Poor perception of airway obstruction in children with asthma.

The aims of this study were to evaluate children's perception of asthma symptoms and to determine a clinically useful method for identifying poor patient perception of airway obstruction. Three methods were used to analyze the relationships among indices of lung function and perception of breathlessness in 35 children. Approximately half the children in our sample did not perceive either airway obstruction or bronchodilation. We propose that <20% improvement in visual analog scale scores post-bronchodilation may provide a simple index for identifying patients with poor perception of airway obstruction, who may be at risk for fatal or near-fatal asthma.

Development of an instrument to assess stress levels and quality of life in children with asthma.

The purpose of this study was to develop and evaluate a new instrument, About My Asthma (AMA), to assess stressors affecting quality of life in children with asthma. The AMA is a 55-item, 4-point Likert-type scale. Concurrent validity was established by comparing the AMA with the Pediatric Asthma Quality of Life Questionnaire (PAQLQ). Increased levels of stress measured by the AMA correlated with a decreased quality of life measured by the PAQLQ. We conclude that the AMA is a valid and reliable instrument to measure the quantity and type of stressors experienced by children who have asthma.

Allergenic fungi in allergic fungal sinusitis.

BACKGROUND: Patients with allergic fungal sinusitis demonstrate skin test reactivity to many fungal extracts. Various fungi have been isolated from the characteristic allergic mucin. OBJECTIVE: This study was designed to identify allergens in allergic mucin and to compare them to those found in commercial fungal extracts. METHODS: Allergic mucin was collected during functional endoscopic sinus surgery from 11 patients meeting strict diagnostic criteria for allergic fungal sinusitis and from three allergic rhinitis patients with chronic sinusitis. A portion was solubilized in saline and centrifuged. To identify allergens, proteins in allergic mucin and fungal extracts were separated by SDS-polyacrylamide gel electrophoresis, transferred to nitrocellulose and immunostained using patient sera and enzyme-labeled anti-human IgE. RESULTS: All patient sera recognized numerous bands ranging from 18 to 90 kD. In mucin, bands were consistently found in the 35 to 50 kD range. Corresponding bands in fungal extracts were found in only 1/11 patients with allergic fungal sinusitis. Sera from 4/11 patients detected an 18-kD protein in allergic mucin, but sera from all patients with allergic fungal sinusitis recognized an 18-kD protein in commercial fungal extracts. Sera from selected patients with allergic fungal sinusitis detected human epithelial proteins in the 35 to 50 kD range. CONCLUSIONS: Fungal allergens were not detected in allergic mucin of all patients with allergic fungal sinusitis. The 18-kD allergen appears to be shared by many fungi, and may be a fungal panallergen. The source of the apparent allergens in the 3550-kD range warrants further study.

Local and systemic eosinophil activation in allergic fungal sinusitis.

BACKGROUND: In allergic fungal sinusitis diagnostic and monitoring criteria are not firmly established, and the role of eosinophils in pathogenesis is not clear. OBJECTIVE: To determine whether assessment of eosinophil activation by measurement of eosinophil cationic protein in serum or allergic mucin would be useful in distinguishing patients with allergic fungal sinusitis from patients with chronic sinusitis of other etiologies. METHODS: Thirteen patients referred for possible allergic fungal sinusitis were evaluated and given a definite allergic fungal sinusitis diagnosis if they met five of the following six criteria: (1) history and physical not suggesting another etiology, (2) sinus computed tomography consistent with allergic fungal sinusitis, (3) typical allergic mucin, (4) fungus isolated from allergic mucin, (5) presence of fungal-specific IgE, and (6) elevated total IgE. Eosinophil cationic protein, a marker of eosinophil activation, was measured in serum and allergic mucin. RESULTS: Nine patients met criteria for allergic fungal sinusitis. All patients had nasal polyps and were atopic. Eight of the patients had allergic rhinitis and three had asthma. Mean total IgE at surgery was 1,385 IU/mL. A fungus was isolated from allergic mucin of eight patients. All patients demonstrated fungal-specific IgE. Mean allergic mucin eosinophil cationic protein levels obtained at surgery were significantly higher in patients with allergic fungal sinusitis than in four patients not meeting strict diagnostic criteria, and in 16 control patients having sinus surgery for other indications. There was no significant difference in serum eosinophil cationic protein levels between the three groups. Serial allergic mucin eosinophil cationic protein levels appeared to correspond with disease activity in some allergic fungal sinusitis patients. CONCLUSIONS: Eosinophils in allergic mucin are activated. Measuring eosinophil cationic protein may be useful in diagnosis of allergic fungal sinusitis and in monitoring response to therapy.

Fungal sinusitis: an update.

OBJECTIVE: To review the classification of fungal sinusitis as well as discuss current approaches to diagnosis and management. DATA SOURCES: A MEDLINE literature search was performed using the index terms sinus infection, fungal, diagnosis, radiology, microbiology, and treatment. The search was restricted to the English language and human subjects. With one exception the references were restricted to the last 10 years. Clinical data from studies performed at our institution were also included. RESULTS: Fungal sinusitis can be divided into four primary categories: (1) acute/fulminant (invasive), (2) chronic/indolent (invasive), (3) fungus ball, and (4) allergic fungal sinusitis. Each subtype has unique immunologic, pathologic, and clinical features. Allergic fungal sinusitis is the most recently described and most common form. The treatment and prognosis of fungal sinusitis varies significantly among the four different categories. CONCLUSION: Recent advances in endoscopy and computed tomography have enhanced the understanding of fungal sinusitis; however, they remain diseases surrounded by controversy. New insights into the etiology and pathogenesis of these diseases along with advances in diagnosis and treatment will lead to improved medical therapy.

Diagnosis and management of exercise-induced asthma.

Exercise-induced asthma (EIA) affects 12% to 15% of the general population. Its symptoms include chest tightness, shortness of breath, coughing, wheezing, fatigue, and prolonged recovery times after exercise. Diagnosis depends on accurate history, physical examination, and lung function testing. Nonpharmacologic management includes modification of both activity and ambient conditions, along with rigorous patient education. Short-acting inhaled beta2 agonists are the pharmacologic treatment of choice for isolated and breakthrough EIA. Anti-inflammatory medications such as inhaled cromolyn sodium, nedocromil sodium, and corticosteroids are used to control underlying asthma as well as EIA. Other agents such as oral theophylline or long-acting beta agonists may be important but their roles aren't clearly defined.

Length of postexercise assessment in the determination of exercise-induced bronchospasm.

Exercise challenges were performed on 397 middle and high school athletes to detect unrecognized exercise-induced bronchospasm. All challenges were completed by a standard treadmill protocol and spirometry was performed prior to exercise and at 1, 10, 20, and 30 minutes after completion of the treadmill regimen. Using FEV1 as the diagnostic standard, we compared the number of students who had initial decreases of > or = 10%, > or = 15%, or > or = 20% at each of the four postexercise spirometric evaluations. FEV1 thresholds of > or = 10%, > or = 15%, and > or = 20%, when analyzed, identified 187, 125, and 90 subjects respectively with a positive response. The majority of those with a positive response were identified soon after completion of the exercise provocation; however, a larger than expected number of athletes had their initial drop in FEV1 > or = 20 minutes after cessation of exercise. This represented 9% to 14% of the total number of responders to exercise challenge. Protocols for evaluation of exercise-induced bronchospasm may need to be designed to include data points up to or beyond 30 minutes after exercise to avoid missing the late appearance of bronchospasm.

The value of screening for risk of exercise-induced asthma in high school athletes.

Exercise challenges were performed on 166 middle and high school student athletes (aged 12 to 18 years) to evaluate undiagnosed exercise-induced asthma (EIA). Seventy-three percent were male, 70% were white, and 30% were black. All students completed a questionnaire and were briefly interviewed to elicit risk factors for EIA. Resting spirometry, exercise treadmill provocation, and postexercise spirometry at 1, 10, 20, and 30 minutes were performed. Twenty-two students had reductions in FEV1 > or = 15% from baseline; 15 of these had FEV1 reductions > or = 20%. Of students considered at risk for EIA by history or baseline spirometry (N = 48, 29%) eight (17%) demonstrated EIA after exercise. Of students with no risk factors (N = 118, 71%), 14 (12%) demonstrated EIA after exercise, but would not have been identified without exercise challenge. The overall incidence of EIA was 12%, a rate that is consistent with previous studies of college and Olympic athletes. Sixty-four percent of students identified with EIA were not considered at risk by routine screening methods. History and spirometry alone may not be adequate as screening tools for EIA in adolescents.

Unrecognized exercise-induced bronchospasm in adolescent athletes.

OBJECTIVE--As part of their preparticipation physical examinations, 1241 middle and high school student athletes completed a questionnaire and were interviewed to elicit risk factors for unrecognized exercise-induced bronchospasm (EIB). Spirometry was then performed when the students were at rest. RESEARCH DESIGN--All participants completed a questionnaire, were interviewed, and underwent baseline testing to determine forced expiratory volume in 1 second (FEV1). SETTING--All testing was performed in a school setting. SELECTION PROCEDURES--Athletes known to have EIB who were receiving appropriate treatment (46 athletes [4%]) and athletes with no risk factors based on medical history and normal results of spirometry (847 athletes [68%]) were eliminated from further evaluation. Students with medical histories indicating risk of unrecognized EIB and students with abnormal results of spirometry were eligible for exercise challenge by standard treadmill protocol. MEASUREMENTS AND RESULTS--Of the 348 eligible students, 230 (66%) completed the exercise challenge. Sixty-six of the 230 students had greater than 15% reduction in FEV1, and 50 of the 66 students had greater than 20% reduction, representing a 29% occurrence of previously undiagnosed EIB in a population of students identified with screening to be at risk of unrecognized EIB. Of the 179 students identified to be at risk based on medical history only, 28% had EIB. Of 33 students with positive results of spirometry but no medical history that put them at risk, 15% had EIB. Of the 18 students with medical histories that put them at risk and positive results of spirometry, 61% had EIB. Including the subpopulation with reduction in FEV1 of greater than 15%, students shown to be at risk after screening, and students previously identified as having EIB, 145 students were identified as having EIB (12%). CONCLUSIONS--These data are in accord with results of previously reported studies of college and Olympic athletes. The data may have implications for more extensive screening in the adolescent population.