction and possibly COPD in early adulthood. (Funded by the Parker B. Francis Foundation and others; ClinicalTrials.gov number, NCT00000575.).

Ambient air pollution, lung function, and airway responsiveness in asthmatic children

BACKGROUND

Although ambient air pollution has been linked to reduced lung function in healthy children, longitudinal analyses of pollution effects in asthmatic patients are lacking.

OBJECTIVE

We sought to investigate pollution effects in a longitudinal asthma study and effect modification by controller medications.

METHODS

We examined associations of lung function and methacholine responsiveness (PC20) with ozone, carbon monoxide (CO), nitrogen dioxide, and sulfur dioxide concentrations in 1003 asthmatic children participating in a 4-year clinical trial. We further investigated whether budesonide and nedocromil modified pollution effects. Daily pollutant concentrations were linked to ZIP/postal code of residence. Linear mixed models tested associations of within-subject pollutant concentrations with FEV1 and forced vital capacity (FVC) percent predicted, FEV1/FVC ratio, and PC20, adjusting for seasonality and confounders.

RESULTS

Same-day and 1-week average CO concentrations were negatively associated with postbronchodilator percent predicted FEV1 (change per interquartile range, -0.33 [95% CI, -0.49 to -0.16] and -0.41 [95% CI, -0.62 to -0.21], respectively) and FVC (-0.19 [95% CI, -0.25 to -0.07] and -0.25 [95% CI, -0.43 to -0.07], respectively). Longer-term 4-month CO averages were negatively associated with prebronchodilator percent predicted FEV1 and FVC (-0.36 [95% CI, -0.62 to -0.10] and -0.21 [95% CI, -0.42 to -0.01], respectively). Four-month averaged CO and ozone concentrations were negatively associated with FEV1/FVC ratio (P < .05). Increased 4-month average nitrogen dioxide concentrations were associated with reduced postbronchodilator FEV1 and FVC percent predicted. Long-term exposures to sulfur dioxide were associated with reduced PC20 (percent change per interquartile range, -6% [95% CI, -11% to -1.5%]). Treatment augmented the negative short-term CO effect on PC20.

CONCLUSIONS

Air pollution adversely influences lung function and PC20 in asthmatic children. Treatment with controller medications might not protect but rather worsens the effects of CO on PC20. This clinical trial design evaluates modification of pollution effects by treatment without confounding by indication.

Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years

OBJECTIVE

To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.

METHODS

Analysis of the medical literature published since the last version of the guideline (2001).

RESULTS

The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

CONCLUSIONS

Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

Population-based screening or case detection for asthma: are we ready?

Asthma is a prevalent health problem for which there are effective treatments. By identifying people with asthma and treating them effectively, the burden of asthma in the United States should be reduced. Detecting people with asthma through screening programs seems a logical approach to the problem. This article assesses our readiness for population-based screening and case detection programs for asthma and examines these activities in relation to World Health Organization criteria for determining the appropriateness of screening programs. Given that, at this time, a number of the criteria have not been met, we conclude that population-based approaches to screening and case detection of asthma are of unproven benefit and need further research. A more appropriate focus may be to ensure that all people who are diagnosed with asthma receive appropriate medical care.

Dietary antioxidants and ozone-induced bronchial hyperresponsiveness in adults with asthma

Ozone exposure aggravates asthma, as has been demonstrated in both controlled exposures and epidemiologic studies. In the current double-blind crossover study, the authors evaluated the effects of dietary antioxidants (i.e., 400 IU vitamin E/500 mg vitamin C) on ozone-induced bronchial hyperresponsiveness in adult subjects with asthma. Seventeen subjects were exposed to 0.12 ppm of ozone or to air for 45 min during intermittent moderate exercise. Bronchial hyperresponsiveness was assessed with 10-min sulfur dioxide (i.e., 0.10 ppm and 0.25 ppm) inhalation challenges. Subjects who were given dietary antioxidants responded less severely to sulfur dioxide challenge than subjects given a placebo (i.e., forced expiratory volume in the 1st sec: -1.2% vs. 4.4%, respectively; peak flow: +2.2% vs. -3.0%, respectively; and mid-forced expiratory flow: +2.0% vs. -4.3%, respectively). Effects were more pronounced when subjects were grouped by response to sulfur dioxide at the screening visit. The results suggest that dietary supplementation with vitamins E and C benefits asthmatic adults who are exposed to air pollutants.

Genetic polymorphisms as biomarkers of sensitivity to inhaled sulfur dioxide in subjects with asthma

BACKGROUND

Individuals with asthma are sensitive to inhaled sulfur dioxide (SO2); decrements in pulmonary function occur after exposure to low concentrations even for a short duration of time. There is a great amount of interindividual variation in response to SO2.

OBJECTIVE

It was our objective to determine whether one of the following polymorphism locations linked with asthma is associated with the bronchial hyperresponsiveness to SO2 observed in some asthmatic patients: the beta2-adrenergic receptor, interleukin-4 (IL-4) receptor alpha subunit, Clara cell secretory protein (CC16), TNF-alpha gene promoter, and first intron of the lymphotoxin alpha (LT-alpha) gene.

METHODS

Subjects were volunteers with physician-diagnosed asthma requiring regular asthma medication. Spirometry was performed before and after a 10-minute exposure to 0.5 ppm SO2. Subjects were classified as SO2 responders if forced expiratory volume in 1 second (FEV1) decreased > or = 12%. DNA obtained from buccal cell samples was analyzed for genetic polymorphisms.

RESULTS

Of the 62 subjects (21 male and 41 female), 13 had a 12% or greater decrement in FEV1 after SO2 exposure (range + 19% to -49%). Response to SO2 was associated with the wild-type allele of the TNF-alpha promoter polymorphism (12 of 12 SO2 responders versus 28 of 46 nonresponders; P < .05) but with no other polymorphisms. Medication category and atopic status showed no association with SO2 sensitivity.

CONCLUSIONS

The wild-type allele of the TNF-alpha promoter polymorphism may be associated with mechanisms of asthmatic sensitivity to inhaled SO2.

Sulphur dioxide sensitivity and plasma antioxidants in adult subjects with asthma

OBJECTIVES

To screen adult subjects with asthma for sensitivity to inhaled sulphur dioxide (SO2) and identify subject characteristics associated with that sensitivity. Medication use, symptoms, and plasma antioxidant nutrients between SO2 responders and non-responders were compared.

METHODS

Adult subjects (ages 18-39 years) with asthma were exposed to 0.5 ppm SO2 for 10 minutes during moderate exercise. Pulmonary function tests and symptom ratings were assessed before and after exposure (n = 47). A subject was classified as sensitive to SO2 if forced expiratory volume in 1 second (FEV1) showed a drop > or = 8% over baseline. Blood samples were obtained from subjects (n = 38) before the SO2 challenge; plasma ascorbate, alpha-tocopherol, retinol, carotenoids, and lipids were measured.

RESULTS

Of the 47 subjects screened, 53% had a drop in FEV1 > or = 8% (ranging from -8% to -44%). Among those 25 subjects, the mean drop in FEV1 was -17.2%. Baseline pulmonary function indices (FEV1% of predicted and FEV1/FVC% (forced vital capacity)) did not predict sensitivity to SO2. Although use of medication was inversely related to changes in pulmonary function after SO2 (p < 0.05), both SO2 responders and non-responders were represented in each medication category. Total symptom scores after exposure were significantly correlated with changes in FEV1 (p < 0.05), FVC (p < 0.05), and peak expiratory flow (PEF) (p < 0.01) but not forced expiratory flow between 25% and 75% vital capacity (FEF25-75). Plasma beta-carotene concentrations were inversely associated with PEF values and ascorbate concentrations were inversely associated with FEV1 and FEV1/FVC (p = 0.05 in all cases). High density lipoprotein concentrations were positively correlated with FEV1% of predicted (p < 0.05) and inversely correlated with change in FEF25-75 (p < 0.05) after SO2.

CONCLUSION

These results show that the response to SO2 among adults with mild to moderate asthma is very diverse. Severity of asthma defined by medication category was not a predictor of sensitivity to SO2. Lung function values were associated with beta-carotene and ascorbate concentrations in plasma; however, plasma antioxidant nutrient concentrations were not associated with sensitivity to inhaled SO2.

Zafirlukast improves asthma symptoms and quality of life in patients with moderate reversible airflow obstruction

BACKGROUND

Previous trials demonstrated the effectiveness of the leukotriene receptor antagonist zafirlukast in patients with mild-to-moderate asthma.

OBJECTIVES

We sought to assess the efficacy and safety of zafirlukast and its effect on patients' quality of life (QOL) during a 13-week, double-blind, placebo-controlled, multicenter trial in adults and adolescents with moderate reversible airflow obstruction.

METHODS

Patients (age range, 12 to 68 years) with total daytime asthma symptoms scores of 10 or greater over 7 consecutive days (maximum, 21/wk), FEV1 45% or greater but less than or equal to 80% of predicted value (>/=6 hours after beta2 -agonist), and reversible airway disease were randomized to 20 mg zafirlukast twice daily (nZ = 231) or placebo twice daily (nP = 223). Efficacy was assessed from changes in daytime and nocturnal symptoms, beta2 -agonist use, nasal congestion score, and pulmonary function. QOL was evaluated with a disease-specific Asthma Quality of Life Questionnaire. Safety was determined from adverse event information and clinical laboratory test results.

RESULTS

Zafirlukast was significantly (P <.001) more effective than placebo, with reductions from baseline in the daytime asthma symptoms score (-23%), nighttime awakenings with asthma (-19%), and beta2 -agonist use (-24%) and improvements from baseline in morning (+25 L/min) and evening (+18 L/min) peak expiratory flow rates. Compared with placebo, zafirlukast significantly (P </=.018) improved scores for QOL domains (activity limitations, symptoms, emotional function, and exposure to environmental stimuli) and overall QOL, with a significantly greater proportion of zafirlukast-treated patients demonstrating clinically meaningful improvements (>/=0.5-unit change from baseline; P </=.037). The safety profile of zafirlukast was clinically indistinguishable from that of placebo.

CONCLUSIONS

Zafirlukast is effective and well tolerated and improves QOL in the long-term treatment of patients with moderate reversible airflow obstruction.

Inflammatory effects of ozone in the upper airways of subjects with asthma

The objective of this study was to determine whether exposure to ozone causes inflammatory or functional changes in the upper or lower airways of asthmatic and nonasthmatic individuals. Ten asthmatic and eight nonasthmatic subjects were exposed to clean air, 120 ppb ozone, or 240 ppb ozone for 90 min during intermittent moderate exercise using a head dome exposure system. Pulmonary function tests, posterior rhinomanometry, and nasal lavage were performed before and after exposure. Leukocyte counts and chemotactic factors leukotriene B4 (LTB4), platelet-activating factor (PAF), and interleukin-8 (IL-8) were analyzed from nasal lavage fluid. In subjects with asthma, a significant increase (p < 0.05) in the number of white blood cells in lavage fluid was detected both immediately and 24 h after exposure to 240 ppb ozone, as was a significant increase in epithelial cells immediately after exposure (p < 0.05). No significant cellular changes were seen in nonasthmatic subjects. A significant correlation was observed between IL-8 and white blood cells counts after exposure to 240 ppb ozone (r = 0.76) in asthmatic subjects. No significant changes in pulmonary or nasal function or biochemical mediators were found in either the asthmatic or nonasthmatic subjects. These data indicate that asthmatic individuals are more sensitive to the acute inflammatory effects of ozone than nonasthmatic individuals.

Respiratory effects of inhaled sulfuric acid on senior asthmatics and nonasthmatics

The objective of this study was two-fold: (1) to investigate the response of asthmatic subjects who were 60 to 75 y of age to inhaled sulfuric acid, and (2) to compare that response to findings from healthy subjects in the same age group. Nine subjects who had asthma and eight healthy subjects participated. Each subject was exposed to clean air, an inert ammonium sulfate aerosol, or 70 micrograms/m3 sulfuric acid during a 40-min exposure period composed of 30 min at rest and 10 min of light exercise on a treadmill. The sulfuric acid was delivered twice, one preceded by a lemonade drink to neutralize oral concentrations of ammonia. Exposures were separated by at least 1 wk. Oral ammonia levels and pulmonary function parameters (forced expiratory volume in one second, forced vital capacity, and total respiratory resistance) were measured before and after each exposure. None of the functional parameters in either group showed significant changes. However, total respiratory resistance changes from baseline after sulfuric acid exposure were significantly higher (+16%) in the asthmatic subjects, compared with the healthy subjects (-6%). These data suggest that older subjects are not at increased risk for adverse respiratory effects from inhalation of sulfuric acid by virtue of age alone, and older subjects with asthma are slightly more vulnerable than are their healthy peers.

Theophylline mitigates the bronchoconstrictor effects of sulfur dioxide in subjects with asthma

The objective of the study was to investigate the ability of a sustained-release (SR) theophylline tablet (Uniphyl; Purdue Frederick Co., Norwalk, Conn.) to block or mitigate sulfur dioxide (SO2)-induced bronchoconstriction in adult subjects with asthma. Eight subjects participated in a double-blind, crossover study with a 400 mg theophylline tablet or placebo once a day for a week before a 10-minute SO2 challenge. FEV1 and total respiratory resistance (RT) were measured before and after the SO2 challenge and on a different day before and after an air exposure. After exposure to SO2, average values of FEV1 dropped 16% after placebo treatment and 7% after theophylline treatment. The corresponding percentages for RT were a 37% increase after placebo and a 7% increase after theophylline treatment. Analysis of variance demonstrated a significant difference between the SO2-induced decrease in FEV1 and increase in RT after SR theophylline treatment compared with that of placebo treatment. Thus, we conclude that SR theophylline tablets, taken at this concentration for 1 week, mitigate SO2-induced bronchoconstriction.

Predicting outcome in schizoaffective psychosis

Predictors of long-term outcome are identified for 68 patients with schizoaffective psychosis from the Chestnut Lodge Follow-up Study. Two dimensions regularly predicted better outcome: better developed premorbid instrumental skills and fewer typically schizophrenic symptoms.

Therapeutic monitoring of theophylline. Rationale and current status

Theophylline has been demonstrated to be a useful agent in the therapy of chronic asthma. Its use must be tempered with knowledge of its adverse effects and that these effects are related primarily to serum concentration. Accordingly, it is mandatory to monitor serum theophylline concentrations on a regular basis with any patient receiving maintenance therapy with theophylline. It is also necessary to recognise the potential side effects of theophylline therapy, and when such a patient displays symptoms of vomiting, headache or seizures, serum theophylline concentration must be checked even if a recent concentration was within the therapeutic range. The means for monitoring theophylline concentrations are now available even to the average physician who does not have immediate access to a laboratory that can provide timely serum theophylline determinations.

Schizoaffective psychosis. II. Manic, bipolar, and depressive subtypes

Three schizoaffective subtypes-manic, bipolar, and depressive-were compared across multiple baseline (demographic, premorbid, morbid) and long-term outcome dimensions. Though the subtypes were comparable at baseline, the patients with depressive schizoaffective disorder scored consistently better at follow-up, although none of these differences was statistically significant. Results failed to support the validity of such subtyping in schizoaffective disorder, at least in predominantly chronic populations.

Schizoaffective psychosis. I. Comparative long-term outcome

Patients from the Chestnut Lodge (Rockville, Md) follow-up study with schizoaffective (SA) psychosis (n = 68) were compared with patients with DSM-III schizophrenia (S, n = 163), bipolar disorder (n = 19), and unipolar disorder (n = 44) on multiple premorbid, morbid, and outcome dimensions. This study required that patients with SA disorder satisfy DSM-III criteria for both S and affective disorder (minus mutual exclusionary criteria). The SA cohort demographic and premorbid profile paralleled that of the cohort with unipolar disorder. At follow-up, however, the profile of SA psychosis paralleled that of S, with no significant differences between these patients on virtually all outcome measures. Results suggest that among samples of long-term inpatient, SA psychosis as defined herein is closer to S than affective disorder.