ABSTRACT
Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disease in which food antigens play a key role. Current therapeutic options are limited to long-term steroid medication and dietary elimination of multiple foods, each of which is challenging. Our objective was to compare single food elimination of cow's milk to swallowed fluticasone in pediatric EoE patients. This is a prospective, comparative effectiveness trial of newly diagnosed EoE patients (ages 2-18 years) treated with swallowed fluticasone (n = 24) or elimination of cow's milk (n = 20). The dual outcome measures of repeat esophageal biopsy (6-8 weeks) and change in Pediatric Quality of Life Inventor (PedsQL) EoE Module and Symptoms Scales were used to assess response to treatment. After 6-8 weeks of treatment, peak esophageal eosinophil counts decreased to below the threshold of 15 eosinophils/high-power field in 64% of patients treated with cow's milk elimination and 80% of patients treated with swallowed fluticasone (P = 0.4). Mean PedsQL EoE Module total scores (69 vs. 82; P < 0.005) and Total Symptoms scores (58 vs. 75; P = 0.001) showed significant improvement with cow's milk elimination. Among children treated with swallowed fluticasone, mean PedsQL EoE Module total scores (64 vs. 75; P < 0.05) and Total Symptoms scores (58 vs. 69; P < 0.01) were also significantly improved after 6-8 weeks of therapy. Removal of cow's milk from the diet is an effective single food elimination treatment for pediatric patients with EoE as assessed by statistically significant histologic and symptomatic improvement. Cow's milk elimination may be more desirable for EoE patients who do not want to take chronic, long-term steroid medications.
Subject(s)
Diet Therapy/methods , Eosinophilic Esophagitis , Esophagus/pathology , Fluticasone , Milk Hypersensitivity , Quality of Life , Adolescent , Animals , Anti-Allergic Agents/administration & dosage , Anti-Allergic Agents/adverse effects , Biopsy/methods , Child , Child, Preschool , Eosinophilic Esophagitis/diagnosis , Eosinophilic Esophagitis/etiology , Eosinophilic Esophagitis/psychology , Eosinophilic Esophagitis/therapy , Eosinophils/pathology , Female , Fluticasone/administration & dosage , Fluticasone/adverse effects , Humans , Male , Milk/adverse effects , Milk Hypersensitivity/complications , Milk Hypersensitivity/immunology , Milk Hypersensitivity/therapy , Prospective Studies , Symptom Assessment , Treatment OutcomeABSTRACT
UNLABELLED: The role of the indoor environment in asthma is of major concern because (i) the disease has become more severe; (ii) we spend>or=90% of our lives indoors and (iii) a large proportion of asthmatic children and young adults are allergic to allergens found indoors. Recent evidence that children raised in a home with animals, i.e. indoor cat or dog, are less likely to become allergic has provided a great opportunity to understand the mechanisms controlling the prevalence of allergic disease. In addition the results pose a challenge to many of the hypotheses about reasons for the increase in asthma. The evidence that children or adults who make a modified TH2 response i.e. immunoglobulin (Ig)G and IgG4 ab without IgE, are not at increased risk of asthma strongly supports the role of IgE in asthma. Equally the results may give insight into a form of tolerance that could be a target for protecting patients against allergic disease. PRACTICAL IMPLICATIONS: Evidence for the immune response to cat allergen shows that the alternative response to an allergy, TH2 response, is a controlled or modified form of the response not a Th1 response. Furthermore, avoiding cats in the home in most communities would not decrease the prevalence of sensitization to cats because there is cat allergen distributed in schools, other public buildings, and homes without a cat.
Subject(s)
Air Pollution, Indoor/adverse effects , Allergens/immunology , Asthma/etiology , Asthma/immunology , Animals , Animals, Domestic , Cats/immunology , Child , Dust , Humans , Hypersensitivity/immunology , Immunoglobulin E/immunology , Immunoglobulin G/immunology , Mites/immunology , Risk FactorsABSTRACT
Vascular compression of the airway is a significant cause of respiratory compromise in children. While the indications for surgical repair are sometimes life threatening, they can also be subtle. This retrospective study examines 45 surgical cases of tracheobronchial compromise secondary to vascular compression at a large children's hospital between July 1983 and February 1996. A total of 34 were diagnosed with innominate artery compression, ten with a double aortic arch and one with an anomalous right subclavian artery. The 45 patients, 25 male and 20 female, ranged in age from 12 days to 11 years at surgery (average 13 months). A total of 21 (47%) presented with proven or suspected episodes of cyanosis or apnea. All 45 patients had evidence of vascular compression during microlaryngoscopy and bronchoscopy. The diagnosis was confirmed by magnetic resonance imaging (MRI) in 23/45 (51%), barium swallow in 22/45 (49%) and aortogram in 3/45 (7%). There was one death. One patient had a tracheotomy before surgery and continues to require it after surgery. Complete resolution of symptoms was achieved in 39/45 (87%) with five requiring more than one operation before their symptoms resolved completely. A total of four patients experienced a recurrence of symptoms within a variable length of time after surgery. Surgical indications and treatment alternatives will be discussed.
