Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children.

BACKGROUND: People with asthma may experience exacerbations or "attacks" during which their symptoms worsen and additional treatment is required. Written action plans may advocate doubling the dose of inhaled steroids in the early stages of an asthma exacerbation to reduce the severity of the attack and to prevent the need for oral steroids or hospital admission. OBJECTIVES: To compare the clinical effectiveness and safety of increased versus stable doses of inhaled corticosteroids (ICS) as part of a patient-initiated action plan for home management of exacerbations in children and adults with persistent asthma. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, which is derived from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to March 2016. We handsearched respiratory journals and meeting abstracts. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared increased versus stable doses of ICS for home management of asthma exacerbations. We included studies of children or adults with persistent asthma who were receiving daily maintenance ICS. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information. MAIN RESULTS: This review update added three new studies including 419 participants to the review. In total, we identified eight RCTs, most of which were at low risk of bias, involving 1669 participants with mild to moderate asthma. We included three paediatric (n = 422) and five adult (n = 1247) studies; six were parallel-group trials and two had a cross-over design. All but one study followed participants for six months to one year. Allowed maintenance doses of ICS varied in adult and paediatric studies, as did use of concomitant medications and doses of ICS initiated during exacerbations. Investigators gave participants a study inhaler containing additional ICS or placebo to be started as part of an action plan for treatment of exacerbations.The odds of treatment failure, defined as the need for oral corticosteroids, were not significantly reduced among those randomised to increased ICS compared with those taking their usual stable maintenance dose (odds ratio (OR) 0.89, 95% confidence interval (CI) 0.68 to 1.18; participants = 1520; studies = 7). When we analysed only people who actually took their study inhaler for an exacerbation, we found much variation between study results but the evidence did not show a significant benefit of increasing ICS dose (OR 0.84, 95% CI 0.54 to 1.30; participants = 766; studies = 7). The odds of having an unscheduled physician visit (OR 0.96, 95% CI 0.66 to 1.41; participants = 931; studies = 3) or acute visit (Peto OR 0.98, 95% CI 0.24 to 3.98; participants = 450; studies = 3) were not significantly reduced by an increased versus stable dose of ICS, and evidence was insufficient to permit assessment of impact on the duration of exacerbation; our ability to draw conclusions from these outcomes was limited by the number of studies reporting these events and by the number of events included in the analyses. The odds of serious events (OR 1.69, 95% CI 0.77 to 3.71; participants = 394; studies = 2) and non-serious events, such as oral irritation, headaches and changes in appetite (OR 2.15, 95% CI 0.68 to 6.73; participants = 142; studies = 2), were neither increased nor decreased significantly by increased versus stable doses of ICS during an exacerbation. Too few studies are available to allow firm conclusions on the basis of subgroup analyses conducted to investigate the impact of age, time to treatment initiation, doses used, smoking history and the fold increase of ICS on the magnitude of effect; yet, effect size appears similar in children and adults. AUTHORS' CONCLUSIONS: Current evidence does not support increasing the dose of ICS as part of a self initiated action plan to treat exacerbations in adults and children with mild to moderate asthma. Increased ICS dose is not associated with a statistically significant reduction in the odds of requiring rescue oral corticosteroids for the exacerbation, or of having adverse events, compared with a stable ICS dose. Wide confidence intervals for several outcomes mean we cannot rule out possible benefits of this approach

Physicians' perception of childhood asthma in Turkey: more appropriate practice among female physicians

<p>Abstract</p> <p>Background</p> <p>Low levels of asthma control worldwide point to the possibility of sub-optimal management; therefore, documentation of physicians' perception is critical for future interventions. Our aim was to examine self-reported management abilities of Turkish physicians dealing with children with asthma, document the factors affecting appropriate decisions and compare the results with those of a previous survey.</p> <p>Methods</p> <p>Physicians were surveyed via a questionnaire aimed to document self-perceived asthma knowledge and attitudes in asthma management.</p> <p>Results</p> <p>The majority of physicians were male (63%) and examined 234 ± 9 patients per week. Infrequent use of objective parameters in asthma diagnosis and attack severity assessment was reported and most preferred nebulized corticosteroids to the systemic form in acute asthma. Even though self-perceived overall asthma knowledge did not differ between genders (p = 0.098), male physicians scored higher than females for inhaled steroids for acute asthma (2.8 ± 0.12 vs 2.17 ± 0.2, respectively, p = 0.007), while female physicians recorded more frequent use of inhaled steroids for chronic asthma (3.72 ± 0.08 vs 3.43 ± 0.07, respectively, p = 0.006). Female physicians' scoring for "symptom control" as the main aim of asthma management was higher than that of their male counterparts (3.88 ± 0.04 vs 3.65 ± 0.06, respectively, p = 0.002).</p> <p>Conclusion</p> <p>Although there were some discrepancies between guidelines and clinical practice, most applications of Turkish physicians dealing with children with asthma were appropriate. Interestingly, when scores of female versus male physicians were compared, it can be suggested that female physicians have a more appropriate perception of asthma, indicating a significant contribution of gender-related factors in clinical attitudes and beliefs.</p

Cow's milk allergic patients should be informed of the sources of caseinate

Cow's milk allergy is one of the most common food allergies prevalent during infancy and it may cause anaphylactic reactions in more sensitive patients. Cow's milk is found in a large variety of processed foods but its presence may be hidden as it is occasionally listed on the product label in an manner unrecognizable to the consumer. The parents of more sensitive patients need to be instructed in the detection of these potential sources of hidden cow's milk by judiciously reading food labels and in recognition of the sources, thus avoiding possible untoward reactions. We report a patient with cow's milk allergy who had an anaphylactic reaction following the ingestion of a hot dog product that contained caseinate. The label of the ingested hot dog product listed only the code number of caseinate. Avoidance of such occurrences would be more likely if firstly food products were labeled more accurately and secondly if physicians were to instruct their patients more thoroughly about their allergies, including the relevant names of all allergens

The cost of childhood asthma and its determinants in Ankara, Turkey

Bronchial asthma is one of the most common chronic diseases of childhood. In recent years a consistent increase in the prevalence, and concomitantly, in the social and economic impact of the disease, has been reported. In order to provide data for the cost of pediatric asthma and its determinants in Turkish children, a study was performed in a single outpatient clinic, which encompasses a questionnaire-guided interview and retrospective evaluation of the last year files. From the 183 patients enrolled, most were males (65.6%) and atopics (63.5%), with a disease severity of mild intermittent (67.7%). Mean annual total costs per patient was US $991.7 +/- 73.2 (median = 688.8) and the largest proportion of the direct costs was due to outpatient clinic costs (48.5$955.5 +/- 16.5. In multivariate analysis, the disease severity, current use of preventive drugs and current use of emergency sevice and/or current hospitalization appeared to be the main determinants of direct costs. Adequate control of the disease plays a key role in decreasing the total direct costs of pediatric asthma although it increases the medication and outpatient costs

The relationship between serum selenium levels and frequent wheeze in children

As an antioxidant, selenium stimulates Th1 immune response against viral infections, and may play a role in the pathogenesis of frequent wheeze due to respiratory viral infections during the first year of life. We investigated the level of selenium in children with frequent wheeze who had no atopic diseases and no family history of atopy to determine whether selenium has an effect on the severity of the diseases. Sixty-one children with frequent wheeze who were in the asymptomatic period and had had no infectious disease for two months and an equal number of age- and sex-matched children, as a control group, without atopy or allergy or systemic diseases were enrolled in the study. In the study group, we determined the levels of serum selenium, total IgE, mixed specific IgE, and total eosinophil count, and we performed epidermal prick tests. Serum selenium levels were (mean and SEM) 61.95 +/- 1.23 microg/L in the study group and 72.71 +/- 1.28 microg/L in the control group (p < 0.001), and there was a negative correlation between the serum selenium levels and number of wheeze attacks during the previous year (r = -0.655; p < 0.001). As a result, selenium may play a role in the progression of respiratory infections during childhood and can be accepted as a risk factor for development of wheezing

Cockroach allergy in a group of Turkish children with respiratory allergies

Exposure to cockroach may lead to exacerbations of bronchial asthma and/or allergic rhinitis in sensitized patients. Although there is a widespread belief that cockroach allergy is a common problem in patients with respiratory allergies, little is known in Turkish children. In order to investigate the prevalence and characteristics of cockroach allergy in respiratory allergic children, we performed a study in newly referred children with respiratory allergies. All patients underwent questionnaire-interview and skin prick tested with common inhalant allergens in addition to two cockroach allergens: Blatella germanica (Bg) and Periplaneta americana (Pa). A subgroup of patients was also serologically investigated for specific IgE against Bg and house dust mite. Three hundred- and thirty-seven children aged 2-16 years were recruited for the study and 77.7% of these were atopic, with the most common indoor and outdoor allergens of house dust mite (47.5%) and grass pollens (45.1%), respectively. According to the prick test results, allergies to Bg and Pa were 11.9% and 7.4%, respectively, and there was a weak correlation between size of the prick test and specific IgE levels for Bg allergen. Almost 30% of the cockroach-sensitive patients were allergic to both cockroach antigens. Seventy percent of cockroach-sensitive patients were also sensitive to house dust mite, and only 1% were monosensitive. Dwellings in the Middle Anatolia and Black Sea regions were less commonly infested by cockroach compared to the dwellings in other regions. In conclusion, our preliminary study showed that cockroach sensitization is common among children with respiratory allergies irrespective of infestation history, suggesting that addition of cockroach allergen to the routine allergy screening panel is critical

Determinants of allergic signs and symptoms in 24- 48-month-old Turkish children

The expression of asthma and allergic diseases depends upon an interaction of genetic and environmental factors and thus may differ between populations. This study was performed to document the factors determining allergic signs and symptoms in early childhood in a group of Turkish children. Children followed at the Well-Baby Clinic who were 2 to 4 years were invited and re-evaluated. In addition to face-to-face questionnaire for allergic signs and symptoms and review of files, skin prick test was performed. The associations between risk factors and different aspects of atopy were analyzed. One hundred and nine patients (mean age: 31.6 +/- 3.5 months) were included in the study. All had been breast-fed with mean exclusive and total breastfeeding durations of 3.3 +/- 2.7 and 13.3 +/- 7.2 months, respectively. Eight children had physician-diagnosed allergic diseases (4 atopic eczema, 3 bronchial asthma and 1 food allergy) and the overall prevalence of sensitization was 13%. Introduction of cow's milk before 12 months appeared to be a significant risk factor for atopy. Smoking during lactation and having an older sibling showed a trend towards an increase while regular yoghurt consumption showed a trend to decrease the risk for atopy. No significant risk factor could be defined for ever wheezing. It was concluded that in young Turkish children, early introduction of cow's milk, passive smoking and having an older sibling may predict atopy whereas regular yoghurt consumption may decrease the risk of atopy. These results also support the concept that variability may exist between populations

Use of polymerase chain reaction for detection of adenovirus in children with or without wheezing

Eighty percent of asthma attacks in children are accompanied by an upper respiratory tract viral infection. Adenovirus is one of the major viral causes of childhood bronchiolitis. As the polymerase chain reaction (PCR) is the most sensitive technique for documenting viral respiratory infections, the PCR method was performed on the throat swab samples of asthmatic children with and without wheezing to investigate the presence of the adenovirus genome in the upper respiratory tract. The frequencies of adenovirus in asymptomatic and symptomatic asthmatic patients, healthy controls and wheezy children were as follows: 33.3%, 71.4%, 37% and 62.96%, respectively. The adenovirus was detected in a significantly higher percentage in the upper airways of patients with asthma exacerbation and in children with wheezing than in patients without asthma exacerbation and in the healthy controls (p < 0.05). The frequency of adenovirus was not different between asthmatic patients receiving or not receiving inhaled corticosteroid. Adenovirus has the potential to precipitate asthma exacerbations in asthmatic patients; its frequency was not affected by the treatment of inhaled corticosteroid

The many faces of pediatric urticaria

Urticaria is a common disease that can affect individuals of all age groups, with approximately one-quarter of the population experiencing it at least once in their lifetime. Lesions characterized by erythema and itchy hives can appear anywhere on the body. These can vary in size ranging from millimeters to centimeters, and typically clear within 24 h. About 40% of patients with urticaria have accompanying angioedema, which involves localized deep tissue swelling. Urticaria usually occurs spontaneously and is classified into acute and chronic forms, with the latter referring to a condition that lasts for more than 6 weeks. The prevalence of chronic urticaria in the general population ranges from 0.5% to 5%, and it can either be inducible or spontaneous. The most common form of pediatric urticaria is acute and is usually self-limiting. However, a broad differential diagnosis should be considered in children with urticaria, particularly if they also have accompanying systemic complaints. Differential diagnoses of pediatric urticaria include chronic spontaneous urticaria, chronic inducible urticaria, serum sickness-like reaction, urticarial vasculitis, and mast cell disorders. Conditions that can mimic urticaria, including but not limited to cryopyrinopathies, hyper IgD syndrome, Periodic Fever, Aphthous Stomatitis, Pharyngitis and Adenitis (PFAPA), Tumor Necrosis Factor Receptor Associated Periodic Syndrome (TRAPs), and Schnitzler syndrome should also be considered. The many faces of pediatric urticaria can be both easy and confusing. A pragmatic approach relies on clinical foresight and understanding the various forms of urticaria and their potential mimickers. This approach can pave the way for an accurate and optimized diagnostic approach in children with urticaria

Meta-analysis of genome-wide linkage studies of asthma and related traits

<p>Abstract</p> <p>Background</p> <p>Asthma and allergy are complex multifactorial disorders, with both genetic and environmental components determining disease expression. The use of molecular genetics holds great promise for the identification of novel drug targets for the treatment of asthma and allergy. Genome-wide linkage studies have identified a number of potential disease susceptibility loci but replication remains inconsistent. The aim of the current study was to complete a meta-analysis of data from genome-wide linkage studies of asthma and related phenotypes and provide inferences about the consistency of results and to identify novel regions for future gene discovery.</p> <p>Methods</p> <p>The rank based genome-scan meta-analysis (GSMA) method was used to combine linkage data for asthma and related traits; bronchial hyper-responsiveness (BHR), allergen positive skin prick test (SPT) and total serum Immunoglobulin E (IgE) from nine Caucasian asthma populations.</p> <p>Results</p> <p>Significant evidence for susceptibility loci was identified for quantitative traits including; BHR (989 pedigrees, n = 4,294) 2p12-q22.1, 6p22.3-p21.1 and 11q24.1-qter, allergen SPT (1,093 pedigrees, n = 4,746) 3p22.1-q22.1, 17p12-q24.3 and total IgE (729 pedigrees, n = 3,224) 5q11.2-q14.3 and 6pter-p22.3. Analysis of the asthma phenotype (1,267 pedigrees, n = 5,832) did not identify any region showing genome-wide significance.</p> <p>Conclusion</p> <p>This study represents the first linkage meta-analysis to determine the relative contribution of chromosomal regions to the risk of developing asthma and atopy. Several significant results were obtained for quantitative traits but not for asthma confirming the increased phenotype and genetic heterogeneity in asthma. These analyses support the contribution of regions that contain previously identified asthma susceptibility genes and provide the first evidence for susceptibility loci on 5q11.2-q14.3 and 11q24.1-qter.</p