A comparative, volumetric survey of airborne pollen in Philadelphia, Pennsylvania (1991-1997) and Cherry Hill, New Jersey (1995-1997).

BACKGROUND: Aeroallergen sampling provides information regarding the onset, duration, and severity of the pollen season that clinicians use to guide allergen selection for skin testing and treatment. OBJECTIVE: This atmospheric survey reports: 1) airborne pollen contributors in Philadelphia, Pennsylvania (1991 to 1997) and suburban Cherry Hill, New Jersey (1995 to 1997); 2) pollen onset, duration, and peak level; and 3) the relationship between airborne pollen and selected meteorologic variables. METHODS: At both locations, separated by 11 km. sampling was performed with a volumetric Rotorod Sampler (Sampling Technologies, Minnetonka, MN). RESULTS: In Philadelphia and Cherry Hill, respectively, 3-year average measurements included 75.0 and 74.2% tree pollen, 10.2 and 8.3% grass pollen, and 14.8 and 17.5% weed pollen. Prominent airborne pollen taxa were Acer, Quercus, Betula, Pinus, Cupressaceae, Poaceae, Ambrosia, and Rumex. The tree, grass, and weed pollen seasons extended from mid-March to mid-June, late April to mid-June, and mid-August to late September, respectively. A secondary Poaceae pollen peak occurred in September. There was a statistically significant correlation between simultaneous weekly average pollen levels in Philadelphia and in Cherry Hill (Acer, r(p) = 0.987, Quercus, r(p) = 0.645, Betula, r(p) = 0.896, Pinus, r(p) = 0.732, Cupressaceae, r(p) = 0.695, Poaceae, r(p) = 0.950, Ambrosia, r(p) = 0.903, and Rumex, r(p) = 0.572, P <0.001). Daily Poaceae pollen levels were positively influenced by same-day high temperature (r(s) = 0.333 in Philadelphia and r(s) = 0.426 in Cherry Hill, P < 0.05). Daily Ambrosia pollen levels were inversely influenced by same-day total precipitation (r(s) = -0.174 in Philadelphia and r(s) = -0.257 in Cherry Hill, P < 0.05). CONCLUSIONS: This is the first volumetric survey performed in either Philadelphia or Cherry Hill. Copious amounts of airborne pollen were seen from late April to early May and in early September. Pollen onset, duration, and year-to-year variability were similar at both sites. An awareness of local aeroallergen patterns is critical in the effective testing and treatment of atopic individuals.

Comparisons of peak diurnal expiratory flow variation, postbronchodilator FEV(1) responses, and methacholine inhalation challenges in the evaluation of suspected asthma.

STUDY OBJECTIVES: The validity of peak expiratory flow variation (PEFvar) as defined by National Heart, Lung, and Blood Institute (NHLBI) guidelines as a diagnostic tool for suspected asthma or its comparative value to methacholine inhalation challenge (MIC) or postbronchodilator (BD) FEV(1) responses has not been formally assessed. We prospectively analyzed the correlation of 28 different PEFvar indexes (including 4 NHLBI-compatible indexes) with MIC and pre-BD and post-BD FEV(1) responses in suspected asthmatic subjects with normal findings on lung examination, chest radiography, and baseline spirometry. DESIGN: Participants were asked to record peak expiratory flow four times daily for 2 to 3 weeks, followed by an MIC. During a minimum 6-month follow-up period, a clinical diagnosis of asthma was made or ruled out based on testing results and response to antiasthma therapy. SETTING: Medical school-affiliated subspecialty private practice of allergy, asthma, and immunology. PARTICIPANTS: One hundred twenty-one suspected asthmatic patients with normal findings on lung examination, chest radiography, and baseline spirometry. MEASUREMENTS AND RESULTS: Fifty-seven subjects completed both the peak flow diary and the MIC and were accepted for statistical analysis. There were no statistically significant correlations between any peak expiratory flow index and MIC. Among the three diagnostic tools evaluated, MIC had the highest sensitivity (85.71%). All the PEFvar indexes and post-BD responses had low sensitivity and high false-negative rates. CONCLUSIONS: PEFvar and post-BD FEV(1) responses are poor substitutes for MIC in the assessment of patients with suspected asthma with normal findings on lung examination, chest radiography, and spirometry. Our findings warrant a reconsideration of the NHLBI guidelines recommendation of the utility of PEFvar as a diagnostic tool for asthma in clinical practice.

Dose-ranging study of a new steroid for asthma: mometasone furoate dry powder inhaler.

A new formulation of mometasone furoate (MF) for administration by dry powder inhaler (DPI) was evaluated for the treatment of asthma. A 12-week, double-blind, placebo-controlled dose-ranging study compared the efficacy and safety of three doses of MF DPI (100, 200 and 400 mcg b.i.d) with beclomethasone dipropionate (BDP) 168 mcg b.i.d. administered by metered dose inhaler in 365 adult or adolescent patients being treated with inhaled glucocorticoids. The mean change from baseline to endpoint (last treatment visit) for forced expiratory volume in 1 sec (FEV1) was the primary efficacy variable. Secondary efficacy variables included other objective measures of pulmonary function [forced vital capacity (FVC), forced expiratory flow 25-75% (FEV25-75%.) and peak expiratory flow rate (PEFR)] as well as subjective measures of therapeutic response (patients' daily evaluation of asthma symptoms and physicians' evaluation). At endpoint, all four active treatments were significantly more effective than placebo (P < 0.01) in improving FEV1 (MF DPI 5 to 7%, BDP 3%, placebo -6.6%) and all other measures of pulmonary function (FVC: MF DPI 4 to 5%, BDP 2%, placebo -4.7%; FEF25-75%: MF DPI 6 to 18%, BDP 7.5%, placebo -9.5%; PEFR (AM): MF DPI 5 to 10%, BDP 5.7%, placebo -7%). A consistent trend was observed for better improvement in patients treated with MF DPI 200 mcg b.i.d. than with MF DPI 100 mcg b.i.d., with no apparent additional benefit of MF DPI 400 mcg b.i.d. Results for the MF DPI 100 mcg b.i.d. and BDP 168 mcg b.i.d. treatment groups were similar. Patients' and physicians' subjective evaluations of symptoms found similar improvement in the MF DPI 200 and 400 mcg b.i.d. treatment groups, which were slightly better than that in the MF DPI 100 mcg b.i.d. group. Symptoms tended to worsen in the placebo group. MF DPI was well tolerated at all dose levels and the most frequently reported treatment-related adverse effects were headache, pharyngitis and oral candidiasis. No evidence of HPA-axis suppression was detected in any treatment group. In summary, all doses of MF DPI were well tolerated and significantly improved lung function and MF DPI 400 mcg (200 mcg b.i.d.) was the optimal dose in this study of patients with moderate persistent asthma.

A dose-ranging study of mometasone furoate aqueous nasal spray in children with seasonal allergic rhinitis.

BACKGROUND: The efficacy and safety of mometasone furoate aqueous nasal spray (MFNS; Nasonex) 200 microg once daily for the treatment and prophylaxis of seasonal allergic rhinitis (SAR) and treatment of perennial rhinitis have been demonstrated in adults. However, the dose response of MFNS in pediatric patients has not yet been characterized. OBJECTIVE: This study was conducted to determine the dose-response relationship of 3 different doses of MFNS in a pediatric population. METHODS: This was a multicenter, double-blind, active- and placebo-controlled study of 679 children 6 to 11 years of age with histories of SAR and documented positive skin test responses. Patients were randomized to one of the following treatment groups for 4 weeks: MFNS 25 microgram once daily, MFNS 100 microgram once daily, MFNS 200 microgram once daily, beclomethasone dipropionate 84 microgram twice daily (168 microgram/day), or placebo. Physician evaluations were performed at days 4, 8, 15, and 29, and patient evaluations were analyzed for days 1 to 15 and 16 to 29. RESULTS: The mean reduction from baseline in physician-evaluated total nasal symptom scores at day 8 (the primary efficacy variable) was significantly greater in the MFNS and beclomethasone dipropionate groups than in the placebo group (P

Effect of functional endoscopic sinus surgery on bronchial asthma outcomes.

BACKGROUND: For more than 70 years, the coexistence of asthma and paranasal rhinosinusitis has been noted in the medical literature. Causal relationships have been proposed but not proved. To date, limited evidence exists suggesting that asthma improves after surgical correction of rhinosinusitis. OBJECTIVE: To determine whether asthma control improved after first-time functional endoscopic sinus surgery (FESS). PATIENTS AND METHODS: A retrospective medical record analysis was performed on 13 patients with chronic bronchial asthma who underwent FESS for medically refractory chronic rhinosinusitis. Patients received comprehensive asthma care before and after FESS (mean, 19.3 and 33.1 months, respectively). Outcomes analyzed included pre- and post-FESS individual and group mean asthma symptom scores, medication use scores, pulmonary function test results, and emergency department visits or hospital admissions for asthma. Patient medical records were obtained from a private allergy-immunology practice affiliated with a medical school. The surgical procedure was performed at a tertiary care teaching hospital by a single ear, nose, and throat surgeon (R.L.). RESULTS: Following FESS, there was no statistically significant change in group mean asthma symptom scores, asthma medication use scores, pulmonary function test results, and the number of emergency department visits or hospital admissions. Only a few patients demonstrated statistically significant improvement after FESS in asthma symptom scores (1 patient), medication use scores (1 patient), or pulmonary function test results (2 patients). CONCLUSIONS: The data do not support the hypothesis that first-time FESS for medically refractory chronic rhinosinusitis in adult patients with chronic asthma leads to reduced postoperative asthma symptoms or asthma medication use or improved pulmonary function. Based on this limited study, a reexamination of the benefits of sinus surgery to coexisting asthma is in order.

Retrospective analyses of methacholine inhalation challenges.

We retrospectively analyzed 198 methacholine inhalation challenges (MICs) of symptomatic patients with normal results of lung examinations, spirometry, and chest radiographs. During MIC, five parameters (FEV1, FEF25-75%, FVC, sGaw, TGV) were measured. Using established changes in these parameters at < or = 8 mg/ml methacholine, there were 175 positive tests (no false positives) and 23 negative tests (15 true negatives, 5 false negatives, and 3 unavailable for follow-up). The MIC sensitivity determined by FEV1 responses was significantly lower than the sensitivity using responses in either three (FEV1, FEF25-75%, and FVC; p < 0.001) or five (FEV1, FEF25-75%, FVC, sGaw, and TGV; p < 0.001) parameter sets. Sensitivities were 60.6 percent, 91.1 percent, and 97.2 percent, respectively. All positive MICs (100 percent) were identified by examining changes in the five-parameter set vs 97.3 percent in the three-parameter set; it was a significant difference at p < 0.01. We conclude that the measurement and analysis of non-FEV1 parameters in addition to FEV1 significantly increases the sensitivity of the MIC.

Stinging insect allergy: natural history and modification with venom immunotherapy.

The natural history of stinging insect allergy and its modification by venom immunotherapy was investigated by follow-up observations of patients with histories of venom anaphylaxis and detectable venom-specific IgE. The patients were divided into three categories: (1) receiving venom immunotherapy, (2) declined venom immunotherapy, and (3) terminated venom immunotherapy. One hundred twenty-seven patients were evaluated after 6 mo to 9 yr of venom immunotherapy. Most received top venom doses of 50 micrograms of yellow jacket and/or honeybee venoms every 4 wk. There were 87 restings in 48 patients resulting in two systemic reactions, only one of which could be considered a treatment failure (1%). Fifty-six patients never received venom immunotherapy. In this group there were 40 restings in 28 patients with 14 systemic reactions (35%). In 88 patients who stopped venom immunotherapy, 61 restings in 41 patients led to 11 systemic reactions (17%). Patients with cardiovascular/or respiratory symptoms with initial sting anaphylaxis were at risk for subsequent reactions. With one exception, patients with hives and edema only as the initial reaction either had a similar or no reaction when they were restung. These results confirm the efficacy of venom immunotherapy but also suggest that there are factors other than the presence of venom-specific IgE modulating the occurrence of clinical anaphylaxis.