The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND: Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations. RESEARCH QUESTION: Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease? MATERIALS AND METHODS: Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses. RESULTS: 47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m2). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001). DISCUSSION AND CONCLUSION: Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated. LEVEL OF EVIDENCE: Level III.

Biological potency of German cockroach allergen extracts determined in an inner city population.

BACKGROUND: Cockroach allergy is an important cause of inner city asthma. To perform valid studies on the diagnosis and treatment of cockroach allergy, biological potencies of test extracts need to be established, and a surrogate in vitro test for biological potency should be chosen. METHODS: Sixty-two cockroach-allergic adult subjects were recruited for quantitative skin testing with three commercial German cockroach extracts. The intradermal D50 values were determined using linear interpolation, and the biologic potencies were determined from D50 data. The extracts were also analysed for relative potency, using a competition ELISA, and for specific allergen content, using a two-site ELISA. RESULTS: Estimates of each extract's D50 were analysable in 48-55 subjects, with D50s between 10.3 and 11.8. All three extracts were bioequivalent using pre-set criteria. The biological potencies of the extracts were 1738-8570 bioequivalent allergy units (BAU)/mL (geometric mean=3300), and these relative potencies were similar to those estimated by competition ELISA and specific allergen content. IgE against cockroach allergens were detected in sera from 34 subjects with analysable D50s, and 17 subjects had IgE directed against specific cockroach allergens. Although the presence of anti-Bla g 5 correlated with the subjects' skin test responses for 2/3 extracts, no single allergen was immunodominant. Antibody responses among the subjects were heterogeneous. CONCLUSIONS: Although commercial cockroach extracts are relatively low in potency, immunotherapeutic doses should be achievable. Biological potency may be estimated using D50 testing, a combination of specific allergen determinations, or by an overall potency assay such as the competition ELISA. CAPSULE SUMMARY: The biological potency of three German cockroach allergen extracts, determined in an inner city population, was 1738-8570 BAU/mL. No one allergen was immunodominant, and surrogate in vitro testing methods were examined.

Skin test reactivity to indoor allergens as a marker of asthma severity in children with asthma.

BACKGROUND: Specific IgE responses to common indoor aeroallergens in children with asthma have been found to be associated with acute asthma. OBJECTIVE: The purpose of this study was to examine the association between asthma severity and skin test reactivity to four common indoor allergens. METHODS: The charts of 139 asthmatic children, aged 5 to 18 years, seen in a pediatric allergy clinic were reviewed to obtain the results of skin tests to cat, dog, cockroach, and dust mite allergens, FEV1, anti-asthma medication requirements and demographic characteristics. Logistic regression for ordinal data was used to examine the association between skin test reactivity and asthma severity (mild, moderate or severe) as determined from FEV1 and medication usage. RESULTS: The rate of allergen sensitivities were dust mite 55%, cockroach 50%, cat 29% and dog 17%. Children with positive skin test to cat allergen were more likely to have a higher asthma severity rating than children with a negative cat allergen skin test [proportional odds ratio (OR) = 3.0, 95% confidence interval (CI) = 1.4 to 6.1, P = .003]. This association remained significant after we controlled for skin test reaction to the other three allergens and various sociodemographic factors (adjusted OR = 3.0, 95% CI = 1.3 to 7.2, P = .013). The ORs for sensitivity to dog, cockroach, and dust mite allergen did not differ significantly from one, but children who were sensitized to all four allergens had an OR of 4.8 (95% CI = 1.3 to 18, P = .019) relative to children who were not sensitized to any of the four allergens. This association also remained significant after controlling for sociodemographic variables (P = .030). CONCLUSION: Children with combined sensitivity to cat, dog, dust mite, and cockroach allergens were at increased risk of having more severe asthma. Our data also suggest that sensitization to cat allergen per se is a risk factor for more severe disease in these asthmatic children.

Assessment of the indoor environment in respiratory allergy.

Many types of allergens may be present in the indoor environment and may lead to sensitization and respiratory allergy. Common indoor allergens include dust mites, animal dander, cockroach exposure and molds. Exposure to indoor pollutants, such as tobacco smoke, wood-burning stoves or fireplaces and chemical sprays, can precipitate and exacerbate symptoms. An allergic reaction in the airways caused by natural exposure to allergens has been shown to lead to an increase in inflammatory reaction, increased airway hyperresponsiveness and increased eosinophils in bronchoalveolar lavage. Other research has demonstrated that asthma symptoms correlate with levels of domestic dust mite and cockroach exposure. In the case of dust mites, ending exposure results in symptomatic relief.

Sensitization to indoor allergens and the risk for asthma hospitalization in children.

BACKGROUND: Hospitalization for asthma continues to present a major health problem despite advances in our understanding that asthma is an inflammatory disease of the bronchi and that exposure to specific allergens can induce and worsen this inflammation. The role of sensitization to specific indoor allergens and hospitalization for acute asthma in children is unclear. OBJECTIVE: The purpose of this study was to evaluate the independent contributions of sensitization to specific indoor allergens among children with asthma to the risk of hospitalization for asthma. METHODS: The charts of 138 consecutive children with asthma, aged 5 to 18 years, seen at pediatric allergy clinics were reviewed to obtain the results of skin tests to cat, dog, cockroach, and dust mite allergens and the history of hospitalization for asthma within the year prior to the clinic visit. Logistic regression analysis was used to examine the association between indoor allergen sensitivity and other factors, and the risk of hospitalization for asthma. RESULTS: In univariate analyses, hospitalization for asthma was significantly associated with cockroach sensitivity (odds ratio [OR] = 2.2; 95% confidence interval [CI] = 1.1, 4.3); cat sensitivity (OR = 2.9; CI = 1.3, 6.4); black race (OR = 2.4; CI = 1.1, 5.1); public aid/self pay (OR = 2.3; CI 1.1, 4.9) and age, (OR [per year increase in age] = 0.8; CI = 0.7, 0.9). In a stepwise multiple logistic regression analysis, only cat sensitivity (OR = 3.8; CI = 1.5, 9.2), age (OR = 0.8; CI = 0.7, 0.9) and race (OR = 3.2; CI = 1.4, 7.5) entered into the model as significant independent predictors. CONCLUSION: Sensitivity to cat allergen may be an important determinant for asthma hospitalization in children. Sensitization to cockroach allergen per se was not found to be an independent risk factor. As observed in previous studies, younger and black children were at increased risk of hospitalization for asthma.

Cockroach allergen (Bla g 1) in school dust.

BACKGROUND: Cockroach allergen, Bla g 1, is an important indoor allergen. Although household exposure has been documented, little is known about the potential for exposure outside the home. OBJECTIVE: We investigated the settled dust concentration of Bla g 1 in 147 samples collected from classrooms, kitchens, cafeterias, and other sites in four primary schools in the city of Baltimore. METHODS: School authorities were questioned about characteristics of schools, teachers, and students, as well as cockroach control and cleaning procedures. Settled dust samples were collected with a hand-held vacuum cleaner from the floors of all classrooms, food-related areas, and other sites of the schools over a 3-week period. A sample collection in each school took 1 to 2 days. Dust samples from each room were pooled and analyzed as a single sample for Bla g 1 by using a two-site monoclonal ELISA. RESULTS: One hundred two (69%) of the 147 samples had detectable Bla g 1 and were within the range reported by other investigators in inner city homes. There was no difference between the median levels of Bla g 1 in three schools: school 1 (5.2 U/gm), school 2 (3.0 U/gm), and school 4 (2.7 U/gm); but school 3 had a significantly lower level (< 0.8 U/gm, p < 0.001). The median level from the food-related areas was significantly higher than the median classroom level (p = 0.048). School 3 had fewer students on subsidized lunch, fewer African-American students, and fewer students per teacher. Bla g 1 levels were compared in the different schools while controlling for potential confounding variables by a stepwise multiple regression analysis with a logit model for ordinal responses. On the basis of this analysis, Bla g 1 levels in schools 1, 2, and 4 differed significantly from levels in school 3 (p < 0.001 in each case). Food-related areas had significantly higher levels than classrooms (p = 0.048). Floor level, the presence of a sink, and the presence of carpeting did not have significant effects. CONCLUSIONS: We conclude that Bla g 1 is detectable at potentially significant concentrations in some inner city schools. Furthermore, the level of exposure is different between different schools and between sites within individual schools.

Sarcoidosis and common variable immunodeficiency. Report of 8 cases and review of the literature.

The true incidence of sarcoidosis in common variable immunodeficiency (CVID) is unknown. We report here 8 cases of sarcoidosis among 80 patients with CVID followed in our clinics, along with 22 well-documented cases reported in the literature. Sarcoidosis, therefore, represents an important entity to consider among patients with CVID who exhibit clinical, radiographic, laboratory, and biopsy findings compatible with sarcoidosis. Conversely, the diagnosis of CVID should be considered in patients with sarcoidosis who do not exhibit the characteristic hypergammaglobulinemia and who have a history of recurrent infections. Although many features of sarcoidosis are similar in patients with CVID to those in patients with sarcoidosis alone, there are many important differences. Patients with CVID in whom sarcoidosis develops present with hypogammaglobulinemia rather than hypergammaglobulinemia and have a higher prevalence of recurrent infections, thrombocytopenia, and splenic involvement. Steroids, in most cases, appeared helpful in reducing adenopathy and splenomegaly, improving uveitis, lowering serum alkaline phosphatase, and reversing hematologic abnormalities. The underlying pathophysiology responsible for the association of these 2 disorders in the same patient remains obscure. However, as more patients are identified, it may be possible to gain a better understanding of the immunologic defect responsible for the dual presentation of these 2 relatively uncommon diseases.

Socioeconomic status and race as risk factors for cockroach allergen exposure and sensitization in children with asthma.

BACKGROUND: The domestic cockroach has been identified as an important source of indoor aeroallergens worldwide in both temperate and tropical climates. Because cockroach populations are highest in crowded urban areas, some have suggested that the increased asthma morbidity and mortality rates in inner cities could be related in part to cockroach allergen exposure. We have examined cockroach allergen exposure in the homes of children with asthma in both urban and suburban locations and have related the rates of exposure and sensitization to socioeconomic, racial, and demographic factors. OBJECTIVE: The study was designed to determine the independent contribution of race, socioeconomic status, and place of residence to the risk of cockroach allergen exposure and sensitization in children with asthma. METHODS: Eighty-seven children with moderate to severe allergic asthma, aged 5 to 17 years, participating in a prospective trial of immunotherapy, were evaluated. Extracted dust samples from three home locations were analyzed by using two-site monoclonal immunoassays for major cockroach allergens (Bla g 1 and Bla g 2). A puncture skin test with a mixed cockroach allergen extract was performed in 81 of the 87 subjects. RESULTS: In the 87 homes evaluated, 26% of the bedroom dust samples had detectable levels of cockroach allergen. In homes with detectable bedroom cockroach allergen levels, mean Bla g 1 and Bla g 2 concentrations in urban and suburban homes were similar. Over 80% of children with bedroom Bla g 1 or Bla g 2 of 1 U/gm or greater demonstrated skin sensitivity to cockroach allergen. The rate of cockroach sensitization was directly related to the level of bedroom exposure. African-American race was the only factor that was independently associated with cockroach allergen exposure (p = 0.05). Lower socioeconomic status, age greater than 11 years, cockroach exposure, and African-American race were all independently associated with cockroach allergen sensitization on the basis of stepwise multiple linear regression analysis. CONCLUSIONS: African-American race and low socioeconomic status were both independent, significant risk factors for cockroach allergen sensitization in children with atopic asthma. Cockroach allergen is detectable throughout the house, including the critical bedroom environment.

Short-term effects of extermination and cleaning on cockroach allergen Bla g 2 in settled dust.

BACKGROUND: Although cockroach allergen is an important indoor allergen in poor urban environments, no studies on the effectiveness of measures to reduce allergen levels in indoor environments have yet been published. METHODS: As a model of home extermination, we studied cockroach allergen levels in an urban dormitory that was chronically infested with German cockroaches and that underwent semiannual extermination. Dust samples were collected from 18 bedrooms and 5 kitchens located in the dormitory and were analyzed for Bla g 2 using an immunoassay. RESULTS: We detected allergen in almost every bedroom, with median levels ranging from 3.0 U/g (units/g) in settled dust on the bed, 4.0 U/g on the carpeted floor, and 2.8 U/g in closets. In the kitchen, we found somewhat higher levels, 10.8 U/g on the floor and 2.8 U/g in floor cabinets. Repeated measures of floor dust were similar (median 4.4 and 4.0 U/g) despite weekly vacuum cleaning. In the 2 weeks before extermination, median levels were 5.2 U/g and in the 2 weeks following extermination and regular vacuuming, median levels fell to 0.95 U/g. CONCLUSIONS: We concluded that successful allergen abatement could be accomplished in cockroach infested indoor environments using routine extermination and vacuuming.

Sirenomelia accompanying exposure of the embryo to cocaine.

We have reported two cases of sirenomelia sequence associated with a history of cocaine exposure during a major part or the entire extent of the first trimester of pregnancy. The two infants were delivered during a 2 1/2-year interval in a newborn population in which prenatal cocaine exposure rose to an estimated 25%. The incidence of sirenomelia in this population was 18-fold higher than previously reported. The potential relationship between sirenomelia and cocaine exposure during the first month of pregnancy warrants further investigation.