Clinical features of adult and pediatric anaphylaxis in Taiwan.

Background: Most epidemiologic studies of anaphylaxis have been on Western populations, leaving the clinical and demographic pattern of this acute allergic condition in Asia unclear. Objective: To investigate the clinical characteristics of patients with anaphylaxis in Chang Gung Memorial Hospital, the largest medical center in Taiwan. Methods: We conducted a retrospective analysis of 201 patients who visited the emergency department or were admitted to the hospital for anaphylaxis from 2000 to 2010. We analyzed the causes, clinical presentation, and management, and also compared adult and pediatric cases. Results: The average patient age was 43.3 years. Mortality from anaphylaxis was 0.5% (1/201). The annual number of cases presenting with anaphylaxis increased throughout the decade we studied. Seven types of etiology were identified: medication (53%), contrast medium (24%), idiopathic condition (8%), food (5%), blood transfusion (4%), insect sting (3%), and others (3%). Skin and respiratory presentations are more common in children than in adults (skin presentation, 81% vs. 51%, p =0.002); respiratory presentation, 74% vs. 49%, p =0.011), and cardio-vascular presentation is more frequent in adults than in children (83% vs. 61%, p =0.006). Clinical presentations with angioedema, gastro-intestinal and neurological system involvement, and management were not significantly different between adults and children. Conclusions: We conclude that anaphylaxis in Taiwan appears to be increasing, just as in the West, but shows a different clinical picture; medication rather than food was the most common cause of anaphylaxis in our population. Moreover, food-induced anaphylaxis in children is not so prevalent in Taiwan.

Prevalence and risk factors for early presentation of asthma among preschool children in Taiwan.

Background: Traditional asthma prevalence surveys were based on the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, which focuses on children aged 6-7 and 13-14. However, asthma-like symptoms usually commence in preschool aged children, in whom it is difficult to make a definite diagnosis of asthma. It is worth determining the prevalence rate of asthma or asthma-like symptoms and analyzing the risk factors for this phenomenon among preschool aged children. Materials and Methods: Children aged 3-6 years were recruited from kindergartens in Keelung City, northern Taiwan. The questionnaire used was based on the ISAAC phase III core and environmental questionnaires and included questions on asthma, rhino-conjunctivitis, and eczema, along with questions to elicit common and early presentations of asthma, as well as other demographic and environmental data. The questionnaires were delivered and completed by parents. Results: 2,395 questionnaires were delivered to parents with children at 50 kindergartens, of which 2,170 questionnaires were returned (return rate 90.6%). 9.9% of these preschool children had physician-diagnosed asthma. However, 20.4% of them experienced asthma-like symptoms while attending kindergarten. Both the physician-diagnosed asthma and asthma-like symptoms groups had more clinical symptoms in all seasons except summer, compared to children without asthma. It was significant that the asthma-like symptoms commenced after joining a kindergarten (P< 0.001), and 66.5% of the children started to experience the symptoms within one month of beginning kindergarten. Using antibiotics or antipyretics in young infancy and mothers having asthma were the risk factors for developing asthma and asthma-like symptoms (P< 0.001), but parental smoking was not contributory to asthma development in preschool children. More frequent use of antipyretics in a year had a higher risk for the development of asthma and asthma-like symptoms. Conclusions: Asthma and asthma-like symptoms were common in preschool children. Early infection of the respiratory tract and use of antibiotics were associated with presentation of symptoms. Attending a kindergarten is also a risk factor for early presentation of asthma among preschool children.

The association of seasonal variations of asthma hospitalization with air pollution among children in Taiwan.

Background: The impact of air pollution on asthma in children in different age group has not been well defined. Objective: This study aimed to evaluate the association between seasonal variations in air pollution and asthma hospitalization of children within a two-year period. Methods: Using the National Health Insurance database, seasonal variations in hospitalization trends in children with a primary diagnosis of asthma (International Classification of Disease 9th revision, code 493) for patients aged < 18 years from 2001 to 2002 were investigated. Data on the average concentration of nitrogen dioxide (NO2), carbon monoxide (CO), ozone(O3), sulphur dioxide (SO2), and particles with aerodynamic diameter < 10 μm (PM10) for each month were obtained from the Environmental Protection Department through 71 stations of air quality monitor distributed nationwide. PSI value (pollutants standard index) > 100 was considered poor air quality. Seasonal variations in asthma admissions were compared to the air pollution quality data using Spearman’s rank correlation. Results: Asthma hospitalization was not related to the number of days when the PSI was > 100 during the 24-months period (r = -0.361; p = 0.083). However, it was significantly associated with seasonal changes in the concentration of each pollutant. The most strongly related air pollutant variable was PM10 (standardized coefficients 0.384), followed by O3 (standardized coefficients 0.255) and SO2 (standardized coefficients 0.162) concentrations. The association of seasonal changes in asthma hospitalization with these pollutants was greater in pre-school and school age children. Temperature and rainfall in all seasons were not related to asthma hospitalization. None of the pollutants were associated with seasonal variations in admission rate for adolescents. Conclusion: Seasonal variations of asthma hospitalization among preschool children are associated with concentration of air pollutants.

Epidemiology and current status of asthma and associated allergic diseases in Taiwan- ARIA Asia-Pacific Workshop report.

The prevalence of allergic diseases appears to have been increasing in recent years. The hospitalization rate of asthma in children showed an increasing trend. House dust mites and cockroaches are the two most common indoor aeroallergens in Taiwan. Various kinds of inhaled corticosteroids or combination medications are available, but in clinical practice these have not been used as much as oral beta-2 agonists. Generally 68% of the physicians would follow the asthma treatment guidelines. Because of the comprehensive health care insurance system, the majority of the population in Taiwan can afford the medical expense of diseases. The country's expenditure of asthma care is around USD 83.1 millions per year which is increasing by the year as well. In clinical aspects, asthma education should still be included as part of its treatment.

Risk factors and bacterial profiles of urinary tract infections in patients with systemic lupus erythematosus.

Bacteremic urinary tract infection (UTI) is known to carry a high mortality rate, especially in immunocompromised patients. Patients with systemic lupus erythematosus (SLE) have an immunocompromised status, and thus an increased risk of infection. To evaluate the risk factors for UTI in SLE patients and to identify factors associated with bacteremic UTI, we reviewed SLE patients hospitalized for UTI over a 20-year study period. Based on our results we conclude that lupus nephritis is a risk factor for UTI in SLE patients. Clinical symptoms do not significantly distinguish bacteremic from non-bacteremic UTI in hospitalized SLE patients. Although Escherichia coli remain the most common bacteria in UTI, Salmonella spp. might need particular attention because of their high likelihood for causing bacteremia.

Prevalence and severity of symptoms of asthma, allergic rhinitis, and eczema in 10- to 15-year-old schoolchildren in central Taiwan.

The International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was distributed through 14 schools and was completed by 11,874 students out of which are parents of 4,167 children aged between 10 and 12 years old and 7,677 older children aged between 13 and 15 years in central Taiwan. The overall cumulative and 12-month prevalence of wheezing, rhinitis, and eczema were 7.4%, 43.0%, and 7.2%, respectively. It was shown that boys had significantly higher prevalence of wheezing and rhinitis (p < 0.001 and p = 0.001) when compared to girls in central Taiwan. The study also found that prevalence rates among younger children with symptoms of wheezing, rhinitis, and recurrent itchy rash in the past 12-month (8.2%, 44.4%, and 8.8%) were higher than that among older children (6.9%, 42.2%, and 6.3%, respectively). In conclusion, boys had significantly higher prevalence of wheezing and rhinitis than girls while younger children tend to have higher prevalence of the disorders than those that are older in age.

Increasing asthma care knowledge and competence of public health nurses after a national asthma education program in Taiwan.

One of the responsibilities of a public health nurse is to provide asthma education to local residents. However, there have been no comprehensive education programs for public health nurses on asthma care in the past. This study aimed to determine level of competence of public health nurses on asthma care in order to improve their capability through a one-day national asthma education course. In addition to lectures on updated asthma management information, data was obtained through demonstrations and practice on inhalation techniques of various kinds of inhaled devices, including the ability to use and interpret the data of a peak flow meter. Two written examinations with the same questions were given to participants before and right after the lectures. All of the 560 public health nurses in the 392 public health bureaus were invited to join the program and 522 (93.2%) participated. Five hundred and six completed both the pre- and post-tests. Before the national education program, only 10.9% of the participants knew the purpose of the peak flow meter, while 62.6% had never heard of it. Initially, they showed less confidence on teaching patients on the use of inhaled devices (2.36 and 2.59 in 5 scales). Comparing the two tests, there was a significant increase in the public nurses' knowledge as regards: 1) the general concept of asthma, 2) prevention of trigger factors and environmental control, 3) proper medication knowledge, 4) peak flow meter (PEF) monitoring, and 5) intervention after acute exacerbation of asthma (p < 0.001). A well-designed course on asthma management is an efficient scheme to improve public health nurses' knowledge and confidence on asthma care.

Survey of the clinical practice of physicians in the management of asthma in Taiwan.

Asthma is a common problem with a prevalence rate increasing every year. However, not all asthmatic patients receive appropriate treatment, partly due to the disease entity or patients' compliance, and partly due to physicians' knowledge and disposition in terms of treatment. This study was designed to investigate the current status of asthma treatment among clinicians in different practice settings, particularly regarding the acceptance of and adherence to asthma treatment guidelines and asthma patient education. Questionnaires were distributed by randomized sampling to doctors throughout the entire country. The questionnaire had six parts, measuring the following: 1) the use of different kinds of medication in the treatment of asthma; 2) adherence to asthma treatment guidelines; 3) the use of inhaled corticosteroids as part of management; 4) the use of peak flow meters in monitoring asthma; 5) relative efficiency in treating asthma; and 6) the use of a referral system, from general practitioners to specialists. There were 531 respondents out of 1,000 questionnaires distributed. The results revealed the following: 1) 20.2% of physicians use oral corticosteroids for maintenance therapy; 2) 31.8% of physicians do not follow asthma treatment guidelines; 3) 77.2% of physicians use inhaled corticosteroids for maintenance therapy (physicians in medical centers and regional hospitals use inhaled corticosteroids more frequently than private practitioners); 4) 51% of doctors do not use peak flow meters to monitor asthma symptoms because of prohibitive costs; 5) approximately 80% of clinicians have confidence in dealing with asthma problems; and 6) 29.2% of general practitioners do not refer patients to asthma specialists unless there is poor control or a need for further evaluation. Adherence to asthma treatment guidelines is poor, and such guidelines need to be popularized or simplified. There are still many discrepancies among doctors at different levels of hospitals. Re-education and review of asthma knowledge is necessary to keep clinical practitioners at the forefront of standard practice.

Asthmatic versus non-asthmatic spontaneous pneumomediastinum in children.

The aim of this study was to analyze the clinical spectrum and seek potential curable causes of spontaneous pneumomediastinum (SPM) in children in order to minimize respiratory morbidity. Medical records from 1986 to 2003 were retrospectively reviewed at a tertiary pediatric facility in northern Taiwan. Sixteen cases of SPM were identified. There were eleven boys and five girls (M:F = 2.2:1) and ages ranged from 2 to 17 years (average, 10 years). Cough (81%), dyspnea (75%) and chest pain (56%) were the predominant symptoms and expiratory wheezing (63%) and neck crepitus (50%) were the most common physical findings. The specific sign of Hamman's crunch was noted in only one child initially. A coughing-related Valsalva maneuver (13 patients/81%) was the most common cause of pneumomediastinum in these children. The most common underlying medical causes were asthma (8 patients/50%) and idiopathic origin (5 patients/31%). Acute gastroenteritis, foreign body aspiration and mycoplasmal pneumonia were each found in one patient respectively. All patients had subcutaneous emphysema on initial chest radiographs. Two patients were complicated by pneumothorax and required intensive respiratory therapy. The average hospital stay was 4 days (range 1-9 days). Rapid resolution of symptoms without long-term sequelae was common except for one patient who had hypoxic-ischemic encephalopathy with epilepsy after foreign body removal. We conclude that in young teenagers, who suffer from cough, dyspnea, chest pain and associated discomfort of throat or neck, the diagnosis of SPM should be considered and chest radiography including posterior-anterior and lateral projections should be performed to verify the diagnosis. Because of the high prevalence of asthma related SPM, children of idiopathic SPM should undergo diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma. Targeted investigations of the underlying causes of SPM might decrease respiratory morbidity and avoid further complications.

Juvenile ankylosing spondylitis with uveitis.

A 17-year-old boy had suffered from right ankle arthralgia when he was 13 years old. He also had bilaterally congested conjunctivas and were erythematous around his right ankle joint. A soft tissue echo showed swelling of the right ankle joint. A Ga 67 scan revealed a focal elevated uptake in the right ankle, but a bone scan was negative. Reactive arthritis was suspected due to conjunctivitis, arthritis and a previous episode of watery diarrhea. An ophthalmologic examination showed no evidence of uveitis. Laboratory data were negative for rheumatoid factor, antinuclear antibody and anti-ds DNA. Erythrocyte sedimentation rate (ESR) was 40 mm/hr and a histocompatibility test was positive for antigen B27. Based on the diagnosis of cellulitis and reactive arthritis, oxacillin and naproxen were given for 14 days. During follow-up at the OPD, bilateral arthralgia of the ankle joints was noted and a sonography showed bilateral edematous ankle joints. Juvenile ankylosing spondylitis (JAS) was suspected. Two years later, he had lower back pain and arthralgia of the knee joints with uveitis of the right eye. He was treated with naproxen and prednisolone. Because few JAS cases initially present as axial arthropathy or enthesopathy and uveitis is uncommon in children, we presented the case with a review of literature and conclusion that the possibility of JAS should be considered in young adolescent boys with arthritis of the lower limbs, enthesitis, a family history of related diseases and positive HLA-B27, as well as negative rheumatoid factor (RF) and anti-nuclear antibody (ANA) results.

Childhood idiopathic hypereosinophilic syndrome: report of a case.

We described a 15-year-old girl who presented with persistent fever, bilateral flank pain, and worsening dyspnea. The peripheral blood cell count showed remarkable eosinophilia at the time of admission. Severe pleural effusion with eosinophilic Infiltrations as well as pericardial effusion were noted thereafter. Bone marrow examination disclosed markedly increased eosinophils. Bilateral ectasia of the renal pelvis was found in an ultrasonographic study of the kidneys. Spiking fever and progressive shortness of breath persisted despite treatment with empiric antibiotics for infection. Based on the clinical course and histological findings, a tentative diagnosis of idiopathic HES was made. After treatment with oral prednisolone daily (1 mg/kg/day) for one week, there was a rapid improvement in her clinical condition. She was discharged a few days later and the steroids were withdrawn gradually when she was asymptomatic. The absolute eosinophil count (AEC) was monitored during follow-up. At 3 weeks, the AEC had fallen from 8,060/mm3 to 4,792/mm3 and it further fell to 1,591/mm3 at 5 months, and to 855/mm3 at 8 months during follow-up. There is no evidence of any other organ involvement until now. The clinical manifestations, diagnosis and management of idiopathic HES in children are also reviewed.