Some selected abstracts:

1

Arcola T, Ruuska T, Keranen J, Hyoty H, Salminen S, Isolauri E.  Rectal bleeding in infancy: clinical,     allergological, and microbiological examination.Pediatrics. 2006 Apr;117(4):e760-8.
 

Department of Paediatrics, Tampere University Hospital, Tampere, Finland. taina.arvola@uta.fi
 

OBJECTIVE: Rectal bleeding is an alarming symptom and requires additional investigation. In infants it has been explained mainly by hypersensitivity. In addition to dietary antigens, intraluminal microbial agents challenge the immature gut mucosa. Although controlled in the mature gut, these antigens may induce inflammation in the developing gastrointestinal tract. The objectives of this study were to evaluate prospectively the clinical course of rectal bleeding and evaluate the impact of cow's milk allergy and aberrant gut microbiota on the condition. Because withdrawal of cow's milk antigens from the infants' diet is used as a first treatment without evidence of its efficacy, we also aimed to asses the effect of a cow's milk-elimination diet on the duration of rectal bleeding. METHODS: The study involved 40 consecutive infants (mean age: 2.7 months) with visible rectal bleeding during a 2-year period at the Tampere University Hospital Department of Pediatrics. Most of the infants (68%) were fully breastfed. At enrollment the infants were randomly allocated to receive a cow's milk-elimination diet (n = 19) or continue their previous diet (n = 21) for 1 month. Findings of colonoscopy, fecal bacterial culture, fluorescence in situ hybridization of selected gut genera, specific detection of fecal enteroviruses, rotaviruses, and adenoviruses, fecal electron microscopy for viruses, and mucosal electron microscopy for viruses were assessed. During each visit the severity of atopic eczema, if any, was assessed according to the SCORAD method. In evaluating the extent of sensitization, serum total immunoglobulin E (IgE) and specific IgE and skin-prick tests for cow's milk, egg, and wheat were studied. Cow's milk allergy was diagnosed by elimination and provocation testing. Five patients were hospitalized; all others were treated on an outpatient basis. The follow-up visits were scheduled 1 month later and at the age of 1 year. Sixty-four healthy reference infants were selected as controls according to the following criteria: age and timing of fecal sampling being identical to within 1 month. RESULTS: Altogether, 32 (80%) infants manifested bloody stools during follow-up (mean [range]: 2.1 [1-15] per day). The mean number of days with rectal bleeding on follow-up was 6. Typically, bloody stools occurred irregularly, for which reason the mean time to the last occurrence of rectal bleeding was 24 (range: 1-85) days from admission. Atopic eczema at presentation or during follow-up was diagnosed in 38% of the infants. Increased specific IgE concentrations or a positive skin-prick test were uncommon. The growth of the infants was normal on admission and during follow-up. Colonoscopy revealed typically focal mucosal erythema and aphthous ulcerations. The mucosa appeared normal in less than half of the patients. No anorectal fissures or colonic polyps were found. Light microscopy revealed that the overall architecture of the mucosa was well maintained. Acute inflammation or postinflammatory state and focal infiltration of eosinophils in the lamina propria were the most common abnormalities. A cow's milk-elimination diet did not affect the duration of rectal bleeding. Cow's milk allergy was diagnosed in 7 (18%) patients. Virus-particle aggregates were found in the microvillus layer of the colon epithelium in 8 cases. The surface epithelium of the virus-positive colon biopsy specimens regularly showed degenerative changes in the microvillus layer and epithelial cells. Electron microscopy study of the colon biopsies disclosed virus particles (30 nm in diameter) on the surface of epithelial cells. Virus particles or RNA were present in feces in only a minority of the patients. All fecal cultures were negative for Salmonella, Shigella, and Yersinia. Campylobacter jejuni was found in the feces of 1 patient, and fecal cultures were positive for Clostridium difficile in 4 patients, Staphylococcus aureus in 8 patients, and yeast in 2 patients. Fluorescence in situ hybridization revealed that at the time of admission the total numbers of bacteria and the numbers of bifidobacteria and lactobacilli in feces were lower in the patients compared with controls. The fecal concentrations of microbes characterized in this study (Bacteroides, bifidobacteria, Clostridium, lactobacilli, and enterococci) did not differ significantly between the time of admission and the second visit in the patients or controls. At the age of 1 year, 7 patients still suffered from cow's milk allergy, 5 of whom also suffered from multiple food allergies. Atopic eczema and histopathologically confirmed inflammation of the colonic mucosa at presentation were associated with persistence of cow's milk allergy at the age of 1 year. No patients exhibited gastrointestinal complaints or visible blood in stools. CONCLUSIONS: Rectal bleeding in infants is generally a benign and self-limiting disorder. Bloody stools occurred irregularly for only a few days during the following months. As in a previous report, most infants were exclusively breastfed. In the majority of the patients the cause of the condition remains unknown. An association with viruses can be seen in some patients. The microbes that commonly lead to bloody diarrhea in older children and adults, Salmonella, Shigella, and Yersinia, were absent in the present material. The low bifidobacterial numbers in fecal samples may indicate a significant aberrance that may provide a target for probiotic intervention to normalize gut microbiota. The gut microbiota overall seemed stable, because the numbers of major groups of microbiota tested did not change significantly between the time of admission and after 1 month. Cow's milk allergy among these patients is more uncommon than previously believed. Cow's milk challenge is thus essential in infants who become symptom-free during a cow's milk-free diet to reduce the number of false-positive cow's milk-allergy diagnoses.

Devadason SG.  Recent advances in aerosol therapy for children with asthma. J Aerosol Med. 2006 Spring;19(1):61-6. Review.

School of Paediatrics and Child Health, University of Western Australia, Princess Margaret Hospital for Children, Perth, Australia. sunalene@ichr.uwa.edu.au

Inhalational drug delivery is the primary mode of asthma therapy in children and is the main focus of this article. Pressurized metered dose inhalers (pMDIs) are now the method of choice in infants and children under 5 years old, when used in combination with an appropriate valved holding chamber or spacer. Spacers are particularly important for steroid inhalation to maximize lung deposition and minimize unwanted oropharyngeal deposition. Optimal inhalation technique with a pMDI-spacer in infants is to inhale the drug by breathing tidally through the spacer. Drug delivery to the lungs using pMDIs can vary greatly, depending on the formulation used and the age of the child. Dry powder inhalers (DPIs) are driven by the peak inspiratory flow of the patient and are usually not appropriate for children under 5 or 6 years of age. Nebulizers continue to play a role in the treatment of acute asthma where high doses of bronchodilator are required, though multiple doses via pMDI spacer may suffice. Important drug delivery issues specific to children include compliance, use of mask versus mouthpiece, lower tidal volumes and inspiratory flows, determination of appropriate dosages, and minimization of adverse local and systemic effects.

Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol. 2006 Jun;6(3):220-5. Review.

Department of Allergy, Royal Children's Hospital, Parkville, Victoria, Australia. ralf.heine@rch.org.au

PURPOSE OF REVIEW: This review assesses the role of food allergy in the pathophysiology of gastroesophageal reflux disease, colic and constipation in infancy. RECENT FINDINGS: Frequent regurgitation, persistent crying and constipation are common clinical problems in infancy. A subgroup of infants with these conditions may respond to hypoallergenic diets, but only few randomized clinical trials have been conducted. Skin prick testing and food-specific antibody levels are usually not elevated in these infants, whereas atopy patch testing may diagnostic. The mechanisms by which cow's milk and other food allergens induce gastrointestinal motility disorders are not understood. Apart from cell-mediated reactions, non-immunological effects of food constituents on gastrointestinal motility and gut microbiota may be involved in the pathogenesis. In the absence of reliable diagnostic tests, dietary elimination and re-challenge are usually required to confirm food allergy. A trial of amino acid-based formula or an oligoantigenic maternal elimination diet may be indicated in infants who have failed conventional medical treatment. SUMMARY: Food allergy may contribute to gastroesophageal reflux disease, colic or constipation in infancy. Infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet. Further research is needed to define the mechanisms and clinical markers of gastrointestinal food allergy in infancy.

Hickey AJ, Lu D, Ashley ED, Stout J.  Inhaled azithromycin therapy. J Aerosol Med. 2006 Spring;19(1):54-60.

Division of Drug Delivery and Disposition, School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina 27599-7360, USA. ahickey@unc.edu

The treatment of pulmonary infectious diseases with pharmaceutical aerosols is an attractive option considering the accessibility of the lungs for topical drug delivery. Aerosols have been targeted to the lungs for the treatment of asthma with great success. Current therapies for other diseases, including Pseudomonas aeruginosa, Pneumocystis jirovecii (formerly Pneumocystis carinii), and mycobacterial infections, remain suboptimal due to the efficacy/safety profile. This may be improved by aerosol targeted pulmonary drug delivery. Azithromycin is a broad spectrum antibiotic that acts by inhibiting protein synthesis. It is associated with side effects that might be avoided by aerosol delivery to the lungs. In the present study three concentrations of azithromycin (10, 50, and 100 mg/mL) were delivered from three nebulizers (Acorn II, Updraft, and LC Plus) operated at 8 L/min. Particles size analyses were conducted by inertial impaction and laser diffraction. In addition, emitted doses were determined. A linear proportionality existed across the concentration range between nominal dose and both fine particle dose/fraction and emitted dose, with R2 > 0.999 in all cases. The mass median aerodynamic diameter increased from 1.4 to 1.9 microm between 10 and 100 mg/mL of azithromycin solution concentration for the Acorn II. The particle size distributions were not all log-normally distributed. The median particle size delivered from the devices was largest for the Updraft (2.8 microm) and smallest for the Acorn II (1.9 microm) for 100 mg/mL azithromycin solution concentrations. The efficiencies of small particle delivery (%<4.7 microm) were as follows, LC Plus = Acorn II (85%) > UpDraft (75%). However, the emitted dose from the LC Plus (55 mg/min) was higher than the Acorn II (31 mg/min) to maximize lung exposure to the aerosol, small median diameters and broad particle size distributions would be most effective. This study demonstrates that the dose delivered to the lungs will be maximized, under the current operating conditions by adopting the LC Plus, and high (100 mg/mL) azithromycin concentrations.

Shiber JR, Santana J. Dyspnea. Med Clin North Am. 2006 May;90(3):453-79. Review.

Department of Medicine, East Carolina University, Greenville, NC 27834, USA. shiberj@mail.ecu.edu

When evaluating a dyspneic patient in the office, a quick initial assessment of the airway, breathing, and circulation, while gathering a brief history and focused physical examination are necessary. Most often, an acute cardiopulmonary disorder, such as CHF, cardiac ischemia, pneumonia, asthma, or COPD exacerbation, can be identified and treated. Stable patients who improve can be sent home, but those in acute distress with unstable or impending unstable conditions need to be transferred emergently to definitive care. Because of the difficult logistics involved in attempting to work up an outpatient for new onset of SOB, some patients will need to be transferred to the nearest ED for a definitive diagnosis.

Sun HL, Kao YH, Chou MC, Lu TH, Lue KH. Differences in the prescription patterns of anti-asthmatic medications for children by pediatricians, family physicians and physicians of other specialties. J Formos Med Assoc. 2006 Apr;105(4):277-83.

Department of Pediatrics, Chung Shan Medical University Hospital, and Institute of Medicine, Taichung, Taiwan.

BACKGROUND: Prescription patterns of anti-asthma medications in children vary among doctors in different disciplines and settings, and may reflect differences in treatment outcome. The purpose of this study was to analyze the prescribing patterns of anti-asthma drugs by pediatricians, family physicians and other practitioners. METHODS: Data for a total of 225,537 anti-asthma prescriptions were collected from the National Health Insurance Research Database for the period from January 1, 2024 to March 31, 2002. These medications included inhaled and oral adrenergics, inhaled and oral corticosteroids, xanthine derivatives, and leukotriene receptor antagonists prescribed by general pediatricians, family physicians and physicians in other disciplines. RESULTS: Oral beta2-agonist was the most commonly prescribed drug used as monotherapy, with prescription rates of 70.4%, 46.9% and 58.0% by pediatricians, family physicians and other physicians, respectively. A xanthine derivative was the next most commonly prescribed monotherapy. Oral corticosteroid combined with oral beta2-agonist, followed by oral beta2-agonist combined with a xanthine derivative were the two most commonly prescribed dual-agent combined therapies by all three physician categories. The prescription rate for inhaled corticosteroid monotherapy was 7.8% by pediatricians, 5.6% by family physicians, and 8.0% by other physicians. The prescription rate for inhaled adrenergic was the highest in family physicians (14.9%), followed by the other physicians (7.2%), and was lowest in pediatricians (3.1%). CONCLUSION: Pediatricians and family physicians appeared to share similar opinions on the medical management of children with asthma in that both most commonly prescribed oral beta2-agonists and xanthine derivatives, either alone or in combination. Family physicians were least likely to prescribe an inhaled corticosteroid and most likely to prescribe an inhaled adrenergic agent.

Watanasomsiri A, Phipatanakul W. Comparison of nebulized ipratropium bromide with salbutamol vs salbutamol alone in acute asthma exacerbation in children. Ann Allergy Asthma Immunol. 2006 May;96(5):701-6.

Department of Pediatrics, Thammasat Chalerm Prakiat Hospital, Thammasat University Medical School, Pathumthani, Thailand. apassornw@yahoo.com

BACKGROUND: Despite multiple doses of beta2-agonists in the treatment of acute asthma exacerbation, significant residual airways obstruction often remains. OBJECTIVE: To determine whether the addition of inhaled ipratropium bromide to salbutamol provides improvement in lung function and clinical asthma symptoms in young children with acute asthma exacerbation. METHODS: This study was a prospective, double-blind randomized control trial of children aged 3 to 15 years who presented with an acute asthma exacerbation at the emergency department or outpatient clinic of Thammasat University Hospital, Pathumthani, Thailand, between September 2001 and February 2003. Subjects were randomized to receive 3 doses of nebulized salbutamol mixed with isotonic sodium chloride solution (control) or ipratropium bromide (treatment) every 20 minutes. Additional doses of salbutamol were given every 30 minutes as needed. Asthma outcome measures were evaluated 40, 70, 100, and 120 minutes after baseline. Primary outcomes were the differences in percent change in asthma clinical score and percent change in peak expiratory flow rate (PEFR) from baseline. Secondary outcomes included change in percent predicted PEFR. RESULTS: Of 74 children randomized and enrolled in the trial, 71 had complete data for analysis. Thirty-three children were in the control group and 38 were in the treatment group. Both the percent change in PEFR and the change in percent predicted PEFR at any time were higher in the treatment group, but these findings were not statistically significantly different. The number of subjects with at least a 100% percent predicted PEFR at any time point was greater in the treatment group. CONCLUSION: Although this study did not demonstrate a significant advantage in clinical score and PEFR, the trend toward additional effect of ipratropium bromide was consistent with previous studies.

Zwerneman K.  End-tidal carbon dioxide monitoring: a VITAL sign worth watching. Crit Care Nurs Clin North Am. 2006 Jun;18(2):217-25, xi. Review.

Neurology Service, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75228, USA. karenz@baylorhealth.edu

Capnography is the monitoring of end-tidal carbon dioxide in waveform and numeric display. For this technology to be useful, the critical care nurse must have a clear understanding of the normal capnography waveform and what the alterations in this waveform represent. The critical care nurse can use this information to plan patient care interventions with other critical care team members and to adjust care based on the patient's response. End-tidal carbon dioxide physiology, normal waveforms, abnormal waveforms, and clinical aspects of capnography monitoring are included.

Diagnosis, Diagnostics, Immunodiagnosis, Immunodiagnostics:

14651.  Al-Shawwa B, Al-Huniti N, Titus G, Abu-Hasan M. Hypercholesterolemia is a potential risk factor for asthma. J Asthma. 2006 Apr;43(3):231-3.

14652.  Canani RB, Cirillo P, Roggero P, Romano C, Malamisura B, Terrin G, Passariello A, Manguso F, Morelli L, Guarino A; Working Group on Intestinal Infections of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). Therapy with gastric acidity inhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children. Pediatrics. 2006 May;117(5):e817-20.

14653.  Christopher KL. Understanding vocal cord dysfunction: a step in the right direction with a long road ahead.Chest. 2006 Apr;129(4):842-3.

14654.  Cockcroft DW, Davis BE. Deep inhalation bronchoprotection in asthma: correlation with airway responsiveness. J Allergy Clin Immunol. 2006 Apr;117(4):951-2.

14655.  Cunha BA. The atypical pneumonias: clinical diagnosis and importance. Clin Microbiol Infect. 2006 May;12 Suppl 3:12-24. Review.

14656.  Delfino RJ. Who are the children with asthma most susceptible to air pollution? Am J Respir Crit Care Med. 2006 May 15;173(10):1054-5.

14657.  Dinakar C, Simon S. The link between the Hippocratic Oath and evidence-based medicine. Ann Allergy Asthma Immunol. 2006 Apr;96(4):511-3.

14658.  Eschenauer GA, Regal RE, DePestel DD. Antibiotic allergy.N Engl J Med. 2006 May 25;354(21):2293-4.

14659.  Flaherman V, Rutherford GW. A meta-analysis of the effect of high weight on asthma.Arch Dis Child. 2006 Apr;91(4):334-9.     Review.

14660.  Heraghty JL, Henderson AJ. Highlights in asthma 2005. Arch Dis Child.2006 May;91(5):422-5. Review. 

14661.  Kanter RK, Moran JR. Recent trends in pediatric hospitalization in New York state. J Pediatr. 2006 May;148(5):637-641.

14662.  Kraft M, Hamid Q.  Mycoplasma in severe asthma. J Allergy Clin Immunol. 2006 May;117(5):1197-8.

14663.  Kugelman A, Shaoul R, Goldsher M, Srugo I. Persistent cough and failure to thrive: a presentation of foreign body aspiration in a child with asthma. Pediatrics. 2006 May;117(5):e1057-60. 

14664.  Kuzucu A.  Parasitic diseases of the respiratory tract. Curr Opin Pulm Med. 2006 May;12(3):212-21. Review.

14665.  Kwon NH, Oh MJ, Min TH, Lee BJ, Choi DC. Causes and clinical features of subacute cough. Chest. 2006 May;129(5):1142-7.

14666.  Linday LA. Nutritional supplements and pediatric upper respiratory tract illnesses. J Allergy Clin Immunol. 2006 Apr;117(4):953-4; author reply 954.

14667.  Niggemann B, Heine RG.  Who should manage infants and young children with food induced symptoms? Arch Dis Child. 2006 May;91(5):379-82.

14668.  Putland M, Kerr D, Kelly AM. Adverse events associated with the use of intravenous epinephrine in emergency department patients presenting with severe asthma. Ann Emerg Med. 2006 Jun;47(6):559-63.

14669.  Raherison C, Abouelfath A, Le Gros V, Taytard A, Molimard M. Underdiagnosis of nocturnal symptoms in asthma in general practice. J Asthma. 2006 Apr;43(3):199-202.

14670.     Rowe BH, Camargo CA Jr. Emergency department treatment of severe acute asthma. Ann Emerg Med. 2006 Jun;47(6):564-6. 

14671.     Siddiqui AM, Bardapurkar JS, Patil VP. Oxidant and antioxidants in bronchial asthma. Indian Med Gazette 2005, 139(5), 174-7.

14672.  Weinberger M.  Exercise induced dyspnoea: if not asthma, then what? Arch Dis Child. 2006 Jun;91(6):543-4.

14673.  Yasmeen S, Romano PS, Schembri ME, Keyzer JM, Gilbert WM.  Accuracy of obstetric diagnoses and procedures in hospital discharge data. Am J Obstet Gynecol. 2006 Apr;194(4):992-1001.

Therapy:

14651.  Bisgaard H, Hermansen MN, Loland L, Halkjaer LB, Buchvald F. Intermittent inhaled corticosteroids in infants with episodic wheezing. N Engl J Med. 2006 May 11;354(19):1998-2005.

14652.  Brightling CE.  Clinical applications of induced sputum. Chest. 2006 May;129(5):1344-8. Review.

14653.  Burns SM. Ventilating patients with acute severe asthma: what do we really know? AACN Adv Crit Care. 2006 Apr-Jun;17(2):186-93. Review.

14654.  Cox G, Miller JD, McWilliams A, Fitzgerald JM, Lam S. Bronchial thermoplasty for asthma. Am J Respir Crit Care Med. 2006 May 1;173(9):965-9.

14655.  Cox LS, Linnemann DL, Nolte H, Weldon D, Finegold I, Nelson HS. Sublingual immunotherapy: a comprehensive review. J Allergy Clin Immunol. 2006 May;117(5):1021-35. 

14656.  Donohue JF, Fromer L.  Long-acting beta-agonists role in asthma management. J Fam Pract. 2006 Apr;Suppl:1-6. Review.

14657.  Glassroth J. The role of long-acting beta-agonists in the management of asthma: analysis, meta-analysis, and more analysis. Ann Intern Med. 2006 Jun 20;144(12):936-7. 

14658.  Harmanci K, Bakirtas A, Turktas I, Degim T. Oral montelukast treatment of preschool-aged children with acute asthma. Ann Allergy Asthma Immunol. 2006 May;96(5):731-5. 

14659.  Hermansen MN, Nielsen KG, Buchvald F, Jespersen JJ, Bengtsson T, Bisgaard H.  Acute relief of exercise-induced bronchoconstriction by inhaled formoterol inchildren with persistent asthma. Chest. 2006 May;129(5):1203-9. 

14660.  Heymann WR.  Intramuscular triamcinolone. J Am Acad Dermatol. 2006 May;54(5):866-7. 

14661.  Johnston SL, Blasi F, Black PN, Martin RJ, Farrell DJ, Nieman RB; TELICAST Investigators.  The effect of telithromycin in acute exacerbations of asthma. N Engl J Med. 2006 Apr 13;354(15):1589-600. 

14662.  Karagiannidis C, Hense G, Rueckert B, Mantel PY, Ichters B, Blaser K, Menz G, Schmidt-Weber CB. High-altitude climate therapy reduces local airway inflammation and modulates lymphocyte activation. Scand J Immunol. 2006 Apr;63(4):304-10. 

14663.  Koopmans JG, Lutter R, Jansen HM, van der Zee JS.  Adding salmeterol to an inhaled corticosteroid: long term effects on bronchial inflammation in asthma. Thorax. 2006 Apr;61(4):306-12.

14664.  Lipworth B. Phosphodiesterase type 4 inhibitors for asthma: a real breakthrough or just expensive theophylline? Ann Allergy Asthma Immunol. 2006 May;96(5):640-2.

14665.  Little FF. Treating acute asthma with antibiotics--not quite yet. N Engl J Med. 2006 Apr 13;354(15):1632-4.

14666.  Palmer K, Burks W.  Current developments in peanut allergy. Curr Opin Allergy Clin Immunol. 2006 Jun;6(3):202-6. Review. 

14667.  Stumpf JL, Shehab N, Patel AC. Safety of Angiotensin-converting enzyme inhibitors in patients with insect venom allergies. Ann Pharmacother. 2006 Apr;40(4):699-703

14668.  Xue CC, Li CG, Hugel HM, Story DF. Does acupuncture or Chinese herbal medicine have a role in the treatment of allergic rhinitis? Curr Opin Allergy Clin Immunol. 2006 Jun;6(3):175-9. Review. 

14669.  Yu JW, Pekeles G, Legault L, McCusker CT. Milk allergy and vitamin D deficiency rickets: a common disorder associated with an uncommon disease. Ann Allergy Asthma Immunol. 2006 Apr;96(4):615-9.