Effectiveness of Acute Asthma Care Among Inner-city Adults

BACKGROUND: Acute asthma often requires expensive emergency department visits and hospitalizations, especially among economically disadvantaged inner-city adults. However, few studies have examined approaches for improving acute asthma care in this population. METHODS: We conducted a cohort study involving patients who were discharged from a public hospital emergency department following acute asthma care between March 31, 1997, and August 5, 1999, to identify processes of care effective for improving peak expiratory flow rate at a 2- to 3-week follow-up. Adult patients who met the predetermined criteria for asthma, who underwent a baseline peak expiratory flow rate reading, and who did not have concurrent acute sinusitis or pneumonia were eligible (N = 448). Of the 365 patients enrolled in the study, 309 (84.7%) completed it. We used a multiple linear regression analysis adjusted for patient risk to assess the association between acute asthma care processes derived from the National Asthma Education Prevention Program guidelines (inhaled beta2-agonists, inhaled corticosteroids, systemic corticosteroids, asthma care follow-up, and patient asthma education) and percentage peak expiratory flow rate change at follow-up. RESULTS: Systemic corticosteroids had a significant effect for increasing percentage peak expiratory flow rate change at the 2- to 3-week follow-up for all asthma exacerbation severity levels (beta = 26.1; 95% confidence interval, 1.8-50.5; P =.04) and severity levels specified by the National Asthma Education Prevention Program guidelines (beta = 31.6; 95% confidence interval, 8.1-55.1; P =.01). CONCLUSION: Outpatient systemic corticosteroids were effective for improving lung function 2 to 3 weeks after acute asthma care, and their use should reduce asthma-related morbidity, especially among economically disadvantaged inner-city adults.     

Drug metabolism, danger signals, and drug-induced hypersensitivity

One of the most difficult challenges for the practicing allergist/immunologist today is that of evaluating and managing patients who present with histories of drug-induced reactions. Adverse drug reactions are heterogeneous, and a single drug can often cause a multitude of reactions. Because the mechanisms responsible for many of these reactions are not known, they can be, and often are, difficult to classify. Moreover, for those that have features consistent with immune-mediated mechanisms, our diagnostic tools remain limited, because little is known about the relevant immunogenic determinants of most drugs. Despite these challenges, management approaches must be devised for patients who present with histories of drug-induced disease. Simply telling such a patient to avoid all drugs that have been associated with previous adverse events leaves both the patient and the referring physician frustrated. The initial part of this review focuses on exciting current research that is furthering our understanding of the mechanisms responsible for drug-induced reactions. Because it will take time to translate this new information into clinical practice, the latter part of the review focuses on ways to evaluate and manage patients who present with drug-induced reactions using the tools and the knowledge that are currently available.     

Penicillin allergy: prevalence of vague history in skin test-positive patients.

OBJECTIVE: Penicillin (PCN) skin testing is a reliable tool for predicting which patients can safely receive the antibiotic. Depending on the study, 7% to 76% of patients who have a history of PCN allergy have positive PCN skin tests. Many physicians approach patients who have a vague history of PCN allergy less cautiously than they approach those who have a convincing history suggestive of an IgE-mediated reaction. We reviewed the published literature to determine how many patients who had a history of PCN allergy and who were skin test-positive had a vague history of allergy. DATA SOURCES: By cross-referencing the keywords "penicillin" and "skin test," an Ovid MEDLINE search for English language studies published from 1966 to 1998 was performed. STUDY SELECTION: Studies in which history positive/skin test-positive patients were identified, and which contained documentation of the type of previous reaction in these patients, were included in the analysis. The MEDLINE search revealed 295 English language articles, of which 27 fulfilled the inclusion criteria. Three additional studies published prior to 1966 (and therefore not available through MEDLINE) also were found, bringing the total to 30. A "convincing" history was defined to be one likely to be IgE-mediated (such as anaphylaxis, urticaria, angioedema or pruritic rash). A "vague" history was one unlikely to be IgE-mediated (such as maculopapular rash, GI symptoms, or an unknown reaction). RESULTS: Overall, 347/1063, or 33%, of history positive/skin test-positive patients had a vague PCN allergy history, with a range of 0% to 70% among the 30 studies. CONCLUSION: A large proportion of patients who have PCN-specific IgE antibodies, as determined by skin testing, have vague PCN allergy histories. These results therefore, indicate that, like patients with convincing histories, patients with vague allergic histories should undergo PCN skin testing prior to PCN administration.     

Ambulatory management of pediatric asthma

Asthma is the most common chronic inflammatory disease of childhood. While specialists should care for the most severe individuals with this disease, the bulk of pediatric asthma care rests in the hands of the primary care physician. This Article details information that should be incorporated into the evaluation and management of the pediatric asthma patient in the ambulatory setting. Through the adoption of proper assessment and monitoring techniques in conjunction with optimal treatment strategies, our pediatric asthma patients should be able to attain the quality of life that all children deserve.     

Lack of penicillin resensitization in patients with a history of penicillin allergy after receiving repeated penicillin courses

BACKGROUND: Up to 10% of the population reports an allergy to penicillin, yet more than 80% of these individuals lack penicillin-specific IgE antibodies. A negative result on a penicillin skin test is highly accurate in identifying who can safely receive the antibiotic at the time of testing. However, its negative predictive value for future courses is unknown because it is uncertain whether patients with a history of penicillin allergy are at risk of becoming resensitized. OBJECTIVE: To determine the rate of penicillin resensitization in adult patients with a history of penicillin allergy after they are challenged with repeated courses of oral penicillin. METHODS: Adult patients with a history of penicillin allergy consistent with an IgE-mediated mechanism were recruited and underwent penicillin skin testing. Those with negative skin test results were challenged with 3 successive 10-day courses of penicillin V potassium (250 mg by mouth 3 times a day), providing their penicillin skin test results remained negative prior to each course. Patients with positive skin test results were not challenged. RESULTS: Of 53 patients with initially negative skin test results, 46 completed the protocol, and each tolerated all 3 courses of penicillin with negative skin test results throughout. No patients had a converted skin test result from negative to a positive, yielding a resensitization rate of 0% (upper 95% confidence interval, 2.1%). CONCLUSIONS: Adult patients with a history of penicillin allergy are not at increased risk of resensitization after receiving 3 courses of oral penicillin. Because a negative penicillin skin test result is predictive for subsequent oral administrations beyond the time of testing, adult patients with a history of penicillin allergy can be skin tested electively, which may avoid unnecessary treatment with alternate broad-spectrum antibiotics.     

Clinical approach to penicillin-allergic patients: a survey.

BACKGROUND: Approximately 10% of individuals report a history of penicillin allergy. OBJECTIVE: We chose to survey various physician groups to determine how they would manage penicillin-allergic patients who present with an infectious process for which penicillin is the drug of choice. METHODS: In situations where penicillin was the drug of choice, physicians were asked to choose the type of antibiotic treatment for patients who presented with diseases of varying severity and who had either vague or convincing penicillin-allergic histories. RESULTS: A total of 601 surveys were mailed and 93 (16%) were returned. For those patients who present with a vague history of penicillin allergy, 58% and 59% of the physicians surveyed stated that they would choose cephalosporins for individuals with mild and moderate diseases, respectively. In contrast, in the vague penicillin history/severe disease scenario, physicians were split between choosing cephalosporins (42% of responders) and vancomycin (40% of responders). For those patients who present with a convincing history of penicillin allergy, 55% of the physicians chose erythromycin for individuals with mild disease; 44% chose quinolones for individuals with moderate disease, and 63% chose vancomycin for individuals with severe disease. In each of the three disease severities, physicians were significantly more likely to choose cephalosporins for patients with a vague history of penicillin allergy than for patients with a convincing history (each P<10-5). CONCLUSION: The choice of antibiotics is influenced both by the type of penicillin allergic history and by the severity of the disease process to be treated. To decrease the use of broad-spectrum antibiotics in patients labeled "penicillin-allergic", an effort should be made to identify, by skin testing, those patients who lack penicillin-specific IgE antibodies.     

Serum IgG Profiling of Toddlers Reveals a Subgroup with Elevated Seropositive Antibodies to Viruses Correlating with Increased Vaccine and Autoantigen Responses

Purpose

The human antibody repertoire forms in response to infections, the microbiome, vaccinations, and environmental exposures. The specificity of such antibody responses was compared among a cohort of toddlers to identify differences between seropositive versus seronegative responses.

Methods

An assessment of the serum IgM and IgG antibody reactivities in 197 toddlers of 1- and 2-years of age was performed with a microfluidic array containing 110 distinct antigens. Longitudinal profiling was done from years 1 to 2. Seropositivity to RNA and DNA viruses; bacteria; live attenuated, inactive, and subunit vaccines; and autoantigens was compared. A stratification was developed based on quantitative variations in the IgG responses. Clinical presentations and previously known genetic risk alleles for various immune system conditions were investigated in relation to IgG responses.

Results

IgG reactivities stratified toddlers into low, moderate, and high responder groups. The high group (17%) had elevated IgG responses to multiple RNA and DNA viruses (e.g., respiratory syncytial virus, Epstein-Barr virus, adenovirus, Coxsackievirus) and this correlated with increased responses to live attenuated viral vaccines and certain autoantigens. This high group was more likely to be associated with gestational diabetes and an older age. Genetic analyses identified polymorphisms in the IL2RB, TNFSF4, and INS genes in two high responder individuals that were associated with their elevated cytokine levels and clinical history of eczema and asthma.

Conclusion

Serum IgG profiling of toddlers reveals correlations between the magnitude of the antibody responses towards viruses, live attenuated vaccines, and certain autoantigens. A low responder group had much weaker responses overall, including against vaccines. The serum antibody screen also identifies individuals with IgG responses to less common infections (West Nile virus, parvovirus, tuberculosis). The characterization of the antibody responses in combination with the identification of genetic risk alleles provides an opportunity to identify children with increased risk of clinical disease.