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.).

International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.

A consensus protocol for the determination of the threshold doses for allergenic foods: how much is too much?

BACKGROUND

While the ingestion of small amounts of an offending food can elicit adverse reactions in individuals with IgE-mediated food allergies, little information is known regarding these threshold doses for specific allergenic foods. While low-dose challenge trials have been conducted on an appreciable number of allergic individuals, a variety of different clinical protocols were used making the estimation of the threshold dose very difficult.

OBJECTIVE

A roundtable conference was convened to develop a consensus clinical protocol for low-dose challenge trials for the estimation of threshold doses for specific allergenic foods.

METHODS

In May 2002, 20 clinical allergists and other interested parties were invited to participate in a roundtable conference to develop consensus of the key elements of a clinical protocol for low-dose challenge trials.

RESULTS

A consensus protocol was developed. Patients with convincing histories of food allergies and supporting diagnostic evidence including past challenge trials or high CAP-RAST scores can be enrolled in low-dose challenge trials. Care must be taken with younger patients to assure that they have not outgrown their food allergy. An approach was developed for the medication status of patients entering such trials. Challenge materials must be standardized, for example, partially defatted peanut flour composed of equal amounts of the three major varieties of peanuts (Florunner, Virginia, Spanish). Challenge materials must be appropriately blinded with sensory evaluation used to confirm the adequacy of blinding. A double-blind, placebo-controlled design should be used for low-dose challenge trials. Low-dose challenge trials would begin at doses of 10 microg of the allergenic food and would continue with doses of 100 microg and 1 mg followed by specific higher doses up to 100 mg depending upon the expert judgement of the physician; even higher doses might be applied to assure that the patient is indeed reactive to the particular food. A 30-min time interval would be used between doses, and reactive doses would be expressed as both discrete and cumulative doses. The goal of each challenge would be to develop objective symptoms; trials should not be discontinued on the basis of subjective symptoms only. Statistically, a minimum of 29 patients would be enrolled in low-dose challenge trials for each allergenic food because 0 reactors out of 29 patients at a particular dose allow the conclusion that there is 95% certainty that 90% of allergic individuals will not react to that dose.

CONCLUSION

A consensus protocol was developed. Using this protocol, it will be possible to estimate threshold doses for allergenic foods, the lowest amount that elicits mild, objective symptoms in highly sensitive individuals.

Developmental follow-up in 15-month-old infants of asthmatic vs. control mothers

The purpose of this study was to evaluate mental and psychomotor development in infants of mothers whose asthma was actively managed during pregnancy and to compare the results with those froms infants of non-asthmatic mothers. Bayley Scales were assessed at age 15 +/- 3 months in 379 infants of asthmatic mothers and 376 control infants. Relationships were assessed between developmental indices and asthma severity, socioeconomic status, and infant prematurity. No significant differences in developmental indices were observed between infants of asthmatic mothers and control infants. No relationships were identified between developmental indices and maternal asthma severity. In the infants of both asthmatic and control mothers, a lower mean psychomotor developmental index was associated with birth weight < 2,500 g, and a lower mental developmental index with lower socioeconomic status. Hence, infants of asthmatic mothers whose asthma has been actively managed during pregnancy have developmental outcomes at 15 months of age that are similar to those of control infants.

Effect of allergist intervention on patient-centered and societal outcomes: allergists as leaders, innovators, and educators

Atopic disorders, which afflict millions of Americans and hundreds of millions worldwide, are at epidemic levels with concomitant increases in morbidity and mortality. Environmental and lifestyle changes over the past three to five decades are proposed causes for this pandemic and as such present major burdens to reverse. The scope of allergy practice bridges directly on this challenge. Allergy as a specialty is a major leader in developing effective strategies to confront this epidemic. Allergists have made major contributions to the understanding of the risk factors, immunology, pathophysiology, immunomodulation, and prevention of atopic and immunologic disorders. Allergist epidemiologists and clinicians have helped develop and implement national and international guidelines in the recognition, management, and prevention of asthma and rhinitis. Allergist clinical researchers are active in (1) outcomes research that demonstrates convincingly the value of allergy as a specialty in asthma, allergic rhinitis, anaphylaxis, drug and food allergy, and other atopic disorders, (2) National Institutes of Health clinical trials that will form the basis for the future treatment of asthma and allergic disease, and (3) pharmaceutical trials that evaluate new, effective, and safe medication to treat atopic disease. Allergist educators, comprising academic and practicing allergists, supported by allied health professionals, national associations, and affiliated lay organizations, provide comprehensive education to fellows, residents, colleague physicians, media, the public, and patients. Documentation of the value of allergists in improving patient-centered and societal outcomes in their core domain, allergy, is the appropriate final topic contribution in the important series "New millennium: The conquest of allergy."

Relationship between increased airway responsiveness and asthma severity in the childhood asthma management program

The relationship between increased airway responsiveness and asthma severity in children is unclear. The Childhood Asthma Management Program (CAMP) with 1,041 children with mild to moderate asthma offers an opportunity to relate the concentration of methacholine that causes a 20% fall in FEV(1) (PC(20)) to level of lung function, occurrence of respiratory symptoms, duration of disease, and assessment of severity by clinical staff. Decreasing PC(20) was found to be associated with lower levels of lung function (prebronchodilator percent predicted FEV(1): r = 0.29, beta = 3.5, p < 0.001), the occurrence of chronic asthma symptoms, persistent wheezing (odds ratio [OR] = 1.66, p < 0.001), subjective clinical staff assessment of asthma severity (p < 0.001), and longer duration of asthma (r = -0.11, beta = -0.20, p < 0.002). These data provide evidence that the degree of airway responsiveness is linked to disease severity in children with mild to moderate asthma.

Quantitative IgE antibody assays in allergic diseases

During the past several years, immunoassays for specific IgE antibodies have been refined to permit reporting results in mass units. Thus quantitative immunoassays for IgE antibodies may be an adjunct to skin tests. In cases of food allergy among children with atopic dermatitis, cutoff values for IgE antibody concentrations to egg, milk, peanut, and fish have been derived to provide 95% positive and 90% negative predictive values. Food-specific IgE antibody determinations can also be used to predict which food allergies are resolving spontaneously. Elevated egg-specific IgE antibody levels in infancy are associated with significantly increased risk for development of inhalant allergies later in childhood. In cases of inhalant allergy, specific IgE antibody levels correlate closely with results of inhalation challenge studies in cat-sensitive persons. Also, mite-specific IgE antibody levels correlate significantly with the mite allergen contents of reservoir dust in the homes of mite-sensitive persons. Immunoassays for quantitation of specific IgE antibodies may be used to document allergen sensitization over time and to evaluate the risk of reaction on allergen exposure. However, immunoassays and skin tests are not entirely interchangeable, and neither will replace the other in appropriate circumstances.

Dietary aspects of food allergy prevention in infants and children

Food allergy occurs in approximately 4% to 6% of children, has increased in prevalence during the past decade, and thus represents a major burden to our young. The natural history of food allergy documents that allergies to cow's milk, egg, and soy frequently remit whereas allergies to peanut, nuts, and fish typically persist to adulthood, although exceptions exist. Food allergen avoidance subsequent to sensitization and manifestation of symptoms appears to hasten tolerance; however, the immunologic mechanism responsible for tolerance to one food group and not another is poorly understood. Identification and characterization of allergens and determination of B- and T-cell epitopes has provided an opportunity to better define these mechanisms. Identifying and developing effective strategies to prevent food and other allergic diseases represents a high priority for medicine at this time because of the unbridled increase in the prevalence and morbidity attributed to them. Immunologic engineering holds the greatest promise for allergy prevention in the not too distant future, but environmental strategies that promote food avoidance provide an avenue for prevention at present. Such efforts rely actively on reducing the food allergenic load and exposure of atopy-prone infants and children.

Soy allergy in infants and children with IgE-associated cow's milk allergy

OBJECTIVES

To determine the prevalence of soy allergy in IgE-associated cow's milk allergy (CMA).

STUDY DESIGN

Children <3.5 years with documented IgE-associated CMA (n = 93) were evaluated for soy allergy by double-blind, placebo-controlled food challenge, open challenge, or convincing previous history of an anaphylactic reaction to soy. Children tolerant to soy at entry received soy formula and were followed up for 1 year.

RESULTS

Of this IgE-associated CMA cohort (ages 3 to 41 months), 14% (95% CI = 7. 7%-22.7%) were determined to have soy allergy, 12 definitely at entry and 1 possibly after 1 year of soy ingestion. The latter child experienced severe failure to thrive at enrollment and exhibited improved growth while receiving soy during follow-up but was diagnosed with eosinophilic esophagitis at study completion. Improved growth (P <.05) occurred in the non-soy-allergic cohort ingesting soy formula (579 31 mL/d) during the year of follow-up.

CONCLUSIONS

Soy allergy occurs in only a small minority of young children with IgE-associated CMA. As such, soy formula may provide a safe and growth-promoting alternative for the majority of children with IgE-associated CMA shown to be soy tolerant at the time of introduction of soy formula.

Relationships between duration of asthma and asthma severity among children in the Childhood Asthma Management Program (CAMP)

BACKGROUND

Many factors, including heredity, atopic status, and environment, have been implicated in the determination of asthma severity. Relatively little is known about the degree to which asthma duration influences asthma severity.

OBJECTIVE

The Childhood Asthma Management Program (CAMP), consisting of 1041 children (age 8. 9 +/- 2.1 years at enrollment) with mild-to-moderate asthma, offers an opportunity to examine the relationship between asthma duration and asthma severity.

METHODS

By using the extensive CAMP baseline cross-sectional data on asthma duration, spirometry, bronchial responsiveness, symptomatology, and markers of atopy, univariate and multivariate regression models were used to evaluate whether asthma duration is associated with asthma severity.

RESULTS

Duration of asthma in the study cohort from time of diagnosis until randomization into CAMP ranged from 0.3 to 12.1 years (mean, 5.0; SD, 2.7; median, 4.8). Asthma duration is associated in univariate analyses both with lower levels of several lung functions (P <.001), including methacholine bronchial reactivity (natural log [ln] FEV1 PC20, mg/mL; r = -0.112), prebronchodilator and postbronchodilator percent predicted FEV1 (r = -0.176 and r = -0.130, respectively), and prebronchodilator and postbronchodilator FEV1 /forced vital capacity (FVC) (%) (r = -0.237 and r = -0.211, respectively), as well as higher levels of symptoms (symptom score: r = 0.147, P <. 001) and borderline greater use of albuterol for symptoms (r = 0.058, P =.064) during a 28-day screening period before randomization. Simple linear regression detected the following differences in lung functions per year of asthma duration: ln FEV1 PC20, -0.050 mg/mL/y; prebronchodilator FEV1, -0.907 percent predicted/y; and prebronchodilator FEV1 /FVC, -0.729 percent predicted/y. After controlling for potential explanatory variables (atopy, inflammatory markers, household Der p 1 levels, anti-inflammatory medication use, and clinical center), regression models revealed that the duration of asthma remained significantly and independently associated with ln FEV1 PC20 (P =.004), prebronchodilator percent predicted FEV1 (P =.043), and prebronchodilator and postbronchodilator FEV1 /FVC (%) (P <.001), as well as being positively associated with mean daily symptom score (P <.001) and albuterol use for symptoms (P =.003) during a 28-day screening period. Duration was also found to be significantly associated with physician/nurse assessment of asthma severity and other historical measures of medication use.

CONCLUSIONS

These data demonstrate that asthma duration is associated with lower lung function, greater methacholine responsiveness, more asthma symptomatology, and greater use of as-needed albuterol, which are all measures of asthma severity. As such, early diagnosis and intervention may be necessary to ameliorate these adverse effects of persistent asthma.

Symptoms in pediatric asthmatics and air pollution: differences in effects by symptom severity, anti-inflammatory medication use and particulate averaging time

Experimental research in humans and animals points to the importance of adverse respiratory effects from short-term particle exposures and to the importance of proinflammatory effects of air pollutants, particularly O(subscript)3. However, particle averaging time has not been subjected to direct scientific evaluation, and there is a lack of epidemiological research examining both this issue and whether modification of air pollutant effects occurs with differences in asthma severity and anti-inflammatory medication use. The present study examined the relationship of adverse asthma symptoms (bothersome or interfered with daily activities or sleep) to O(3) and particles (less than or equal to)10 micrometer (PM10) in a Southern California community in the air inversion zone (1200-2100 ft) with high O(3) and low PM (R = 0.3). A panel of 25 asthmatics 9-17 years of age were followed daily, August through October 1995 (n = 1,759 person-days excluding one subject without symptoms). Exposures included stationary outdoor hourly PM10 (highest 24-hr mean, 54 microgram/m(3), versus median of 1-hr maximums, 56 microgram/m(3) and O(3) (mean of 1-hr maximums, 90 ppb, 5 days (greater than or equal to)120 ppb). Longitudinal regression analyses utilized the generalized estimating equations (GEE) model controlling for autocorrelation, day of week, outdoor fungi, and weather. Asthma symptoms were significantly associated with both outdoor O(3) and PM(10) in single pollutant- and co-regressions, with 1-hr and 8-hr maximum PM(10) having larger effects than the 24-hr mean. Subgroup analyses showed effects of current day PM(10) maximums were strongest in 10 more frequently symptomatic (MS) children: the odds ratios (ORs) for adverse symptoms from 90th percentile increases were 2.24 [95% confidence interval (CI), 1.46-3.46] for 1-hr PM10 (47 microgram/m(3); 1.82 (CI, 1.18-2.81) for 8-hr PM10 (36 microgram/m(3); and 1.50 (CI, 0.80-2.80) for 24-hr PM10 (25 microgram/m(3). Subgroup analyses also showed the effect of current day O(subscript)3 was strongest in 14 less frequently symptomatic (LS) children: the ORs were 2.15 (CI, 1.04-4.44) for 1-hr O(3) (58 ppb) and 1.92 (CI, 0.97-3.80) for 8-hr O(3) (46 ppb). Effects of 24-hr PM10 were seen in both groups, particularly with 5-day moving averages (ORs were 1.95 for MS and 4. 03 for LS; p(less than or equal to)0.05). The largest effects were in 7 LS children not on anti-inflammatory medications [5-day, 8-hr PM10, 9.66 (CI, 2.80-33.21); current day, 1-hr O(3), 4.14 (CI, 1.71-11.85)]. Results suggest that examination of short-term particle excursions, medication use, and symptom severity in longitudinal studies of asthma yields sensitive measures of adverse respiratory effects of air pollution.

Safe administration of influenza vaccine to patients with egg allergy

OBJECTIVES

Specific recommendations for administering the influenza vaccine to patients with egg allergy are based on limited scientific data. The objectives of this investigation were to determine the safety of a 2-dose administration of an influenza vaccine to patients with egg allergy and to evaluate the usefulness of skin testing with the influenza vaccine before administration.

STUDY DESIGN

In this multicenter clinical trial, clinical histories of egg allergy were confirmed by skin testing with egg and, if possible, by oral challenges with egg. Subjects with egg allergy received the vaccine in 2 doses, 30 minutes apart; the first dose was one tenth and the second dose nine tenths of the recommended dose as determined by age. Subjects without egg allergy were recruited as control subjects and received 1 age-determined dose of the vaccine. Skin prick tests with the influenza vaccine were performed on all subjects.

RESULTS

From 1994 to 1997, 83 subjects with egg allergy and 124 control subjects were evaluated. The content of ovalbumin/ovomucoid was 0.1, 1.2, and 0.02 micrograms/mL, respectively in the 1994-95, 1995-96, and 1996-97 influenza vaccines. Results of vaccine skin prick tests were positive in 4 subjects with egg allergy and in 1 control subject. All patients with egg allergy tolerated the vaccination protocol without any significant allergic reactions.

CONCLUSIONS

These results demonstrate that patients with egg allergy, even those with significant allergic reactions after egg ingestion, can safely receive an influenza vaccine in a 2-dose protocol when the vaccine preparation contains no more than 1.2 micrograms/mL egg protein.

The safety of asthma and allergy medications during pregnancy

BACKGROUND

Although no asthma or allergy medications can be considered proven safe for use during pregnancy, these medications are often used to prevent the potential direct and indirect consequences of uncontrolled asthma or allergy.

OBJECTIVE

The safety of asthma medications, antihistamines, and decongestants was assessed in a prospectively monitored cohort of 824 pregnant women with and 678 pregnant women without asthma.

METHODS

Medications used since conception were recorded on each subject's initial visit (< 28 weeks' gestation). Thereafter, diary cards for medications were completed by the patient through the time of delivery. Perinatal outcomes were compared in exposed versus unexposed individuals. A multivariate analysis accounted for the potential effects of age, parity, smoking, race, weight gain during pregnancy, maternal pulmonary function, acute asthmatic episodes, and multiple medication exposure.

RESULTS

No significant relationships were identified between major congenital malformations and first trimester or any exposure to beta-agonists, theophylline, cromolyn, corticosteroids, antihistamines, or decongestants. In the multivariate analyses, oral corticosteroids were independently associated with preeclampsia (odds ratio = 2.0, p = 0.027), but no other independent associations were observed between asthma or allergy medications and adverse perinatal outcomes.

CONCLUSION

Use of most common asthma and allergy medications during pregnancy was not associated with increased perinatal risks. Maternal use of oral corticosteroids was independently associated with the occurrence of preeclampsia in this study, although the mechanism of this association is not clear. However, because prior observations suggest that severe asthma may be associated with maternal and/or fetal mortality, risk-benefit considerations still favor the use of oral corticosteroids when indicated for the treatment of asthma during pregnancy.

The effect of outdoor fungal spore concentrations on daily asthma severity

The relationship between day-to-day changes in asthma severity and combined exposures to community air pollutants and aeroallergens remains to be clearly defined. We examined the effects of outdoor air pollutants, fungi, and pollen on asthma. Twenty-two asthmatics ages 9-46 years were followed for 8 weeks (9 May-3 July 1994) in a semirural Southern California community around the air inversion base elevation (1,200 ft). Daily diary responses included asthma symptom severity (6 levels), morning and evening peak expiratory flow rates (PEFR), and as-needed beta-agonist inhaler use. Exposures included 24-hr outdoor concentrations of fungi, pollen, and particulate matter with a diameter < 10 microns (PM10; maximum = 51 micrograms/m3) and 12-hour day-time personal ozone (O3) measurements (90th percentile = 38 ppb). Random effects longitudinal regression models controlled for autocorrelation and weather. Higher temperatures were strongly protective, probably due to air conditioning use and diminished indoor allergens during hot, dry periods. Controlling for weather, total fungal spore concentrations were associated with all outcomes: per minimum to 90th percentile increase of nearly 4,000 spores/m3, asthma symptom scores increased 0.36 (95% CI, 0.16-0.56), inhaler use increased 0.33 puffs (95% CI, -0.02-0.69), and evening PEFR decreased 12.1 l/min (95% CI, -1.8-22.3). These associations were greatly enhanced by examining certain fungal types (e.g., Alternaria, basidiospores, and hyphal fragments) and stratifying on 16 asthmatics allergic to tested deuteromycete fungi. There were no significant associations to low levels of pollen or O3, but inhaler use was associated with PM10 (0.15 inhaler puffs/10 micrograms/m3; p < 0.02). These findings suggest that exposure to fungal spores can adversely effect the daily respiratory status of some asthmatics.

Asthma and allergy in pregnancy

Rhinitis is extremely common during pregnancy, and asthma is one of the most common potentially serious medical problems to complicate pregnancy. Cutaneous allergy (urticaria/angioedema and eczema) also may occur during pregnancy. All of these entities may worsen with pregnancy in some patients and appear to improve in others. Uncontrolled asthma may directly threaten the fetus, and morbidity from the other illnesses may indirectly affect pregnancy through an effect on eating, sleeping, or emotional well-being. Appropriate diagnosis, avoiding triggering factors when possible; appropriate use of pharmacotherapy; and, when indicated, allergen immunotherapy usually allow these chronic conditions to be controlled during pregnancy so as to optimize both the health of the mother and that of her baby.

Daily asthma severity in relation to personal ozone exposure and outdoor fungal spores

Epidemiologic investigations of ambient ozone (O3) effects on daily asthma status have not used personal O3 exposures and have often lacked well-characterized allergen exposures. To address this, we studied 12 asthmatic subjects aged 9 to 16 yr, who recorded daily asthma symptoms (functional levels 0 to 5) and as-needed inhaler use during September and October 1993 in San Diego, California, Outdoor aeroallergens, O3, and fine particle concentrations were measured at a central outdoor site, and personal 12-h daytime exposures to O3 were measured daily. Personal O3 differed greatly between subjects and was 27% of mean outdoor O3. In random-effects autoregression models controlling for weekend days and fungal spores, personal O3 was associated with asthma severity: for a 90th percentile increase in O3 (25 ppb), symptom scores increased by 25% (95% CI: 0 to 49%) and inhaler use increased by 26% (95% CI: 3 to 48%) over their averages. Outdoor 12-h O3, but not 1-h maximum O3, was associated with inhaler use (p < 0.03). Fungal spores were significantly associated with symptoms (scores increased by 0.1 to 0.3/1,000 spores/m3) and inhaler use (0.1 to 0.4 puffs/1,000 spores/m3) across speciated groups. Pollen and fine particles (low levels) were not associated with any outcomes. These findings illustrate that the epidemiologic importance of O3 and allergenic cofactors can be underestimated by failure to account for personal O3 and fungal exposures.

The development and prediction of atopy in high-risk children: follow-up at age seven years in a prospective randomized study of combined maternal and infant food allergen avoidance

BACKGROUND

The natural history of allergic disease and its potential for prevention merit close examination because of the explosive worldwide increase in the prevalence and morbidity of atopic disorders. This study examines the development of atopy at age 7 years in 165 children in a high-risk cohort, previously reported from birth to age 4 years.

METHODS

In this prospective, randomized, controlled study of food allergen avoidance in infancy, the prophylactic-treated group consisted of infants whose mothers avoided cow's milk, egg, and peanut during the last trimester of pregnancy and lactation and who, themselves, avoided cow's milk until age 1 year (casein hydrolysate supplementation before age 1), egg until age 2 years, and peanut and fish until age 3 years. The control group consisted of maternal/infant pairs who followed standard feeding practices.

RESULTS

Despite a significant reduction in food allergy and milk sensitization before age 2 years, none of the following differed between the groups at age 7 years: food allergy, atopic dermatitis, allergic rhinitis, asthma, any atopic disease, lung function, food or aeroallergen sensitization, serum IgE level, or presence of nasal eosinophils or nasal basophilic cells. Children with food allergy by 4 years evidenced higher 7-year (current) prevalences of allergic rhinitis and asthma (p < 0.01). Atopic diseases/parameters at age 7 years were shown, by multivariate analysis (p < 0.05), to be associated with several genetic and environmental risk factors (male gender, maternal nonwhite ethnicity and asthma, and household smoking), as well as predictive atopic markers during infancy (elevated serum IgE level; egg, cow's milk, and peanut sensitization; and nasal eosinophils and nasal basophilic cells).

CONCLUSIONS

These findings help to: (1) elucidate the natural history of atopic disease in high-risk children; (2) document the progression of allergy from atopic dermatitis, food allergy, and food sensitization to respiratory allergy and aeroallergen sensitization despite food allergy prevention in infancy; (3) identify allergy predictive markers; and (4) expand our appreciation of the interactions of genetic and environmental factors in the development of atopy.

Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis

Prior studies have found an increased incidence of adverse perinatal outcomes of pregnancies in asthmatic mothers, but these studies have been poorly controlled for asthma therapy and other confounding factors. The purpose of this study was to assess perinatal outcomes in actively managed pregnant asthmatic women as compared with matched nonasthmatic controls. Using an inception cohort design, we studied a volunteer sample of 486 pregnant (< 28 wk) women with documented asthma and 486 pregnant nonasthmatic controls with normal pulmonary function. Cases and controls were matched for age, smoking status, parity, and year of delivery. Asthma was managed with step therapy to prevent acute asthmatic episodes and asthma symptoms that interfered with sleep or normal activity. Chronic hypertension was significantly more common (p = 0.007) in asthmatic subjects (3.7%) than in matched controls (1.0%). However, no significant differences in incidences of preeclampsia, perinatal mortality, preterm births, low-birth-weight infants, intrauterine growth retardation, or congenital malformations were observed in the pregnancies of the asthmatic women as compared with the matched controls. Trends were observed toward relationships between more severe asthma requiring emergency therapy or corticosteroids and increased incidences of preeclampsia and low-birth-weight infants, but these associations were not statistically significant. These data suggest that the overall perinatal prognosis for women with actively managed asthma during pregnancy is comparable to that for the nonasthmatic population.

Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial

STUDY OBJECTIVE

This randomized clinical trial tested a behavioral medicine program designed to reduce asthmatic children's exposure to environmental tobacco smoke (ETS) in the home.

DESIGN

Families were randomly assigned to an experimental preventive medicine counseling group, a monitoring control group, or a usual treatment control group. Families were measured six times over 1 year.

PARTICIPANTS

Ninety-one families were recruited from four allergy clinics.

INTERVENTION

The experimental group received a 6-month series of counseling sessions designed to decrease ETS exposure. This group also monitored smoking, exposure, and children's asthma symptoms. The monitoring group did not receive counseling and the usual treatment control group received outcome measures only.

MEASUREMENTS AND RESULTS

Parents reported the daily number of cigarettes children were exposed to during the week preceding interviews. A nicotine air monitor and construct validity analysis confirmed the validity of exposure reports. Exposure to the parent's cigarettes in the home decreased for all groups. The experimental group attained a 79 percent decrease in children's ETS exposure, compared with 42 percent for the monitoring control and 34 percent for the usual treatment control group. Repeated-measures analysis of variance resulted in a significant (F([10,350] = 1.92, p < 0.05) group by time effect. At the final 12-month visit, the experimental/counseling group sustained a 51% decrease in children's exposure to cigarettes in the home from all smokers, while the monitoring control group showed an 18% decrease and the usual treatment control group a 15% decrease from pre-intervention [corrected].

CONCLUSION

A behavioral medicine program was successful in reducing exposure to ETS in the home for these asthmatic children.

Osteoporosis in corticosteroid-treated asthmatic patients: clinical correlates

This study sought to identify clinical and laboratory characteristics associated with the development of osteoporosis in 44 corticosteroid (CS)-treated asthmatic patients. Percentage predicted bone density was inversely correlated with both the duration of CS therapy (r = -.39, p = 0.009) and 24-hour urine calcium excretion (chi 2 = 5.2, p = 0.022). Bone density was not related to prednisone equivalent dose, alternate day versus daily therapy or serum cortisol levels. These data suggest that (1) long duration of CS therapy and increased urine calcium may identify patients at increased risk of developing CS-induced osteoporosis, and (2) urinary loss of calcium may be of particular importance in the pathogenesis of this condition.

Development of nasal basophilic cells and nasal eosinophils from age 4 months through 4 years in children of atopic parents

BACKGROUND

The importance of the inflammatory response in allergic disease has warranted investigation of two of the more integral cells in the pathogenesis of allergic rhinitis, namely, nasal basophilic cells (NBCs) and nasal eosinophils (NEs). In the present study the natural history of NBCs and NEs was studied from birth through 4 years of age in infants of atopic parents to better understand their relationship to the development of various atopic disorders.

METHODS

During a prospective, randomized, controlled trial of the effect of maternal and infant food avoidance on the development of atopic disorders in 288 infants of atopic parents, NBCs and NEs were determined semiquantitatively on Wright-Geimsa stained nasal mucosal scrapings and related to each other and to various atopic parameters.

RESULTS

In these infants who are at high risk NBCs developed in both those becoming atopic and those remaining nonatopic, but they occurred with increased frequency and quantity in those children in whom most allergic disorders and food or inhalant sensitization developed. NEs, rare at 4 months in all infants, increased in atopic children from 1 to 4 years, and remained infrequent and nominal in nonatopic children. Levels of NBCs and NEs (1) correlated with each other strongly, directly, and with increasing magnitude in children from ages 4 months to 4 years and (2) correlated with log serum IgE levels weakly and moderately in children from ages 2 to 4 years. Stepwise linear regression analyses revealed that allergic rhinitis accounted for most of the variance seen in the level of NBCs and NEs during early childhood, reaching 50% by age 4 years. Asthma, atopic dermatitis, food allergy, food and inhalant sensitization, serum IgE level, and IgG beta-lactoglobulin level accounted for a small proportion of the variance in NBCs and NEs from ages 4 months to 4 years.

CONCLUSIONS

These findings help to elucidate the natural history of NBCs and NEs in infants at risk for atopic disorders and document the temporal association of these cells with the development of atopic disease, principally allergic rhinitis.

The impact of status asthmaticus practice guidelines on patient outcome and physician behavior

This study assesses the effects of a status asthmaticus guideline on patient outcome and pediatrician behavior in a staff model health maintenance organization (HMO). The guidelines were drafted by an asthma specialist in the HMO and then discussed with key clinical personnel. A preprinted protocol order form was developed to help implement the guideline into clinical practice. The medical records of pediatric patients admitted to the hospital with status asthmaticus before (N = 67) and after (N = 59) guideline development and implementation were reviewed. This study demonstrates that locally developed, treatment-specific guidelines based on scientific evidence and combined with a staff consensus process and a user-friendly protocol form can influence physician behavior and patient outcome positively.

Prospects for ancillary treatment of sinusitis in the 1990s

The basis for ancillary therapy of sinusitis derives from anecdotal accounts and personal beliefs rather than definitive data. The recent appreciation that noninfectious inflammatory causes predispose to infectious sinusitis has stimulated renewed interest in developing and documenting efficacious ancillary therapies that could supplement or abrogate antibiotic use. Ancillary therapies of sinusitis could be directed toward (1) preventing viral upper respiratory tract infections (immunizations, virucidal-impregnated tissues, and proper hand-washing techniques); (2) blocking rhinoviral replication and suppressing mediator release with supraphysiologic nasal hyperthermia, although contradictory studies exist with regard to efficacy; (3) promoting sinus and nasal ventilation with both topical and oral alpha-agonists and exercise; (4) improving mucociliary clearance by reducing mucus viscosity and elasticity with saline solution irrigation, mucoregulators (N-acetylcysteine, S-carboxymethylcysteine, and iodinated glycerol), and ciliary stimulants (adenosine triphosphate); and (5) suppressing/modulating cellular inflammation (eosinophilic, basophilic, and neutrophilic) with topical nasal corticosteroid sprays and mediator antagonists. Recommendations are forwarded for future investigations of promising nonantibiotic ancillary therapies of chronic sinusitis.

Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits

Facilitated asthma-specialist care delivered by allergists was compared to generalist care on the rate of relapse of asthma emergency room (ER) visits and hospitalizations and on asthma control in a prospective, controlled study of San Diego Kaiser Health Plan members with asthma. Subjects with asthma between the ages of 6 and 59 years presenting for acute ER care for asthma were systematically assigned by alternating, consecutively, the day of their ER visit to receive either (1) facilitated referral to an asthma specialist within the allergy department and concomitant comprehensive ongoing asthma care (intervention group, n = 149) or (2) continued outpatient management from generalist physicians (control group, n = 160). The course of their asthma was evaluated blindly during the subsequent 6 months by review of medical records, initial and follow-up questionnaires, and spirometry. Compared to the control group, the intervention group noted (1) a 75% reduction in the number of, and percent of, subjects with asthma awakenings per night (p less than or equal to 0.0001), (2) an almost 50% reduction in asthma ER relapses (p = 0.017) resulting from a reduction in the frequency of multiple relapse (p = 0.005), and (3) a greater use of inhaled corticosteroids (p less than 0.00001) and cromolyn (p = 0.002). Thus, facilitated referral of subjects with asthma to specialists in asthma therapy after acute ER therapy appears to reduce asthma ER relapses and to improve asthma outcome.

Increased transient tachypnea of the newborn in infants of asthmatic mothers

OBJECTIVE

To compare the incidence of transient tachypnea of the newborn (TTN) in infants of asthmatic vs nonasthmatic mothers.

RESEARCH DESIGN

Case-control analysis.

SETTING

Group model health maintenance organization.

PATIENTS

A volunteer sample of 294 pregnant asthmatic women and 294 pregnant nonasthmatic women with normal pulmonary function test results, matched on the basis of age and smoking status. All subjects entered the study before their third trimester of pregnancy. Subjects with multiple gestations and abortions (less than 20 weeks' gestation) were excluded.

INTERVENTION

Asthma was treated in the allergy department. Routine obstetric, neonatal, and pediatric care was provided to all patients by staff physicians.

MEASUREMENTS/RESULTS

Transient tachypnea occurred in 11 infants (3.7%) of asthmatic women and in one control infant (0.3%). There were no significant differences between asthmatic and matched control subjects in previously defined TTN risk factors, such as the occurrence of longer labors, failure to progress, cesarean sections, premature births, male sex, Apgar scores of less than 7 at 1 minute, or birth weight greater than 4 kg. Although infants of asthmatic mothers were more likely to exhibit wheezing by age 15 months compared with control infants (12.0% vs 3.2%), none of the infants with TTN manifested wheezing by age 15 months. No relationships could be identified in the asthmatic cohort between the occurrence of TTN and asthma severity or medication use (during the pregnancy in general or during labor and delivery in particular).

CONCLUSION

Although the mechanism is uncertain, maternal asthma appears to increase the risk of infant TTN.

Intrauterine growth is related to gestational pulmonary function in pregnant asthmatic women. Kaiser-Permanente Asthma and Pregnancy Study Group

Asthmatic mothers have been reported to deliver infants of lower mean birth weight than nonasthmatic mothers. This study examined the relationship between intrauterine growth and serial gestational spirometry in 352 pregnant asthmatic women who were prospectively treated and observed during pregnancy. A small (r = 0.11) but significant (p less than 0.04) direct correlation was demonstrated between infant birth weight and individual mean percent predicted FEV1 during pregnancy. In addition, lower maternal mean FEV1 during pregnancy was associated with increased incidences of birth weight in the lower quartile of the infant population (p = 0.002) and ponderal indices less than 2.2 (suggestive of asymmetric intrauterine growth retardation) (p less than 0.05), but not with increased incidences of preterm (less than 38 weeks) or low birth weight (less than 2,500 g) infants. Although lower mean birth weight occurred in infants of smoking compared with nonsmoking asthmatic mothers (p less than 0.02), the relationships of lower FEV1 to birth weight in the lower quartile of the population (odds ratio 3.0, p = 0.002) and ponderal indices less than 2.2 (odds ratio 2.8, p less than 0.05) were shown by multivariate analysis to be above and beyond the influence of smoking and also independent of the effects of age, parity, acute asthmatic episodes, and asthma medications. These data support the hypothesis that lower maternal gestational FEV1 during pregnancy is related to intrauterine growth retardation and suggest that the goals of gestational asthma therapy should include optimization of pulmonary function in addition to achievement of symptomatic control.

Effect of combined maternal and infant food-allergen avoidance on development of atopy in early infancy: a randomized study

The effect of maternal and infant avoidance of allergenic foods on food allergy was examined in a prenatally randomized, controlled trial of infants of atopic parents. The diet of the prophylactic-treated group (N = 103) included (1) maternal avoidance of cow's milk, egg, and peanut during the third trimester of pregnancy and lactation and (2) infant use of casein hydrolysate (Nutramigen) for supplementation or weaning, and avoidance of solid foods for 6 months; cow's milk, corn, soy, citrus, and wheat, for 12 months; and egg, peanut, and fish, for 24 months. In the control group (N = 185), mothers had unrestricted diets, and infants followed American Academy of Pediatrics feeding guidelines. The cumulative prevalence of atopy was lower at 12 months in the prophylactic-treated (16.2%) compared to the control (27.1%) group (p = 0.039), resulting from reduced food-associated atopic dermatitis, urticaria and/or gastrointestinal disease by 12 months (5.1% versus 16.4%; p = 0.007), and any positive food skin test by 24 months (16.5% versus 29.4%; p = 0.019), caused primarily by fewer positive milk skin tests (1% versus 12.4%; p = 0.001). The prevalences of allergic rhinitis, asthma, and inhalant skin tests were unaffected. Serum IgE levels in the prophylactic-treated group were marginally lower only at 4 months. Thus, reduced exposure of infants to allergenic foods appeared to reduce food sensitization and allergy primarily during the first year of life.

Double-blind, placebo-controlled food challenge (DBPCFC) as an office procedure: a manual

There is now enough experience with the use of double-blind, placebo-controlled, food challenge (DBPCFC) to recommend its use as an office procedure for most patients complaining of adverse reactions to foods. This manual discusses the practical methods required for the allergist to undertake DBPCFC in the office. Thorough histories supplemented by food allergen skin testing are used to design a DBPCFC that carefully attempts to reproduce the history of food-induced symptoms described by the patient. Precautions that must be taken are delineated before challenge, as is treatment that may be required if a reaction occurs. For those foods to which challenges are positive, longitudinal evaluation with repeated challenge at appropriate intervals help to determine whether or not the problem will resolve over a period of time.

IgG-, IgA-, and IgE-induced release of leukotriene C4 by monocytes isolated from patients with atopic dermatitis

Purified peripheral blood monocytes isolated from patients with atopic dermatitis (AD) and from nonallergic normal donors were compared for their abilities to release leukotriene C4 (LTC4), leukotriene B4 (LTB4) and beta-glucuronidase in response to challenge with aggregated immunoglobulins or anti-immunoglobulins. The relationship between mediator release and the number of monocytes that formed rosettes with immunoglobulin-coated indicator cells was examined. Patients with AD had twice as many IgA- and three times as many IgE-rosetting monocytes as normal donors (48 +/- 12% versus 27 +/- 10% and 40 +/- 15% versus 14 +/- 3%, respectively), and yet the amounts of IgA- and IgE-induced LTC4 released were similar for both groups. This apparent discrepancy did not result from a decreased capacity for arachidonate metabolism via the C5-lipoxygenase pathway, since stimulation of monocytes from patients and normal donors with the calcium ionophore A23187 induced similar amounts of LTC4 and LTB4 release (LTC4, 3.0 +/- 1.7 versus 3.0 +/- 1.0 ng/10(6) cells; LTB4, 5.3 +/- 0.7 versus 5.2 +/- 0.5 ng/10(6) cells, respectively). In addition, aggregated IgG-induced LTC4 release by monocytes of both groups was similar, concomitant with an equivalent number of IgG-rosetting cells. Determination of cytophilically bound IgG and IgE by flow cytometry demonstrated that monocytes from atopic patients had more IgG bound than monocytes from normal donors. Similar amounts of IgE were detected on most monocytes from both groups, despite the higher serum IgE levels of patients. However, approximately 3% to 8% of monocytes from atopic but not normal donors stained brightly for IgE, suggesting that relatively large amounts of cytophilic IgE were bound to a small percentage of the patients' monocytes. Challenge of monocytes with anti-IgE or anti-IgG induced release of similar amounts of LTC4 for both groups, despite the presence of more cytophilic IgG on monocytes from atopic donors. These data indicate that monocytes from patients with AD release LTC4 and LTB4 in response to challenge with aggregated IgE or anti-IgE, as well as aggregated IgG, IgA, and anti-IgG. However, under our in vitro conditions, stimulation of patients' monocytes with aggregated IgA or IgE was not associated with increased mediator release, despite higher percentages of IgA- and IgE-rosetting cells compared to normal donors.

The safety of inhaled beta-agonist bronchodilators during pregnancy

To assess the safety of inhaled beta-agonist bronchodilators during pregnancy, perinatal outcomes in 259 prospectively managed women with asthma using these medications during pregnancy were compared to perinatal outcomes in 101 concurrently followed pregnant subjects with asthma not using inhaled bronchodilators and to perinatal outcomes in 295 concurrently followed pregnant control subjects without asthma. No significant differences between women with asthma using inhaled bronchodilators and subjects not receiving inhaled bronchodilators were found in the following parameters: perinatal mortality, congenital malformations, preterm births, low birth weight infants, mean birth weight, small for gestational age or low ponderal index infants, Apgar scores, labor/delivery complications, or postpartum bleeding. Increased incidences of maternal chronic and pregnancy-induced hypertension and transient tachypnea of the neonate were observed in the pregnancies of subjects with asthma using regular inhaled bronchodilators compared to control subjects, but a logistic regression analysis within the sample of subjects with asthma did not significantly associate the use of inhaled bronchodilators with these outcomes. In the light of the known substantial perinatal risks of severe, uncontrolled asthma and the relatively sparse evidence of human gestational safety for alternative asthma medications, these data support the use of inhaled beta-agonist bronchodilators as part of the management of asthma during pregnancy.

Diagnosis and management of rhinitis during pregnancy

Chronic nasal symptoms occur commonly in pregnant women. The most frequent causes of rhinitis during pregnancy are allergic rhinitis, bacterial rhinosinusitis and rhinitis medicamentosa. The appropriate diagnosis in the individual pregnant woman can usually be established on the basis of the history, physical examination and nasal cytology. Benefit-risk considerations in the management of gestational rhinitis are discussed in detail.

A multicenter evaluation of the clinical benefits of cromolyn sodium aerosol by metered-dose inhaler in the treatment of asthma

The efficacy and safety of cromolyn sodium by metered-dose inhaler (MDI) (1 mg per actuation) was evaluated with a double-blind, placebo-controlled, parallel-study design. Subjects with asthma, aged 8 to 58 years, whose asthma was well controlled taking cromolyn sodium capsules by Spinhaler turboinhaler, plus beta 2-agonists, entered the study after being maintained with cromolyn sodium capsules for a minimum of 4 weeks. The investigation began with a 2-week control interval with cromolyn sodium capsules followed by a 4-week single-blind period with placebo capsules. Subjects whose asthma significantly worsened while they were receiving placebo therapy were then randomized to a 10-week double-blind phase in which they received either active cromolyn sodium or placebo by MDI. Efficacy variables included diary data, physician evaluation, and spirometry. Comparisons were made between baseline period scores and each assessment variable over time. Of 155 subjects entered, 93 qualified for the double-blind, randomized phase. Eighty-three subjects completed the study and were analyzed. At baseline there existed no significant differences between the active-treatment and placebo-treatment groups. Significant differences (p less than 0.05) in favor of the cromolyn sodium-treatment group, however, were noted at all time points for daily diary symptoms (cough, breathlessness, and overall asthma severity), physician's assessments at each clinic visit, physician's and patient's overall final assessments, FEV1 at each clinic visit, and FVC and peak expiratory flow rate at the final visit. Concomitant bronchodilator medication use was less in the cromolyn sodium-treatment group. Cromolyn sodium by MDI is highly effective for (1) controlling asthmatic symptoms, (2) improving lung functions, and (3) decreasing the need for concomitant bronchodilators.

The course of asthma during pregnancy, post partum, and with successive pregnancies: a prospective analysis

We studied 366 pregnancies in 330 prospectively managed women with asthma to determine the effect of pregnancy on asthma. Asthma activity was assessed by (1) daily symptom and medication diaries and (2) monthly auscultation and spirometry during pregnancy and for 3 months post partum. At 3 months post partum, subjects were asked to assess the overall course of their asthma during pregnancy compared to the usual course for them, and the course of their asthma during the 3 months post partum compared to the asthma during pregnancy. Asthma worsened during pregnancy in 35% of the women, improved in 28%, and was unchanged in 33%. Based on diary-card analysis, asthma was significantly less frequent and less severe during the last 4 weeks of pregnancy than during any other gestational interval. In women whose asthma improved during pregnancy, diary-card analysis revealed a gradual improvement with progressive pregnancy, whereas in women whose asthma worsened during pregnancy, there was an increase in asthma symptoms during 29 to 36 weeks gestation. During labor and delivery, asthma symptoms occurred in 10% of women with approximately equal proportions of these women receiving either no treatment or inhaled bronchodilators; only two subjects required intravenous aminophylline. During the 3 months post partum, asthma reverted toward its prepregnancy course in 73% of women. In 34 subjects prospectively studied for two successive pregnancies, there existed a significant concordance between the asthma course during the first and second pregnancies. The mechanistic and clinical implications of these findings are discussed.

Challenges in the prevention of allergic disease in infancy

The prevention of atopic disease, though admirable, remains a difficult endeavor. One must overcome inherent and natural forces constantly working to sensitize humans to produce IgE antibodies. These multiple risk factors for developing allergies (Table 1) act in concert to oppose preventive efforts. IgE mediated disorders potentially could be prevented by selectively interfering with the major genetic, cellular, and environmental factors that determine the ultimate phenotypic expression of atopy. Present efforts to prevent allergic disease remain relegated to manipulating the environment by reducing the allergenic load. Unfortunately, however, there has yet to exist a definitive, prospective study that conclusively documents and defines optimal or proven effective dietary and environmental regimens that prevent allergic disease. Until such studies emerge, physicians interested in prevention should be cognizant of the data derived from the limited published reports of dietary and environmental prevention efforts in order to appreciate current espoused recommendations. In addition to developing effective and proven prevention regimens, other issues deserving scrutiny include the following: 1) recognition of those groups (individuals) most at risk, amenable, and/or responsive to preventive efforts; 2) determination of the cost-effectiveness of such endeavors; and 3) identification of interfering variables, ie, noncompliance to recommendations.

Effectiveness of dietary manipulation in the prevention of food allergy in infants

The desire to alter the natural incidence of atopic illness has piqued physicians' imaginations for decades. Specifically, the phenotypic expression of IgE-mediated disorders, which appears regulated by multiple genetic factors and modulated by environmental experiences (allergen exposure, infection, and smoking), has been a target for preventive medicine since the 1920s when dietary intervention was espoused in infancy. To be successful, such intervention must overcome many patient factors that in concert markedly increase the risk for development of atopic disease (Table XII). During the past 60 years, much controversy has emerged from multiple clinical studies designed to evaluate the effect of dietary and other environmental exclusions on the subsequent manifestation of atopy. One may conservatively conclude, from critical evaluation of these conflicting studies, that sole breast feeding for about 6 months combined with delayed introduction of solid foods for at least 6 months may reduce atopic dermatitis and food allergy in early infancy. A randomized, prospective study of allergy prophylaxis during infancy is mandatory to determine definitely the benefits and feasibility of such a regimen and its long-term effects on the development of atopy. From our recent findings, which demonstrate the development of atopy in infants entered in a strict prophylactic protocol, it becomes apparent that monumental obstacles confront preventive efforts to overcome the strength of the allergic constitution. In the very near future, results from our prospective study of prenatally randomized allergy prophylaxis should be available for critical scrutiny of the effectiveness and feasibility of allergy prevention during infancy.

Milk-sensitive and eosinophilic gastroenteropathy: similar clinical features with contrasting mechanisms and clinical course

We studied 12 children with peripheral eosinophilia, iron deficiency anemia secondary to blood loss in the stools, protein-losing enteropathy, and eosinophilic infiltration of the stomach and small intestine. On the basis of immunologic features and responses to therapy, these patients could be divided into two groups. In the first group the disease was transient, presented in the first year of life, remitted on withdrawal of milk from the diet, and was not associated with IgE-mediated immediate hypersensitivity (milk-sensitive enteropathy). In contrast, the second group, which we termed eosinophilic gastroenteropathy, represented patients with a chronic disease that had its onset later in childhood, did not respond to dietary manipulations, was associated with atopy and IgE-mediated immediate hypersensitivity reactions to food, and required corticosteroid therapy to establish remission and control. The mechanism by which food causes gastrointestinal damage appears to be different in these two groups even though the clinical syndromes are similar.

Aspirin-sensitive rhinosinusitis asthma: a double-blind crossover study of treatment with aspirin

Twenty-five ASA-sensitive patients with rhinosinusitis asthma underwent oral ASA challenges followed by desensitization to the adverse respiratory effects of ASA. We then compared the efficacy of continuous ASA treatment for their respiratory tract disease to that of a placebo treatment during a double-blind crossover study. For this group of 25 patients, there was significant improvement in nasal symptoms and a reduction in use of nasal beclomethasone during the months when they received ASA treatment. Lower respiratory tract symptoms, values of FEV1, and the use of antiasthmatic medications including prednisone were not significantly changed during ASA treatment. Desensitization to ASA followed by ASA treatment appears to significantly alleviate symptoms of rhinosinusitis. However, only half the patients experienced improvement in their asthma symptoms during ASA treatment.

Characterization with monoclonal antibodies of T lymphocytes bearing Fc receptors for IgE (T epsilon cells) and IgG (T gamma cells) in atopic patients

Peripheral blood T lymphocytes from nonatopic control donors, asymptomatic atopic donors, and patients with moderate to severe atopic dermatitis were analyzed for Fc receptors for IgE (T epsilon cells) and IgG (T gamma cells) by rosette assays and were characterized with monoclonal antibodies. The T cells were reacted first with monoclonal antibodies, followed by fluoresceinated F(ab')2 goat antimouse Ig; they were then rosetted, and subsequently the rosetting cells were examined for immunofluorescence. Seven nonatopic control donors had less than 0.1% T epsilon cells and a mean +/- SD of 10.5% +/- 4.1 T gamma cells. Seven asymptomatic atopic donors with low IgE levels (2 to 233 IU/ml) varied from less than 0.1 to 1.3% T epsilon cells and 7.2% +/- 3.7 T gamma cells. Six of seven patients with moderate to severe atopic dermatitis and IgE levels of 1339 to 24,261 IU/ml had less than 0.1% T epsilon cells and significantly fewer T gamma cells (3.1% +/- 2.7, p less than 0.01) than the nonatopic control donors and the atopic donors in remission. Both T epsilon and T gamma cells reacted with the pan-T cell antibody Lyt-3 (anti-sheep red cell receptor) but not with antibodies OKT3, OKT4, or OKT6. Subpopulations of both T epsilon and T gamma cells reacted with antibodies OKT8 and the antimonocyte antibody OKM1. The OKM1+ cells did not appear to be monocytes, however, because the T cells did not react with another antimonocyte antibody, BRL.2, and were negative for nonspecific esterase activity. (ABSTRACT TRUNCATED AT 250 WORDS)

Lack of pokeweed mitogen-induced IgE formation in vitro by human peripheral blood mononuclear cells: detection of cross-reacting idiotypic determinants on polyclonal Ig by antibodies to a single IgE myeloma protein

The ability of human peripheral blood mononuclear cells to synthesize IgE in vitro in response to pokeweed mitogen (PWM) is controversial. To determine whether the conflicting results obtained by different laboratories could be due to inherent qualitative differences in the anti-IgE antibodies used to measure low concentrations of IgE in culture supernatants, we compared the specificities of anti-IgE reagents prepared by various methods. Immunoadsorbent-purified antibodies were isolated from a goat antiserum to the lambda, IgE myeloma protein PS and a rabbit antiserum to the kappa, IgE protein Bed in three ways: 1) antibodies to IgE PS (anti-PS) were isolated from the goat antiserum by affinity chromatography with PS coupled to Sepharose 4B; these antibodies consisted of anti-epsilon chain-specific and anti-idiotypic antibodies to protein PS; 2) antibodies specific for the epsilon-chain (anti-epsilon) were purified by affinity chromatography with IgE myeloma proteins that were not used for immunization; and 3) antibodies to idiotypic determinants of proteins PS (anti-id PS) and Bed (anti-id Bed) were isolated on affinity columns with the respective myeloma proteins after absorption of the epsilon-chain-specific antibodies. These three types of antibodies were then used in a solid phase radioimmunosorbent test to quantitate the amount of "IgE" synthesized by peripheral blood mononuclear cells from nonatopic and atopic donors cultured for 7 days in the presence and absence of PWM. ANTI-PS antibodies detected a PWM-induced "IgE formation" in cell culture supernatants of both non-atopic and atopic donors. (ABSTRACT TRUNCATED AT 250 WORDS)

Characterization with monoclonal antibodies of T lymphocytes bearing Fc receptors for IgE (T epsilon cells) and IgG (T gamma cells) in atopic patients

Peripheral blood T lymphocytes from nonatopic control donors, asymptomatic atopic donors, and patients with moderate to severe atopic dermatitis were analyzed for Fc receptors for IgE (T epsilon cells) and IgG (T gamma cells) by rosette assays and were characterized with monoclonal antibodies. The T cells were reacted first with monoclonal antibodies, followed by fluoresceinated F(ab')2 goat antimouse Ig; they were then rosetted, and subsequently the rosetting cells were examined for immunofluorescence. Seven nonatopic control donors had less than 0.1% T epsilon cells and a mean +/- SD of 10.5% +/- 4.1 T gamma cells. Seven asymptomatic atopic donors with low IgE levels (2 to 233 IU/ml) varied from less than 0.1 to 1.3% T epsilon cells and 7.2% +/- 3.7 T gamma cells. Six of seven patients with moderate to severe atopic dermatitis and IgE levels of 1339 to 24,261 IU/ml had less than 0.1% T epsilon cells and significantly fewer T gamma cells (3.1% +/- 2.7, p less than 0.01) than the nonatopic control donors and the atopic donors in remission. Both T epsilon and T gamma cells reacted with the pan-T cell antibody Lyt-3 (anti-sheep red cell receptor) but not with antibodies OKT3, OKT4, or OKT6. Subpopulations of both T epsilon and T gamma cells reacted with antibodies OKT8 and the antimonocyte antibody OKM1. The OKM1+ cells did not appear to be monocytes, however, because the T cells did not react with another antimonocyte antibody, BRL.2, and were negative for nonspecific esterase activity. (ABSTRACT TRUNCATED AT 250 WORDS)

Lack of pokeweed mitogen-induced IgE formation in vitro by human peripheral blood mononuclear cells: detection of cross-reacting idiotypic determinants on polyclonal Ig by antibodies to a single IgE myeloma protein

The ability of human peripheral blood mononuclear cells to synthesize IgE in vitro in response to pokeweed mitogen (PWM) is controversial. To determine whether the conflicting results obtained by different laboratories could be due to inherent qualitative differences in the anti-IgE antibodies used to measure low concentrations of IgE in culture supernatants, we compared the specificities of anti-IgE reagents prepared by various methods. Immunoadsorbent-purified antibodies were isolated from a goat antiserum to the lambda, IgE myeloma protein PS and a rabbit antiserum to the kappa, IgE protein Bed in three ways: 1) antibodies to IgE PS (anti-PS) were isolated from the goat antiserum by affinity chromatography with PS coupled to Sepharose 4B; these antibodies consisted of anti-epsilon chain-specific and anti-idiotypic antibodies to protein PS; 2) antibodies specific for the epsilon-chain (anti-epsilon) were purified by affinity chromatography with IgE myeloma proteins that were not used for immunization; and 3) antibodies to idiotypic determinants of proteins PS (anti-id PS) and Bed (anti-id Bed) were isolated on affinity columns with the respective myeloma proteins after absorption of the epsilon-chain-specific antibodies. These three types of antibodies were then used in a solid phase radioimmunosorbent test to quantitate the amount of "IgE" synthesized by peripheral blood mononuclear cells from nonatopic and atopic donors cultured for 7 days in the presence and absence of PWM. ANTI-PS antibodies detected a PWM-induced "IgE formation" in cell culture supernatants of both non-atopic and atopic donors. (ABSTRACT TRUNCATED AT 250 WORDS)