Sensitivity and specificity of asthma definitions and symptoms used in a survey of childhood asthma.

We compared the ability of definitions/symptoms of asthma to identify urban, elementary schoolchildren with physician-diagnosed asthma and bronchial hyperresponsiveness (BHR) post-exercise challenge. Definitions of asthma from the literature were compared, including American Thoracic Society (ATS) and British Medical Research Council (BMRC) definitions. Modified ATS had the highest sensitivity (77%), whereas BMRC had the highest specificity (99%). The most sensitive symptom was "wheeze with cold" (89%). The most specific symptoms were "medication required," and "breathing normal between attacks" (95%). Definitions and symptoms were poor predictors of BHR. Researchers can use these estimates in selecting and defining specific populations of children with asthma.

Self-reported adherence, management behavior, and barriers to care after an emergency department visit by inner city children with asthma.

OBJECTIVE: The inability to adhere to a prescribed therapeutic program for the treatment of a chronic disease may be responsible in part for continued disease activity. This problem may be more of an issue in the treatment of asthma, a common, potentially lethal chronic condition in which the lack of symptoms may be interpreted as remission. Adherence was one of the key areas of interest for the National Cooperative Inner-City Asthma Study. The focus of this study was to identify those issues reported by families that could adversely affect their adherence to an asthma care program. The identification of barriers to adherence could then form the basis of a successful intervention program. This study describes barriers to adherence, asthma management behavior, and self-reported adherence. METHODS: Patients presenting during an acute attack of asthma at an emergency department (ED) were recruited for this study. The medical record of the ED encounter was abstracted and compared with information that was obtained during a baseline interview 3 to 5 weeks later. During the baseline interview, parents were asked about health care behaviors related to adherence. RESULTS: There were 344 children 4 to 9 years of age living in inner city census tracts in the study. Four areas of adherence (medicine use, appointment-keeping, emergency actions, and asthma attack prevention) were investigated. The parental report of medications prescribed at the ED and the information on the abstracted ED report agreed 94.9% of the time for the beta-agonists, 86.8% for steroids, and 69.4% for cromolyn. Among respondents, 85.4% of parents reported that they are able to follow the ED recommendations almost all of the time; side effects of medicines were a concern for 81.1% of caretakers who were adherent and for 89.5% of caretakers who were nonadherent. Doubts regarding the usefulness of medications occurred in 34.4% of those considered adherent and 54.2% who admitted nonadherence. Medications were forgotten some of the time by 45.2% of the children, and 52.8% tried to get out of taking medicine. Appointments for follow-up care were kept by 69% of those given an appointment in the ED, by an estimated 60.0% of those who were told specifically to call for an appointment, and by an estimated 25.2% of those who were neither given an appointment nor told specifically to make one. Only one third of parents report that they were able to keep the child away from known asthma triggers nearly all of the time. Approximately half avoided allergens; however, only 37.5% reported avoidance of cigarette smoke. The use of preventive medicines occurred in 23.5%. Using a medicine and taking the child to a physician were reported as the first or second action during an acute attack of asthma by 72.1% of respondents. CONCLUSIONS: Adherence to an asthma-management program involves a number of areas: medication, appointment-keeping, prevention, and applying an emergency plan of action. Barriers to adherence may exist in one or all four of these areas, leading to ineffective control of asthma. Recommendations are made for improving the patient-physician partnership to improve adherence.

Design and methods of the National Cooperative Inner-City Asthma Study.

The National Cooperative Inner-City Asthma Study (NCICAS) was established to identify and then intervene on those factors which are related to asthma morbidity among children in the inner-city. This paper describes the design and methods of the broad-based initial Phase I epidemiologic investigation. Eight research centers enrolled 1,528 children, 4 to 9 years of age, from English- or Spanish-speaking families, all of whom resided in major metropolitan inner-city areas. The protocol included an eligibility assessment and an extensive baseline visit, during which symptom data, such as wheezing, lost sleep, changes in activities of daily living, inpatient admissions, and emergency department and clinic visits were collected. A comprehensive medical history for each child was taken and adherence to the medical regimen was assessed. Access, as well as barriers, to the medical system were addressed by a series of questions including the location, availability, and consistency of treatment for asthma attacks, follow-up care, and primary care. The psychological health of the caretaker and of the child was also measured. Asthma knowledge of the child and caretaker was determined. Sensitization to allergens was assessed by skin-prick allergen testing and exposure to cigarette smoke and the home environment were assessed by questionnaire. For more than a third of the families, in-home visits were conducted with dust sample allergen collection and documentation of the home environment, such as the presence of pets and evidence of smoking, mildew, and roaches. Urine specimens were collected to measure passive smoke exposure by cotinine assays, blood samples were drawn for banking, and children age 6 to 9 years were given spirometric lung function assessment. At 3, 6 and 9 months following the baseline assessment, telephone interviews were conducted to ask about the child's symptoms, unscheduled emergency department or clinic visits, and hospitalizations. At this time, peak flow measurements with 2-week diary symptom records were collected.

Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study.

Asthma morbidity has increased dramatically in the past decade, especially among poor and minority children in the inner cities. The National Cooperative Inner-City Asthma Study (NCICAS) is a multicenter study designed to determine factors that contribute to asthma morbidity in children in the inner cities. A total of 1,528 children with asthma, ages 4 to 9 years old, were enrolled in a broad-based epidemiologic investigation of factors which were thought to be related to asthma morbidity. Baseline assessment included morbidity, allergy evaluation, adherence and access to care, home visits, and pulmonary function. Interval assessments were conducted at 3, 6, and 9 months after the baseline evaluations. Over the one-year period, 83% of the children had no hospitalizations and 3.6% had two or more. The children averaged 3 to 3.5 days of wheeze for each of the four two-week recall periods. The pattern of skin test sensitivity differed from other populations in that positive reactions to cockroach were higher (35%) and positive reactions to house dust mite were lower (31%). Caretakers reported smoking in 39% of households of children with asthma, and cotinine/creatinine ratios exceeded 30 ng/mg in 48% of the sample. High exposure (> 40 ppb) to nitrogen dioxide was found in 24% of homes. Although the majority of children had insurance coverage, 53% of study participants found it difficult to get follow-up asthma care. The data demonstrate that symptoms are frequent but do not result in hospitalization in the majority of children. These data indicate a number of areas which are potential contributors to the asthma morbidity in this population, such as environmental factors, lack of access to care, and adherence to treatment. Interventions to reduce asthma morbidity are more likely to be successful if they address the many different asthma risks found in the inner cities.

Psychosocial characteristics of inner-city children with asthma: a description of the NCICAS psychosocial protocol. National Cooperative Inner-City Asthma Study.

Previous research has demonstrated a significant reciprocal relationship between psychosocial factors and asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated both asthma-specific and non-specific psychosocial variables, including asthma knowledge beliefs and management behavior, caregiver and child adjustment, life stress, and social support. This article presents these psychosocial characteristics in 1,528 4-9-year-old asthmatic urban children and their caretakers. Caretakers demonstrated considerable asthma knowledge, averaging 84% correct responses on the Asthma Information Quiz. However, respondents provided less than one helpful response for each hypothetical problem situation involving asthma care, and most respondents had more than one undesirable response, indicating a potentially dangerous or maladaptive action. Both adults and children reported multiple caretakers responsible for asthma management (adult report: average 3.4, including the child); in addition, children rated their responsibility for self-care significantly higher than did adults. Scores on the Child Behavior Checklist indicated increased problems compared to normative samples (57.3 vs. 50, respectively), and 35% of children met the criteria for problems of clinical severity. On the Brief Symptom Inventory, adults reported elevated levels of psychological distress (56.02 vs norm of 50); 50% of caretakers had symptoms of clinical severity. Caretakers also experienced an average of 8.13 undesirable life events in the 12 months preceding the baseline interview. These findings suggest that limited asthma problem-solving skills, multiple asthma managers, child and adult adjustment problems, and high levels of life stress are significant concerns for this group and may place the inner-city children in this study population at increased risk for problems related to adherence to asthma management regimens and for asthma morbidity.

Prevalence of possible undiagnosed asthma and associated morbidity among urban schoolchildren.

OBJECTIVE: The extent to which urban children endure the symptoms and consequences of asthma without a physician diagnosis has not been well studied. Our objective was to obtain an estimate of the prevalence of possible undiagnosed asthma in a population of urban schoolchildren. DESIGN AND METHODS: A population-based cross-sectional study was conducted in urban schoolchildren, grades 3 to 5. Undiagnosed asthma was defined as caretaker report of symptoms and/or bronchial hyperresponsiveness, defined as a 15% or greater drop in baseline forced expiratory volume in 1 second, after exercise challenge. RESULTS: A total of 230 children (61% of those eligible) participated in the study. Forty children (17.4%; 95% Confidence interval (CI) = 12.5% to 22.3%) had reports of a physician diagnosis of asthma. Of these, 33 (14.3%; (95% CI = 9.8% to 18.9%) reported wheezing in the past 12 months. Among the remaining 189 eligible children, 11 (5.8%; 95% CI = 2.5% to 9.2%) met study criteria for undiagnosed asthma based on bronchial hyperresponsiveness (BHR). Another 16 (8.5%; 95% CI = 4.5% to 12.4%) met study criteria for undiagnosed asthma through modified American Thoracic Society symptom criteria. Overall, 27 children (27/189; 14.3%) fulfilled criteria for undiagnosed asthma. Children identified as having undiagnosed asthma were compared with children who had no BHR and no symptoms and who did not report a physician diagnosis of asthma (children without asthma). Children with BHR were more likely to have a report of allergies and eczema than children without asthma, odds ratios (OR) = 8.5 (95% CI = 2.4 to 30.7) and 6.4 (95% CI = 1.1 to 38.1), respectively. Children meeting symptom criteria were more likely to have a report of allergies, OR = 6.2 (95% CI = 2.0 to 19.1), and bronchitis, OR = 6.7 (95% CI = 2.0 to 22.4), and were also more likely to report sleep disruption, OR = 7.1 (95% CI = 2.3 to 21.8) and missed physical education classes, OR = 15.0 (95% CI = 4.8 to 46.7), compared with children without asthma. CONCLUSIONS: We estimated a prevalence of 14.3% for possible undiagnosed asthma among urban schoolchildren, grades 3 to 5, through caretaker report of symptoms or BHR postexercise challenge. Children with undiagnosed asthma reported more atopic disease than children without asthma. In addition, children meeting symptom criteria for asthma reported more bronchitis, sleep disruption, and missed physical education classes than did those without asthma. These results suggest that rates of undiagnosed asthma may be high in this predominantly black school-age population.

A comparison of bronchodilator responses to albuterol delivered by ultrasonic versus jet nebulization in moderate to severe asthma.

BACKGROUND: Nebulization of beta-agonists is preferred as a mode of treatment in moderate to severe asthma. Few studies, however, have compared its use in this population using an ultrasonic versus a jet nebulizer. OBJECTIVE: The purpose of the study was to compare bronchodilator responses to albuterol between an ultrasonic and a jet nebulizer in moderate to severe asthma. METHODS: Fifteen stable, moderately to severely asthmatic patients were randomized to receive the ultrasonic or jet nebulizer for 2 weeks. They were then crossed over for an additional 2 weeks. Albuterol was the agent used. The bronchodilator response was measured at baseline, and up to four hours after treatment with each nebulizer. Daily peak flows were then done for 2 weeks. RESULTS: The maximal percentage of increase in FEV1 at 30 minutes using the ultrasonic nebulizer was 39.9 +/- 8% (P < 0.001) versus 25.1 +/- 7.6% (P = .005) using the jet nebulizer. There were no other differences between the ultrasonic and the jet nebulizer in FEV1 or FVC during the 4-hour spirometry. During the home trial, the difference in evening PEFR between the jet nebulizer (69.05 +/- 14.9 L/min) and the ultrasonic nebulizer (90.11 +/- 18.7 L/min) was significant (P = .04). CONCLUSIONS: In summary, the ultrasonic and the jet nebulizer produced comparable bronchodilator responses to albuterol in stable moderately to severely asthmatic patients.

Cutaneous granulomatous lesions in patients with ataxia-telangiectasia.

Ataxia-telangiectasia is a genetic syndrome with progressive cerebellar ataxia, oculocutaneous telangiectasias and other skin manifestations, variable immune system defects, chronic progressive sinopulmonary disease, and a high incidence of cancer. Cutaneous granulomas developed and persisted in eight patients with ataxia-telangiectasia, despite treatment with intravenously administered immune globulin, topical antibiotic therapy, and potent topical corticosteroid therapy. We were unable to identify an infectious agent; the granulomas may develop in an attempt to localize antigen in the presence of a dysfunctional immune system.

Quantitative parameters of body composition and theophylline disposition.

The BA-101 Body Composition Analyzer provides values for percent fat, percent and total body water, percent lean body weight, and the lean to fat ratio. In 16 healthy adult male subjects, the volume of distribution of theophylline was found to be strongly correlated with the lean/fat ratio (r = .767) and to the percent fat (r = (-)0.79). Knowledge of body composition, however, did not allow for a more accurate prediction of a starter dose of theophylline.

Watermelon and ragweed share allergens.

A biotin-avidin amplified ELISA was used to measure antigen-specific IgE for ragweed, representative members of the gourd family (watermelon, cantaloupe, honeydew melon, zucchini, and cucumber), and banana in the sera of 192 allergic patients, each with an IgE greater than or equal to 180 microns/ml. Sixty-three percent (120/192) of the sera contained antiragweed IgE, and of these patients, 28% to 50% contained IgE specific for any single gourd family member. In contrast, no greater than 11% of the sera positive for a given gourd or banana were negative for ragweed. Correlations between ragweed and gourd-specific IgE levels were significant (p less than 0.001), and correlation coefficients between any two gourds exceeded 0.79. In an ELISA system, the extracts of watermelon and ragweed inhibited each other in a dose-dependent manner; the resulting nonparallel inhibition curves indicate that some, but not all, of the allergens in the two extracts are cross-reactive. Isoelectric focusing of watermelon and ragweed extracts in narrow range gel (pH 4 to 6) followed by immunoblotting demonstrated six watermelon allergen bands with isoelectric points identical to those of ragweed allergens. Several remaining bands in the two extracts had differing isoelectric points, however. Six of 26 patients interviewed with watermelon-specific IgE reported developing oropharyngeal symptoms (itching and/or swelling of the lips, tongue, or throat) after ingesting at least one of the study foods, whereas only one of 25 patients interviewed without detectable watermelon-specific IgE reported similar symptoms (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Successful treatment of autoimmune hemolytic anemia in common variable immunodeficiency with high-dose intravenous gamma globulin.

A patient with common variable immunodeficiency and autoimmune hemolytic anemia was given high-dose (450 mg/kg) intravenous gamma globulin (Sandoglobulin) for five days, followed by single doses of 100 to 200 mg/kg at four-week intervals or whenever the hemoglobin level and hematocrit fell or the reticulocyte count increased. This treatment was accompanied by a stabilization of hematopoietic parameters and reversal of Coombs' positivity, which have been sustained for 34 months. The use of high-dose gamma globulin for autoimmune hemolytic anemia can eliminate the need for other therapeutic modalities that may be detrimental to an immunocompromised host.

Adsorbent and cathartic inhibition of enteral drug absorption.

The effects on absorption of drugs given by mouth of adsorbents (charcoals and resins) and cathartics (osmotic and oil) were studied in vitro and in vivo using acetaminophen (paracetamol) as a test drug. In vitro adsorption isotherms were measured at 37 degrees C in simulated gastric and gastric plus intestinal juices. Maximum binding capacity (MBC) of 16 charcoals and resins varied 30-fold, from 0.36 to 9.32 mol/kg. Dissociation constants varied directly with MBC. In vitro adsorption was little changed by addition of d-mannitol and d-sorbitol, N-acetylcysteine (NAC) or l-methionine. Acetaminophen (0.6 g/kg by orogastric tube) was given to 17 dogs protected by i.v. injections of NAC and methylene blue. One minute later, dogs were given: 1) water; 2) Norit A or Nuchar 1110 charcoal, 3 g/kg; 3) d-mannitol and d-sorbitol, 2 g/kg or castor oil, 3 ml/kg; or 4) both charcoal and either d-mannitol and d-sorbitol or castor oil. Cathartics alone decreased the area under plasma acetaminophen concentrations 15 to 30%. Charcoals alone reduced the area under plasma acetaminophen concentration 93%. Each cathartic diminished the charcoal inhibition of acetaminophen absorption. In mice given acetaminophen by orgastric tube, the acute lethality was decreased more by a new petroleum-based charcoal than by standard wood-based charcoals. Reduction of acetaminophen lethality in mice paralleled the in vitro MBC of adsorbents. Charcoals did not avidly adsorb l-methionine or NAC in vitro. Charcoal did not decrease the l-methionine or NAC protection of acetaminophen-poisoned mice. Charcoals with large MBC diminish absorption and lethality of acetaminophen taken by mouth; cathartics have little effect on acetaminophen absorption.