Unresponsiveness to colchicine therapy in patients with familial Mediterranean fever homozygous for the M694V mutation

OBJECTIVE

More than 50 disease-associated mutations of the Mediterranean fever gene (MEFV) have been identified in familial Mediterranean fever (FMF), some of which were shown to have different clinical, diagnostic, prognostic, and therapeutic implications. The aim of our study was to define the frequency of mutation type, genotype-phenotype correlation, and response to colchicine treatment in patients with FMF.

METHODS

This study included 222 pediatric FMF patients. All patients were investigated for 6 MEFV mutations. Then patients were divided into 3 groups according to the presence of M694V mutation on both of the alleles (homozygotes), on only 1 allele (heterozygotes), and on none of the alleles, and compared according to their phenotypic characteristics and response to treatment. M694V/M694V was denoted Group A, M694V/Other Group B, and Other/Other, Group C.

RESULTS

Complete colchicine response was significantly lower while the rate of unresponsiveness was significantly higher in Group A compared to Groups B and C (p = 0.031, p < 0.001 and p = 0.005, p = 0.029, respectively). No differences except proteinuria were found between the phenotypic features of 3 groups. Group C had the lowest rate of proteinuria development (p = 0.024). All the amyloidosis patients were in Group A.

CONCLUSION

Our results indicate that the M694V/M694V mutation is associated with lower response to colchicine treatment. Therefore, patients homozygous for M694V/M694V may be carrying an increased risk for development of amyloidosis.

Training of trainers on epinephrine autoinjector use

The majority of physicians do not know how to use epinephrine autoinjectors. This displays that current education of physicians on anaphylaxis is inadequate for a thorough practice. We hypothesize that a theoretical lecture together with a practical session on epinephrine autoinjector use will improve its proper use by physicians. Residents, specialists, and consultants from General Pediatrics excluding allergists and allergy fellows were included in this study. All physicians were given an eight-item questionnaire followed by a practical session scoring and timing ability to use epinephrine autoinjector trainer. This ensued with one-to-one hands-on training on correct autoinjector use. Finally, a joint theoretical lecture on anaphylaxis including re-demonstration of epinephrine autoinjector use was given. All physicians were scored a second time on use of epinephrine autoinjector 6 months later. One hundred fifty-one of 196 participants completed all steps of the study in four tertiary hospitals. Correct use of epinephrine autoinjector improved from 23.3% to 74.2%, mean score from 3.49 ± 1.14 to 4.66 ± 0.65, need for prospectus from 91.4% to 29.1%, and mean time to administer autoinjector from 28.01 ± 6.22 s to 19.62 ± 5.01 s (p < 0.001 for each). The rate of most common mistakes during autoinjector use decreased but the ranking did not change. An integrated theoretical and practical education increased correct of epinephrine autoinjector use by physicians. Ongoing mistakes despite this education may be related with its design.

A real-life study on acquired skills from using an adrenaline autoinjector

BACKGROUND

Training programs performed by allergists have increased the ability of patients' recognition and management of anaphylaxis. We aim to investigate the permanence of effect of an anaphylaxis training program and to determine the factors affecting it beyond training given by allergists.

METHODS

Children and/or their caregivers who had been prescribed an adrenaline autoinjector at least 1 year before were invited to take part in the study. The knowledge about anaphylaxis was assessed using a questionnaire and the skills were practically tested.

RESULTS

Sixty-four (50 caregivers/14 children >12 years of age) of 80 patients who accepted the invitation were included in the study. Fifty-nine patients obtained the autoinjector after initial prescription. Among them, 42 (71%) still had the device at the time of the study. The most common reason for not having the autoinjector was no longer feeling it was necessary (54.6%). Of the cases, 39.4% were competent in autoinjector use. There was a significant relation between adrenaline autoinjector competency and regular allergy visits (p = 0.010), believing that it is necessary (p = 0.04), having an adrenaline autoinjector (p = 0.003), and previous history of severe anaphylaxis (p = 0.010). Autoinjector competency score decreased as time elapsed from the last visit (rho = -0.382; p = 0.002) and the first instruction (rho = -0.317; p = 0.01). Regular visits (p = 0.009) and history of severe anaphylaxis (p = 0.007) were found as independent factors having an effect on adrenaline autoinjector competency.

CONCLUSIONS

Training of patients/caregivers by allergists does not guarantee the permanence of acquired skills on anaphylaxis in the long run. Regular follow-up visits should be fostered.

Anaphylaxis in infancy compared with older children

Although there has been increasing data on pediatric anaphylaxis, information about anaphylaxis in the 1st year of life is scarce. This study provides detailed information on clinical signs and symptoms of anaphylaxis in the 1st year of life. A retrospective review was performed of our pediatric allergy database between 2007 and 2011. Children who met the diagnostic criteria of anaphylaxis were included. They were categorized as "infant" if they were ≤12 months of age at the time of anaphylactic reaction and "children" if >12 months. There were 104 patients (60 male and 44 female subjects) who met the diagnosis criteria of anaphylaxis. From the 104 cases of anaphylaxis, 23 (22.1%) were infants. Boys (p = 0.043), atopic eczema (p = 0.049), and history of food allergy (p < 0.001) were significantly higher in infants than in children with anaphylaxis. Severe anaphylaxis was less frequent in infants than in children (p = 0.04). There was no significant difference between infants and children considering cutaneous and respiratory symptoms (p > 0.05 for both) but persistent vomiting was (p = 0.023). Irritability, persistent crying, and somnolence are the signs which are difficult to interpret in infants with anaphylaxis. Within these signs, irritability, persistent crying, and somnolence were present in 69.6, 43.5, and 26.1% of infants, respectively. Blood pressure was measured in 5 infants (21.7%) compared with 44 children (54.3%; p = 0.005). Four children (4.9%) required more than one epinephrine treatment, but no infant did. Median observation periods were 4 hours in both groups (p = 0.087) and no biphasic reactions occurred in either. Food (p < 0.001) was significantly more and drugs (p = 0.015) were a less frequent cause of anaphylaxis in infants than in children. Anaphylaxis in infants is not rare but many signs of anaphylaxis are overlooked and still undertreated.

Make-up of the epinephrine autoinjector: the effect on its use by untrained users

BACKGROUND

Part of the problems related to proper use of the epinephrine autoinjector may be related to the design of the autoinjector itself.

AIM

We investigated whether minor modifications in the design of the currently available epinephrine autoinjector ease its use and abrogate common use errors.

METHODS

All interns other than those who had previously worked in allergy department in a medical school were invited to the study. Two identical epinephrine autoinjector trainers (Epipen trainer(®) ) were used, one of which was modified by changing the gray safety cap to red and placing a yellow arrow pointing to the black injection tip. A written and visual instruction sheet for each trainer was provided. Participants were asked to demonstrate the use of the Epipen trainer either with the original or with the modified one. They were scored and timed for their demonstration.

RESULTS

Out of the 224 interns who were invited to participate, one hundred and sixty-four interns (73.2%) participated in the study. The number of participants correctly demonstrating the use of epinephrine autoinjectors was 22.6% and 65% in unmodified and modified trainer groups, respectively (p < 0.001). The mean time to administer trainers was 26.78 ± 10.6 and 15.88 ± 2.55 s; total median scores were 3.08 ± 1.48 and 4.47 ± 0.84 in unmodified and modified groups, respectively (p < 0.001 for both). Significantly fewer participants had presumptive unintentional injection injury while using modified (5%) compared with unmodified trainer (45.2%) (p < 0.001).

CONCLUSION

Few and simple modifications in the design of epinephrine autoinjector were found effective in increasing its correct use and decreasing common use errors by untrained users. (Clinical trials identifier: NCT01217138).

Assessment of atherosclerosis risk due to the homocysteine-asymmetric dimethylarginine-nitric oxide cascade in children taking antiepileptic drugs

PURPOSE

The aim of this study was to assess the atherogenicity risk of antiepileptics in children by investigating the cascade, "hyperhomocysteinemia (HHcy)→asymmetric dimethylarginine (ADMA) increase→nitric oxide (NO) decrease", which is thought to contribute to the developmental process of atherosclerosis.

METHODS

The participants included 53 epilepsy patients who received either valproic acid (VPA, n=26) or oxcarbazepine (OXC, n=27). Twenty-four healthy sex- and age-matched children served as controls. Fasting plasma total homocysteine (tHcy), ADMA and NO levels were measured.

RESULTS

The differences in Hcy, ADMA, NO, vitamin B(12) and folate levels between VPA, OXC and control groups were all insignificant (p>0.05 for all). In the patient group (VPA and OXC groups), 22.6% of the children (12/53) had tHcy levels above the normal cutoff (13.1μmol/l) for children and 17% of the children (9/53) had tHcy levels of greater than 15μmol/l which is accepted as the critical value for an increased atherosclerosis risk (p<0.05 for both). The difference in rate of HHcy between VPA and OXC groups was statistically insignificant (p>0.05, for both cut off levels of HHCy). There was a positive correlation of tHcy levels and antiepileptic drug treatment duration in the patient group (r=+0.276, p<0.05).

CONCLUSION

HHcy may develop in patients using OXC. Contrary to some previous publications, our data do not suggest that OXC is safer than VPA in terms of HHcy risk. Further prospective, large scale and longer term studies investigating all suggested pathways responsible for development of atherosclerosis due to HHcy should be conducted to define the exact mechanism responsible for AEDs related atherosclerosis.

Pediatricians manage anaphylaxis poorly regardless of episode severity

BACKGROUND

No information exists on how the knowledge or the practice of pediatricians regarding anaphylaxis episodes vary with episode severity. The aim of this study was to assess and compare pediatrician knowledge on the management of mild and severe anaphylaxis using clinical scenarios and to determine factors that affect their decisions.

METHODS

A questionnaire consisting of eight questions on the diagnosis and management of anaphylaxis was distributed at two national congresses. A uniform answer box including possible response choices was given below each question, and respondents were asked to check the answers that they thought appropriate. The management of mild and severe anaphylaxis was examined using two clinical case scenarios involving initial treatment, monitoring, and discharge recommendations.

RESULTS

Four hundred and ten questionnaires were analyzed. The percentage of pediatricians who correctly answered all questions on the management of mild and severe anaphylaxis scenarios was 11.3% and 3.2%, respectively. Pediatricians did significantly better with initial treatment, but they were less knowledgeable with respect to observation time and discharge criteria in the mild anaphylaxis case scenario compared with the severe one (both P < 0.001). Multiple logistic regression analysis identified only working in an emergency department or intensive care unit as significantly predicting correct diagnosis of anaphylaxis among pediatricians (P = 0.01, 95% confidence interval: 0.11-0.57). No pediatrician-related factors predicted physician knowledge on the management of anaphylaxis.

CONCLUSIONS

Pediatricians have difficulty with different steps in managing mild and severe anaphylaxis. Their deficiencies in management may result in failure to prevent recurrences of mild anaphylaxis and may increase mortality in severe anaphylaxis.

When should we perform a repeat training on adrenaline auto-injector use for physician trainees?

BACKGROUND

Studies demonstrate that both doctors and patients may use adrenaline auto-injector improperly and the usage skills are improved by training. In this study, we aimed to determine the appropriate frequency of training to maintain skills for adrenaline auto-injector use.

METHODS

We invited all interns of 2011-2012 training period. At baseline, all participants were given theoretical and practical training on adrenaline auto-injector use. The participants were randomly assigned into two groups. We asked those in group 1 to demonstrate the use of adrenaline auto-injector trainer in the third month and those in group 2 in the sixth month.

RESULTS

One hundred and sixty interns were enrolled. Compared with the beginning score, demonstration of skills at all the steps and total scores did not change for the group tested in the third month (p=0.265 and p=0.888, respectively). However; for the group examined in the sixth month; the demonstration of skills for proper use of the auto-injector at all steps and the mean time to administer adrenaline decreased (p=0.018 and p<0.001, respectively). Besides, the group which was tested in the third month was better than the group which was tested in the sixth month in terms of demonstrating all steps (p=0.014), the total score (p=0.019), mean time of change to administer adrenaline (p<0.001) and presumptive self-injection into thumb (p=0.029).

CONCLUSIONS

Auto-injector usage skills of physician trainees decrease after the sixth month and are better in those who had skill reinforcement at 3 months, suggesting continued education and skill reinforcement may be useful.

Risk factors for cisplatin-induced long-term nephrotoxicity in pediatric cancer survivors

BACKGROUND

The aim of this study was to compare the nephrotoxicity risk of cisplatin (CPL) and ifosfamide (IFO) combination treatment (CT) with that of CPL alone and to evaluate the prevalence of CPL-induced long-term nephrotoxicity in pediatric cancer survivors (CS).

METHODS

A total of 33 patients with pediatric solid tumors who have been cured of their disease were included in the study. They were divided into two groups based on the type of chemotherapeutics, either CPL (n = 21) or CT (n = 12), given during cancer treatment and were evaluated for glomerular and tubular function using the Skinner grading system.

RESULTS

Nephrotoxicity was found in 15 CS (45.4%): seven (21.3%) of those had moderate, six (18.2%) had mild, and two (6.1%) had severe nephrotoxicity. Neither the rates of overall nephrotoxicity, glomerular toxicity and tubular toxicity, nor the mean overall, glomerular and tubular toxicity scores differed significantly among the CPL and CT groups (P > 0.05 for all parameters). Cumulative IFO dose and age at treatment were found to be independent risk factors for both development and severity of CPL-induced nephrotoxicity (P = 0.025 and P = 0.036 for development of nephrotoxicity; P = 0.004 and P = 0.050 for severity of nephrotoxicity, respectively).

CONCLUSIONS

Although CPL-induced long-term nephrotoxicity was found in half of the pediatric CS of solid tumors, clinically significant nephrotoxicity was detected only in a minority of them. Both higher cumulative IFO dose and younger age at treatment were found to be independent risk factors for both development and severity of CPL-induced nephrotoxicity.

Potential predictors of relapse after treatment of asthma exacerbations in children

BACKGROUND

Knowledge of factors that affect relapse will allow close monitoring of patients at risk, resulting in a decreased rate of readmission to the emergency department.

OBJECTIVE

To determine risk factors associated with relapse within 7 days after treatment of asthma exacerbations in children.

METHODS

This was a multicenter, prospective study of children with asthma attacks. Patients between the ages of 6 months and 17 years who met the criteria between June 2009 and September 2012 were considered.

RESULTS

The study included 1177 patients (775 males [65.8%]) with a mean (SD) age of 70.72 (48.24) months. Of them, 199 (16.9%) had a relapse within 1 week after being discharged from the hospital. Factors independently associated with relapse identified by a logistic regression model for the 1,177 study visits were having taken a short-acting inhaled β2-agonist within 6 hours before admission (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.728-3.426; P = .001), presence of retraction on physical examination (OR, 1.76; 95% CI, 1.123-2.774; P = .01), no prescription for high-dose inhaled steroids on release (OR, 2.02; 95% CI, 1.370-3.002; P < .001), and not being given a written instructional plan (OR, 1.55; 95% CI, 1.080-2.226; P = .02).

CONCLUSION

Whereas having taken short-acting β2-agonists within 6 hours before admission and the presence of retractions on physical examination increased the risk of relapse after treatment of the acute attack, being given high-dose inhaled steroids and a written instructional plan when being sent home reduced the risk.

Predictive factors to differentiate between allergic and nonallergic rhinitis in children

BACKGROUND

Although symptoms and signs of allergic rhinitis (AR) and nonallergic rhinitis (NAR) are similar, treatment and follow-up are different. We aimed to find predictive factors that can be used in primary health care to differentiate AR from NAR.

METHODS

We made a retrospective analysis of cases aged 6-18 years old who were diagnosed as having chronic rhinitis within a 1-year period. Skin-prick tests were done and severity of rhinitis symptoms was recorded on a visual analog scale in all patients.

RESULTS

There were 472 cases whose medical records were complete and included in the analysis. The median age was 11 (interquartile range [IQR], 5) years. AR was diagnosed in 363 patients (76.9%) and was different from NAR with respect to: median age (p = 0.042), seasonality of the symptoms (p = 0.002), persistent symptoms (p = 0.003), moderate/severe according to visual analogue scale (VAS) score (p = 0.017), conjunctivitis (p < 0.001), parental history of AR (p = 0.026), rhinorrhea (p < 0.001), sneezing (p = 0.005), mucosal pallor (p = 0.004), and response to antihistamines (p = 0.035). All parameters with a significance of p < 0.1 between AR and NAR were included in logistic regression analysis. Seasonality, sneezing, moderate/severe rhinitis, and response to antihistamines were identified as significant independent parameters to differentiate AR from NAR.

CONCLUSION

Features of rhinitis patients with seasonality, sneezing, moderate/severe rhinitis, and response to antihistamines may help in differentiation of AR from NAR at the primary care level.

Does self-monitoring by means of symptom diaries improve asthma control in children?

OBJECTIVE

Keeping symptom diaries on a regular basis may facilitate the execution of symptom-based action plans, enhance the patients' adherence to treatment program and finally allow better asthma control. We hypothesize that disease control in children who keep symptom diaries regularly would be better compared to children who do not keep symptom diaries regularly.

METHODS

Asthmatic children, aged between 6 and 17 years, who were monitored at least 2 years at our outpatient clinic and examined at least twice within the last year, were enrolled in this study. The patients were assigned to the following two groups: group I included the patients who keep symptom diaries regularly and group II included the patients who do not keep symptom diaries regularly. Asthma control parameters of patients during the last year were investigated. The number of asthma attacks require systemic corticosteroid use, the frequency of emergency department (ED) admissions and the number of attacks requiring hospitalization, forced expiratory volume in 1 s (FEV1) values and asthma control test (ACT) scores were compared.

RESULTS

89 (26.2%) of 340 patients included in the study were identified to keep a symptom diary regularly. Although age (p = 0.20) and sex (p = 0.48) did not differ significantly between the groups, regular use of anti-inflammatory drug was found to be significantly higher in group I (p < 0.001). When all of the study parameters were compared using a multivariate analysis, the number of systemic corticosteroid use, ED visits, attacks requiring hospitalization and ACT scores and FEV1 did not differ significantly between the groups (p > 0.05 in all of the parameters).

CONCLUSIONS

Keeping a symptom diary on a regular basis in asthmatic children was shown to have neither beneficial effect on the day-to-day asthma control nor a decrease in the future risk of asthma control.

Effect of epinephrine autoinjector design on unintentional injection injury

Epinephrine is an essential medication for the treatment of anaphylaxis. Factors associated with autoinjector design may have a role in its correct use. We compared a new and old epinephrine autoinjector with respect to correct autoinjector use. We invited all interns of the 2011-2012 training period in our medical school. The participants were randomly assigned into two groups. After all participants were given a three-step written and visual instruction sheet about epinephrine autoinjector use, they were asked to show its use either with the old or the new epinephrine autoinjector trainer. The old and new trainers, which were exactly identical to the original epinephrine autoinjectors except for the medication and needle, were used. The performance of each participant was assessed with a standardized scoring system. Among 220 invited interns, 180 (81.8%) were enrolled. The number of participants correctly showing the use of epinephrine autoinjectors and the mean total score did not differ significantly between the two groups (p = 0.639 and p = 0.233, respectively). Significantly fewer participants had unintentional injections in the new compared with the old epinephrine autoinjector group (p < 0.001). When all assessment steps are considered, only the rate of placing a wrong tip into the outer thigh was significantly lower in the new compared with the old epinephrine autoinjector group (p < 0.05). The new epinephrine autoinjector is more effective in unintentional injection injuries than the old one; however, it still does not fulfill the criteria of an ideal epinephrine autoinjector.

Healthcare workers` knowledge level regarding anaphylaxis and usage of epinephrine auto-injectors

BACKGROUND

Inadequate practices in diagnosis and management of anaphylaxis in parallel with an increase in its prevalence may cause serious public health problems today. This is the first study aiming to assess the theoretical knowledge of professional and non-professional healthcare workers from different lines of the healthcare service chain about anaphylaxis management, and their practice approaches for epinephrine autoinjectors (EAIs) together.

METHODS

The study included 697 participants comprising physicians, dentists, pharmacists, and school staff. In face-to-face interviews, each participant was asked to fill out the questionnaire forms prepared for assessing their demographic characteristics, experience with a case of anaphylaxis and EAI and theoretical knowledge about the diagnosis and treatment of anaphylaxis, and to demonstrate how to use EAI in practice with trainer device.

RESULTS

The rates of 391 physicians, 98 dentists, 102 pharmacists and 105 school staff of knowing the diagnosis criteria of anaphylaxis were 47.6%, 31.6%, 31.1%, 19%, and knowing the first and life-saving treatment of anaphylaxis were 87.2%, 79.6%, 47.6%, 15.2%, respectively. Predictors that affected physicians in knowing the first and life-saving treatment of anaphylaxis were having experience with EAIs [OR:5.5, (%95CI:1.330-23.351, p=0.015)] and a case of anaphylaxis [OR:2.4, (%95CI:1.442-4.020, p=0.001)], and knowing the administration route of epinephrine correctly [OR:1.9, (%95CI:1.191-3.314, p=0.008)]. 31.1% of the participants demonstrated the EAI usage correctly. The EAI usage steps with the most errors were `Place the appropriate injection tip into outer thigh/Press the trigger so it `clicks`` and `Turn the trigger to arrow direction` (60.3% and 34.9%, respectively).

CONCLUSIONS

Healthcare workers` knowledge level regarding anaphylaxis management and ability to use EAIs correctly are not adequate. That most errors were made in the same steps of EAI usage indicates that the industry should continue to strive for developing the ideal life-saving device.

Urinary tract infections in children with myelodysplasia in whom clean intermittent catheterization was administered

AIM

In this study, it was aimed to evaluate the frequency of significant bacteriuria and antibiotic resistance characteristics in children with myelodysplasia in whom clean intermittent catheterization was administered.

MATERIAL AND METHODS

The study group was composed of 71 patients with myelodysplasia who were found to have significant bacteriuria (age: 8.20±4.57 years; 39 girls) and the control groups was composed of 49 children who were diagnosed with community-acquired urinary tract infection (age: 7.94±4.17 years; 29 girls). The patient and control groups were evaluated in terms of the microorganisms grown in urinary cultures and antibiotic resistance characteristics. The study approved by the ethics committe (14/02/2012-19/E).

RESULTS

Growth of Escherichia coli (E. coli) was found with the highest rate in myelodysplasic patients. However, when compared with the control group in terms of microorganism types, an increase in the growth rates of the microorganisms excluding E. coli was observed in the patients with myelodysplasia which was close to the significance limit (p=0.055). When antibiotic resistance properties were examined, a significantly increased resistance against cotrimaxazole was found in the patient group compared to the control group (p=0.001). 84.5% of the patients were using prophylactic antibiotic including mainly co-trimoxazole. A significantly increased co-trimoxazole resistance was also found in the patients who were using prophylactic antibiotic compared to the patients who were not using prophylactic antibiotic (p=0.025). The rate of symptomatic UTI was found to be 21% in the patients with myelodysplasia and a significant increase was found in the complaints of abdominal/side pain and nausea/vomiting as well as fever in these patients compared to the patients with asymptomatic bacteriuria (p=0.029 and p=0.032, respectively).

CONCLUSION

Our results show that UTI is still a significant problem in patients with myelodysplasia. In addition, they show that use of prophylactic antibiotic may increase the frequency of development of resistance and co-trimoxazole used for this objective is not a good option..

Can exhaled nitric oxide be a surrogate marker of bronchial hyperresponsiveness to adenosine 5'-monophosphate in steroid-naive asthmatic children?

BACKGROUND

The interrelation between airway inflammation, bronchial hyperresponsiveness (BHR) and atopy remains controversial.

OBJECTIVE

The aim of this study was to document whether exhaled nitric oxide (eNO) may be used as a surrogate marker that predicts BHR to adenosine 5'-monophosphate (AMP) in steroid-naive school children with asthma.

METHODS

This study was a retrospective analysis of steroid-naive school age children with atopic and non-atopic asthma. All patients whose eNO levels had been measured and who had been challenged with both methacholine (MCH) and AMP were included. Receiver operation characteristic analysis was performed, in both the atopic and the non-atopic groups, to evaluate the ability of eNO to detect the BHR to AMP.

RESULTS

One hundred and sixteen patients, sixty-nine (59.5%) of whom had been atopic, were included in the analysis. In the atopic group, eNO values were significantly higher in patients with BHR to AMP compared to those without BHR to AMP (51.9 ± 16.9 p.p.b. vs. 33.7 ± 16.4 p.p.b.; P < 0.001), whereas in the non-atopic group, the differences were not statistically significant (29.7 ± 16.9 p.p.b. vs. 22.6 ± 8.1 p.p.b.; P = 0.152). In the atopic group, eNO levels (R(2) : 0.401; β: 0.092; 95% CI: 1.19-14.42; OR: 7.12; P = 0.008) were found to be the only independent factor for BHR to AMP, whereas none of the parameters predicted BHR to AMP in the non-atopic group. The best cut-off value of eNO that significantly predicts BHR to AMP was 33.3 p.p.b. in the atopic group (P < 0.001), whereas a significant cut-off value for eNO that predicts BHR to AMP was not determined in the non-atopic group (P = 0.142). An eNO ≤ 17.4 p.p.b. has 100% negative predictive values and 100% sensitivity and 60.47% PPV for prediction of BHR to AMP in the atopic group.

CONCLUSIONS

Exhaled NO may be used to predict BHR to AMP in atopic but not in non-atopic steroid-naïve asthmatic children.

Comparison of practical application steps of the previously used adrenaline auto injector in Turkey (EpiPen) and the currently available adrenaline auto injector (Penepin): a multi-center study

Aim

It has been shown by a great number of studies that the correct use of adrenaline auto injectors prescribed to patients with anaphylaxis is associated with the design of the auto injector, in addition to training. The aim of this study was to compare the skills of adults in using two different auto injectors prescribed to patients with anaphylaxis.

Material and Methods

Parents of patients aged between 1 and 18 years who referred to allergy outpatients were included in the study.

Results

A total of 630 volunteers from nine centers were included in the study. Four hundred fifty-seven (72.5%) of the participants were females and 235 (37.3%) were undergraduates. The rate of showing all the steps of auto injector trainers correctly by the participants was found as (60.2%) (n=379) for EpiPen and 42.9% (n=270) for Penepin (p<0.001). The most frequent mistake with both auto injector trainers was the step of "place appropriate injection tip into outer thigh/press the trigger so it clicks." When the preferences of the volunteers were asked after training and application, 527 (83.7%) chose EpiPen, stating that it was easier and simpler to use.

Conclusions

Our study showed that the correct usage rates of both adrenaline auto injectors were much lower than expected and there could be mistakes in the application of both. It could be appropriate to make improvements in the design of Penepin, which is still the only available adrenaline auto injector in Turkey, such that its application steps will be simpler and quicker.

Subclinical cardiovascular dysfunction in children and adolescents with asthma

BACKGROUND

There is close association between asthma and cardiovascular functions as both diseases share common inflammatory pathways. The current study was aimed at investigating the risk factors, associated with endothelial and cardiac functions in children with newly-diagnosed mild-persistent asthma.

METHODS

A total of 33 steroid-naive asthmatic children [median(interquartile-range); 9.1 years(7.8-13.5)] and 16 healthy controls [11.5 years(9.9-13.6)] were included. Their demographic, clinical and laboratory findings were recorded. Carotid Artery intima-media thickness (CIMT), stiffness, distensibility and strain were measured as atheroclerosis markers. Conventional and tissue Doppler imaging was performed to evaluate ventricular function.

RESULTS

The patients with asthma had higher CIMT and stiffness and lower strain and distensibility compared to controls (p < 0.001 for all). There was a significant correlation between the duration of asthmatic symptoms and subclinical-atherosclerosis as well as peripheral eosinophil count (p < 0.001, p < 0.05). The patients had lower tricuspid-annular-plane-systolic-excursion (TAPSE), ejection time, and higher isovolumetric relaxation time (IRT), isovolumetric contraction time (ICT), and left ventricle myocardial performance index (LVMPI) than the control subjects (p < 0.001 for all). A positive correlation was also observed between the duration of asthmatic-symptoms and cardiac-function parameters.

CONCLUSION

Children with mild persistent asthma had subclinical atherosclerosis and ventricular dysfunction even in the early stage of disease. Symptom duration was closely associated with both subclinical atherosclerosis and ventricular dysfunction. Myocardial performance index was abnormal in the asthmatic children when assessed by tissue Doppler Imaging even though they had normal ejection fraction in conventional echocardiography. Future prospective studies with larger sample sizes are needed to confirm these findings and to assess the possible protective effect of ICSs in the prevention of subclinical atherosclerosis.

The first experience of eosinophilic esophagitis in Turkish children

BACKGROUND/AIMS

Eosinophilic esophagitis is a rare allergic disease of the esophagus with no published data in Turkish children.

METHODS

This is an observational study of children diagnosed as eosinophilic esophagitis in our hospital between February 2009 and January 2011. We retrospectively analyzed the clinical features, allergic work-up, endoscopic and histological findings, and response to treatment.

RESULTS

We followed seven patients in this period with a histopathologic diagnosis of eosinophilic esophagitis. The mean age at diagnosis was 5.05±2.97 years (range: 1-9 years), and four of them were male. The most frequent symptom was gastroesophageal reflux disease-like symptoms (vomiting, regurgitation, and heartburn) (42.9%). Peripheral eosinophilia and high serum total IgE levels were found in four patients (57.2%). Sensitization to food (71.4%) was more frequent than that of aeroallergens (28.6%). Endoscopic findings suggestive of eosinophilic esophagitis were present in four patients (57.2%). Comorbid allergic disease was present in five patients (71.4%). All patients were treated by elimination diet (85.7%) and/or inhaled corticosteroid treatment (71.4%). The mean follow-up period was 12.4±6.1 months (range: 6-24 months). All but one patient showed complete clinical response to their treatment. No significant side effect was observed during the follow-up period.

CONCLUSIONS

Eosinophilic esophagitis is a rare gastrointestinal allergic disorder frequently comorbid with other allergic diseases and with different manifestations and response profiles to treatment modalities.

Proven Food-Induced Acute Urticaria and Predictive Factors for Definitive Diagnosis in Childhood

BACKGROUND

Urticaria can be the only sign of a food allergy or can be seen together with other signs and symptoms of a food allergy.

OBJECTIVE

To determine the demographic, etiologic, and clinical features of food-induced acute urticaria in childhood.

METHODS

Patients suspected of food-induced acute urticaria were included in this prospective cross-sectional multicenter study.

RESULTS

Two hundred twenty-nine urticaria cases were included in this study. Seventeen patients who did not meet the inclusion criteria of the study were excluded. Of the 212 included cases, 179 (84.4%) were diagnosed with definitive food-induced acute urticaria. The most common foods causing acute urticaria were cow's milk, hen's eggs, and nuts in 56.4, 35.2, and 19% of cases, respectively. The positive predictive value of a history of milk-induced acute urticaria together with a milk-specific IgE >5 kU/L for cow's milk-induced acute urticaria was 92% (95% CI: 81-96%). A history of cow's milk-induced and/or hen's egg-induced acute urticaria was consistent with a definitive diagnosis of food-induced urticaria (Chen's kappa: 0.664 and 0.627 for milk and eggs, respectively). Urticaria activity scores were higher in patients with food-induced acute urticaria (p = 0.002).

CONCLUSION

Cow's milk, hen's eggs, and nuts were the most common allergens in the etiology of childhood food-induced acute urticaria. Although the urticaria activity score provides guidance for diagnosis, an oral food challenge is often essential for the definitive diagnosis of a patient with a history of food-induced acute urticaria.

Independent predictive factors for the persistence and tolerance of cow's milk allergy

BACKGROUND

Cow's milk protein allergy (CMPA) is usually transient, with most children tolerating ingested cow's milk by 3 years of age. This study aimed to determine factors that promote or hindering the development of tolerance to CMPA.

METHODS

A logistic regression model was used to determine independent risk factors associated with tolerance and persistence of CMPA.

RESULT

A total of 178 children diagnosed with CMPA were included in the study. The patients' median age was 32 months (minimum-maximum, 14 to 144 months), and their median follow-up period was 30 months (minimum-maximum, 12 to 54 months). In the follow-up, CMPA persisted in 62 (34.8%) patients. The patients were divided into 2 groups according to patient's age. Group I was <3 years old and group II was ≥3 years old. The factors independently associated with the persistence of CMPA for group I were as follows: comorbid food allergies (p = 0.021), the presence of an immunoglobulin E (IgE)-mediated reaction (p = 0.001), and respiratory system symptoms (ie, tachypnea) (p = 0.036). The presence of gastrointestinal-related discomfort (p = 0.001) was an independent risk factor associated with the development of tolerance. The presence of comorbid food allergies (p = 0.03) was the only independent predictive factor for CMPA persistence for group II.

CONCLUSION

The prognosis in cases of CMPA, a food allergy, is good, with tolerance developing over time. The presence of IgE-mediated CMPA, respiratory-related symptoms (ie, tachypnea), and the presence of comorbid food allergies have negative effects on tolerance.

Management preferences of pediatricians in moderate and severe acute asthma

OBJECTIVE

To assess and compare management preferences of physicians for moderate and severe acute asthma based on case scenarios and to determine the factors influencing their decisions.

METHODS

A questionnaire based on the Global Initiative on Asthma (GINA) guideline and comprising eight questions on management of acute asthma was delivered to participants of two national pediatric congresses. Management of moderate and severe acute asthma cases was evaluated by two clinical case scenarios for estimation of acute attack severity, initial treatment, treatment after 1h, and discharge recommendations. A uniform answer box comprising the possible choices was provided just below the questions, and respondents were requested to tick the answers they thought was appropriate.

RESULTS

Four-hundred and eighteen questionnaires were analyzed. All questions regarding moderate and severe acute asthma case scenarios were answered accurately by 15.8% and 17.0% of physicians, respectively. The initial treatment of moderate and severe cases was known by 100.0% and 78.2% of physicians, respectively. Knowledge of the appropriate plan for treatment after 1h was low both for moderate (45.0%) and severe attacks (35.4%). Discharge recommendations were adequate in 32.5% and 70.8% of physicians for moderate and severe attacks, respectively. Multiple logistic regression analysis revealed that working at a hospital with a continuing medical education program was the only significant predictor of a correct response to all questions regarding severe attacks (p = .04; 95%CI, 1.02-3.21). No predictors were found for information on moderate attacks.

CONCLUSIONS

Pediatricians have difficulty in planning treatment after 1 hour both for moderate and severe asthma attacks. Postgraduate education programs that target physicians in hospitals without continuing medical education facilities may improve guideline adherence.