Prevalence of sensitization to aeroallergens in California patients with respiratory allergy. Allergy Skin Test Project Team.

BACKGROUND: The number of allergy skin tests required to evaluate patients with respiratory allergy has recently been challenged by the managed care community. OBJECTIVES: The purpose of this study was to determine which aeroallergens are prevalent in patients with respiratory allergy (allergic rhinitis and bronchial asthma) in California. METHODS: Utilizing aeroallergens thought to be relevant from recent aerobiologic and botanic data, 141 allergic and 17 asymptomatic control subjects were tested for the prevalence of 103 allergens. A standardized prick puncture technique and standardized interpretation of wheal/flare responses were utilized using the same lot of allergen for 13 allergy practices distributed throughout California. Frequency curves based on prevalence were established to determine the number of tests required to give up to 90% of positive responses for tree, weed and grass pollen, mold spores, and miscellaneous allergens which included house dust mite, cat, dog, and cockroach allergens. RESULTS: Positive responses in allergic subjects for grasses ranged from 46% to 54%, for weeds 19% to 37%, and for trees 10% to 42%. For molds the range was from 11% to 22%. The response rate for Dermatophagoides pteronyssinus was 53%, for Dermatophagoides farinae 42%, for cat pelt 39% and cat hair 37%, for cockroach 23% and dog dander 19%. Asymptomatic control subjects responded to only 4% of all allergens tested. Ninety percent of all positive tests required three miscellaneous allergens (house dust mite, cat, and cockroach), 9 molds, 2 grasses, 16 weeds, and 27 trees for a total of 57 allergens (56% of total tested). There was no clear relationship between locale and specific allergen response, probably related to the limited number of subjects tested and variability within the same geographic region. Several seldom tested tree and weed allergens showed a higher prevalence rate than several commonly tested for allergens. CONCLUSIONS: This preliminary study suggests that approximately 57 aeroalleroens might be adequate to detect 90% of all positive responses in patients with respiratory allergy in California. This study was limited by subject number and variability between study sites. It is hoped a standardized model can be developed from this pilot study to definitively determine which aeroallergens are relevant in the United States.

Salmeterol improves quality of life in patients with asthma requiring inhaled corticosteroids. Salmeterol Quality of Life Study Group.

BACKGROUND: Traditional clinical outcomes have demonstrated that salmeterol improves pulmonary function and reduces asthma symptoms. However, they do not evaluate how patients perceive the effect of therapeutic intervention on day-to-day functioning and well-being. OBJECTIVE: We sought to evaluate the impact of salmeterol on disease-specific quality of life with the Asthma Quality-of-Life Questionnaire, as well as the efficacy and safety of salmeterol in patients with stable asthma who were symptomatic despite daily use of inhaled corticosteroids. METHODS: This was a randomized, double-blind, placebo-controlled, parallel-group study of 506 patients. Patients were treated with 42 microg salmeterol or placebo twice daily for 12 weeks delivered through a metered dose inhaler. RESULTS: Mean change from baseline in asthma quality-of-life scores was significantly greater (p < or = 0.006) after 12 weeks of treatment with salmeterol compared with placebo ("as-needed" albuterol) in global scores (1.08 vs 0.61) and individual domains (activity limitations, 0.91 vs 0.54; asthma symptoms, 1.28 vs 0.71; emotional function, 1.17 vs 0.65; and environmental exposure, 0.84 vs 0.47). Patients treated with salmeterol experienced significantly greater improvements from baseline to week 12 compared with placebo in FEV1 (0.42 L vs 0.15 L, p < 0.001), morning peak expiratory flow (47 L/min vs 14 L/min, p < 0.001), evening peak expiratory flow (29 L/min vs 11 L/min, p < 0.001), and asthma symptom scores (daytime scores reduced by 0.55 vs 0.30, p < 0.001). Patients treated with salmeterol used significantly less supplemental albuterol (reduced by 3 puffs/day vs 1 puff/day, p < 0.001). CONCLUSION: Salmeterol provided significantly greater improvement in quality-of-life outcomes in patients whose asthma symptoms are not well controlled with inhaled corticosteroids. These results demonstrate that the benefits of salmeterol are not limited to conventional clinical measures of efficacy.

Diagnosis and treatment of rhinitis during pregnancy and lactation.

Many women develop rhinitis during pregnancy. However, to call this "rhinitis of pregnancy" may be misleading. Many of these women who seem to have "developed" rhinitis during pregnancy turn out, on careful questioning, to have had similar preexisting symptoms. Furthermore, these women and those who truly appear to have developed their symptoms for the first time during pregnancy are often found to have common causes for their rhinitis. Certain factors have been cited to account for the frequent appearance (or reappearance) of rhinitis during pregnancy (Table 1). Nasal vascular pooling from the increased circulating blood volume and possibly from progesterone induced vascular smooth muscle relaxation will enhance nasal stuffiness. Stress associated with even a normal pregnancy may have a similar effect. Hormonally induced increased nasal mucous gland activity also has been suggested. The peak age of onset of classical inhalant allergic disease falls within the child bearing time of life, and hence could be coincidental with a pregnancy. Even routine episodes of bacterial rhinosinusitis are increased up to 6-fold during pregnancy. This report will review the clinical approach to rhinitis in the pregnant patient with reference to pathophysiology, differential diagnosis, and treatment during this complex time in a woman's life.

The pathophysiology and treatment of sinusitis.

When faced with the diagnosis of sinusitis, the physician should carefully review the clinical setting from which the condition arose, its potential origins, as well as initiate management. In most instances, medical management will suffice for acute and subacute disease although some surgical intervention is occasionally helpful. If nasal polyps are present with radiographic evidence of sinus obstruction, standard medical treatment is initiated with the addition of systemic corticosteroids once the suppurative component is controlled. A lack of response in each of these circumstances is evaluated on an ongoing basis. If successful treatment is seen clinically, repeat radiographs with those views which best reveal the sinus involved are obtained in approximately 6 weeks to hopefully demonstrate normality. Persistent radiographic abnormalities can then be either treated surgically or, if clinical judgement dictates, further medical management can be pursued. However, in the chronic phase of sinusitis or after the patient has been followed with persistent abnormalities for over three months, irreversibly diseased mucosa is generally present and surgical intervention is commonly indicated. We would like to emphasize that during the course of treatment, frequently consider the origin of the sinusitis. Commonly it is infectious (e. g. viral) and no further investigation is necessary. However, anatomic abnormalities or systemic disease may be present whose correction can prevent the recurrence of acute sinusitis or, more importantly, the evolution into chronic irreversible sinus disease.

Intranasal flunisolide in the treatment of perennial rhinitis: Correlation with immunologic parameters.

The effectiveness and safety of 200 micrograms/day of intranasal flunisolide in the treatment of perennial rhinitis was studied in 56 patients in a 6 wk double-blind parallel vehicle controlled clinical trial. In addition, patients failing to respond to placebo were entered into a 6 wk open trial with the active drug. Forty-six percent of the flunisolide-treated patients achieved total or substantial control of their nasal symptoms compared to 11% of the placebo-treated group in the double-blind study (p = 0.031). Eighty percent of patients achieved total or substantial control of their nasal symptoms in the 6 wk open study. No adverse effects attributable to flunisolide were observed. Parameters of IgE-mediated reactivity, including immediate-type skin test reactivity, total serum and nasal secretion IgE, specific serum and nasal secretion IgE, and nasal eosinophilia, were also assessed in these patients. Although benefit from flunisolide significantly correlated with all of these parameters except specific serum IgE, the absence of these findings did not preclude significant benefit from the drug. This study demonstrates the efficacy and safety of intranasal flunisolide in the treatment of perennial rhinitis, especially but not exclusively in those patients with evidence of IgE-mediated reactivity.

Administration of local anesthetics to patients with a history of prior adverse reaction.

The clinical histories of 71 patients evaluated for suspected local anesthetic (LA) allergy were reviewed retrospectively. The clinical histories were classified into (1) immediate generalized reactions (15%), (2) localized swelling at the injection site (25%), (3) nonspecific systemic symptoms (42%), and (4) other histories (17%). Serial dilutional intradermal skin tests were performed with mepivacaine, lidocaine, and procaine in 59 patients. There were 5 skin test--positive patients found, and each had a positive reaction to an LA to which, by history, they had not reacted. In 50 patients, when an LA was subsequently required, a subcutaneous challenge was performed with an LA chosen for chemical nonsimilarity. No significant reactions were observed in this group. Three patients tolerated a challenge with an LA to which they were skin test--positive. These data indicate (1) the low incidence of reactions compatible with a systemic IgE-mediated mechanism by history in patients referred for evaluation of LA allergy, (2) the lack of specific and clinically relevant information provided by dilutional skin tests, and (3) the apparent safety and usefulness of careful challenge with an alternative LA.

Cryoprecipitates and immune complexes: differentiation between cold insoluble immune complexes and nonspecific cryoprecipitates.

Cold insoluble circulating immune complexes occurred in 77% of rabbits immunized with 125I BSA. 9.8% of the total cryoprotein was 125I BSA. This represented 43% of the serum antigen. Tripling the antigen concentration in vitro decreased the amount of cold insoluble antigen by as much as 83%. In nonspecific cryoprecipitates only 0.4% of the total cryoprotein was 125I BSA. This represented only 0.028% of the serum antigen. Tripling of the antigen concentration in vitro increased the amount of cold insoluble antigen. Cold insoluble circulating immune complexes occur at a critical antigen-antibody ratio and can be differentiated from nonspecific cryoprecipitates.